Case Report

Strongyloides Hyperinfection Syndrome Complicating (Ectopic) Cushing Syndrome

Authors: Raja S. Vadlamudi, MD, MPH, Martin Van Dort, MD, Thomas Barklow, MD, Ryland P. Byrd Jr., MD, Jonathan P. Moorman, MD, PhD

Abstract

Strongyloidiasis can present with a wide variety of symptoms and can lead to a potentially fatal hyperinfection. Although any factors that suppress the host defense mechanisms can potentially trigger hyperinfection, prolonged steroid use has been quite well described. A patient with disseminated small cell lung cancer suffered a Strongyloides stercoralis hyperinfection syndrome complicating ectopic adrenocorticotropic hormone (Cushing syndrome). Evaluation revealed lymphopenia, elevated levels of adrenocorticotropic hormone in the setting of elevated cortisol levels, a normal pituitary, and metastatic malignancy. S. stercoralis larval forms were seen in the stool and sputum. At autopsy, S. stercoralis larval forms were seen in the lung along with evidence of metastatic small cell lung carcinoma.


Key Points


* Hyperinfection syndrome from Strongyloides stercoralis can occur in the setting of Cushing syndrome from ectopic adrenocorticotropic hormone production by metastatic small cell carcinoma of the lung.


* Physicians in endemic areas should be aware of the occurrence of potentially fatal hyperinfection syndrome with strongyloidiasis and be aware that it could occur as a complication of immunosuppressant therapy.

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References

1.Concha R, Harrington W Jr, Rogers AI. Intestinal strongyloidiasis: recognition, management, and determinants of outcome. J Clin Gastroenterol 2005;39:203–211.
 
2.Cruz T, Reboucas G, Rocha H. Fatal strongyloidiasis in patients receiving corticosteroids. N Engl J Med 1966;275:1093–1096.
 
3.Siddiqui AA, Berk SL. Diagnosis of strongyloides stercoralis infection. Clin Infect Dis 2007;33:1040–1047.
 
4.Gotuzzo E, Terashima A, Alvarez H, et al. Strongyloides stercoralis hyperinfection associated with human T cell lymphotropic virus type-1 infection in Peru. Am J Trop Med Hyg 1999;60:146–149.
 
5.Singh S. Human strongyloidiasis in AIDS era: its zoonotic importance. J Assoc Physicians India 2002;50:415–422.
 
6.Cummins RO, Suratt PM, Horwitz DA. Disseminated strongyloides stercoralis infection. Association with ectopic ACTH syndrome and depressed cell-mediated immunity. Arch Intern Med 1978;138:1005–1006.
 
7.Vadlamudi RS, Chi DS, Krishnaswamy G. Intestinal strongyloidiasis and hyperinfection syndrome. Clin Mol Allergy 2006;4:8.
 
8.Siddiqui AA, Genta RM, Berk SL. Strongyloides stercoralis, in Blaser, Smith, Ravdin, Greenberg, Guerrant (eds): Infections of Gastrointestinal Tract. Philadelphia, Lipponcott Wiliams & Wilkins, 2002, ed 2, pp1113–1126.
 
9.Gill GV, Welch E, Bailey JW, et al. Chronic strongyloides stercoralis infection in former British far east prisoners of war. QJM 2004;97:789–795.
 
10.Huaman MC, Sato Y, Aguilar JL, et al. Gelatin particle indirect agglutination and enzyme-linked immunosorbent assay for diagnosis of strongyloidiasis using Strongyloides venezuelensis antigen. Trans R Soc Trop Med Hyg 2003;97:535–538.
 
11.Uparanukraw P, Phongsri S, Morakote N. Fluctuations of larval excretion in Strongyloides stercoralis infection. Am J Trop Med Hyg 1999;60:967–973.
 
12.Gann PH, Neva FA, Gam AA. A randomized trial of single- and two-dose ivermectin versus thiabendazole for treatment of strongyloidiasis. J Infect Dis 1994;169:1076–1079.