Introduction Severe eosinophilia is defined as the association of high numbers of eosinophils 5000 x 10 3 cells uL in the peripheral blood When caused by Strongyloidiasis in an immunocompromised host the elusive nature of the parasite is an obstacle for establishing a diagnosis Strongyloidiasis Stercoralis is considered a marker to evaluate the immunosuppressed state of patients with impaired cell mediated immunity in many countries The vast majority if not all of Strongyloidiasis cases that are documented are found in patients that are extremely immunosuppressed most commonly accompanied by specific risk factors and present as chronic low intensity infections which present as asymptomatic while still remaining dangerous due to the potential of developing fatal disseminated forms Although reactivation of a latent infection is rare and scarce in literature cases have been documented where organ recipients who were negative for IgG levels before transplantation received an organ from an IgG positive donor and severe disseminated forms of Strongyloidiasis occurred Case We present for your consideration the case of a 63 year old man with history of liver transplant performed in July 2015 with no record of rejection and a positive response to Tacrolimus and Corticosteroid immunosuppressive therapy
A right nephrectomy was performed on January 2017 due to a primary renal pelvis carcinoma discovered by CT Scan with evidence of metastasis to the lungs liver and bone for which he received his first round of chemotherapy Shortly after his first cycle of chemotherapy he was found with incidental leukocytosis 88 59 x 10 3 cells L and severe eosinophilia 67 33 x 10 3 cells L in a control work up which was associated with skin eruption and pruritus lower back and gluteal pain secondary to metastatic disease He lived in Caguas his whole life and worked as telephone and cable specialist He traveled to the Dominican Republic constantly last trip was reported to be during 2014 He also had history of alcoholism and smoking prior to transplant He was treated with Cefepime to resolve his Gram negative bacteremia with reported E Coli predominance and vast susceptibility to antibiotics Prednisone and Tacrolimus were placed on hold when the eosinophilia emerged Completed eosinophilia workup during his inpatient period He was started on Hydroxyurea and after his leukocytes were seen on a decreasing trend he was discharged home on the medication
The eosinophilia workup showed positive Strongyloides IgG hence the treatment was initiated with Ivermectin which had a positive response as evidenced by the gradual decreasing values of eosinophils Discussion Strongyloidiasis rarely presents as reactivation of a latent infection and in this case where there has been no known exposure to the parasite Clinical manifestations at the initial stage of Strongyloidiasis vary from urticaria generalized pruritus to abdominal pain This patient presented pruritus and skin eruption after his first round of chemotherapy No other noticeable symptoms manifestations or signs in contrast to laboratory results other than high eosinophilic values over 20 000 in the peripheral blood were found high IgE levels and a positive Strongyloides Stercoralis IgG The detection of Gram negative bacteremia with E Coli was a pivotal sign that pointed towards the diagnosis of Strongyloides which is usually the result of larvae penetrating through the intestinal wall contaminating the exterior with the intestinal flora We propose the possibility of 3 ways of infection reactivation of a latent infection exposure to the parasite recently or the result of organ transplantation hence our motives of presenting the case being that the incidence and prevalence of the parasite remains unknown in Puerto Rico Other complications such as hyper infection syndrome and disseminated Strongyloidiasis could have easily presented in this patient due to the multiple present risk factors The possibilities of identifying the etiology of this patient s infection are minimal due to no history of exposure to the parasite and secondly the absence of Strongyloides screening in the actual organ transplant protocol approved by the American Society of Transplantation Conclusion This case raised awareness of the potential of development of severe and disseminated forms of Strongyloidiasis in patients who have traveled to lived in any endemic area or patients with fluctuant eosinophilia since unlike other intestinal parasites Strongyloides may remain latent for years and the presence of eosinophilia could be the only sign of infection Ever since the Organ Transplant Department of Hospital Auxilio Mutuo has started its operations there has not been any documented cases of Strongyloidiasis in a post transplanted patient
This investigation has raised awareness of the risk of Strongyloidiasis in the institution and it has helped implement screening measures even when the protocol for organ transplantation established by the American Society of Transplantation does not include any screening for Strongyloides Stercoralis in non endemic areas References Schär F Trostdorf U Giardina F et al Strongyloides stercoralis Global Distribution and Risk Factors Brooker S ed PLoS Neglected Tropical Diseases 2013 7 7 e2288 doi 10 1371 journal pntd 0002288 Chen Y YK Khoury P Ware JM et al Marked and persistent eosinophilia in the absence of clinical manifestations The Journal of allergy and clinical immunology 2014 133 4 1195 1202 e2 doi 10 1016 j jaci 2013 06 037 Roufosse F Weller PF Practical approach to the patient with hypereosinophilia The Journal of allergy and clinical immunology 2010 126 1 39 44 doi 10 1016 j jaci 2010 04 011 Abanyie FA Gray EB Delli Carpini KW et al Donor Derived Strongyloides stercoralis Infection in Solid Organ Transplant Recipients in the United States 2009 2013 American journal of transplantation official journal of the American Society of Transplantation and the American Society of Transplant Surgeons 2015 15 5 1369 1375 doi 10 1111 ajt 13137 Martin P DiMartini A Feng S Brown R and Fallon M 2014 Evaluation for liver transplantation in adults 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation Hepatology 59 1144 1165 doi 10 1002 hep 26972
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