Content uploaded by Mohanraj Rathinavelu
Author content
All content in this area was uploaded by Mohanraj Rathinavelu on Aug 09, 2017
Content may be subject to copyright.
Indian Journal of Pharmacy Practice, Vol 10, Issue 2, Apr-Jun, 2017 153
Case Study
www.ijopp.org
DOI: 10.5530/ijopp.10.2.32
Address for
correspondence:
Dr. Raghu Prakash Reddy
Nayakanti. M.D,
Medical Microbiologist, Rural
Development Trust (RDT) HOSPI-
TAL, Bathalapalli, Ananthapura-
mu, Andhra Pradesh, INDIA.
Phone no: +91 9490419834
E-mail: raghusvims@gmail.com
Hyper Infection of Strongyloides Stercoralis
Associated With Secondary Bacterial Pneumonia in a
Malnourished Patient
Raghu Prakash Reddy Nayakanti1, Rama Kesava Reddy Motati2, Nettikantaiah Muneppagari3,
Mohanraj Rathinavelu Mudhaliar4
1Medical Microbiologist, Rural Development Trust (RDT) Hospital, Bathalapalli, Ananthapuramu, Andhra Pradesh, INDIA
2Consultant Physician, Department of General Medicine, Rural Development Trust (RDT) Hospital, Bathalapalli, Ananthapuramu,
Andhra Pradesh, INDIA
3Microbiologist, Rural Development Trust (RDT) Hospital, Bathalapalli, Ananthapuramu, Andhra Pradesh, INDIA
4Drug Information Pharmacist, Poison and Drug Information Center (PDIC), Rural Development Trust (RDT) Hospital, Bathalapalli,
Ananthapuramu, Andhra Pradesh, INDIA
ABSTRACT
Strongyloides stercoralis, an intestinal nematode is more prevalent in the tropics or subtropics. Hyper infection
syndrome in immuno competent patients is due to asymptomatic infections, increased parasite number,
dissemination and it leads to death if unnoticed. Use of corticosteroids, HIV, HTLV-1, malignancies and malnutrition
are predisposing factors for hyper infection. Secondary bacterial infections are known to cause increased mortality
in these patients in antibiotic resistant era. Here we report a case of strongyloides hyper infection syndrome
associated with secondary bacterial pneumonia in a malnourished female patient.
Key words: Hyper infection syndrome, Immune compromised, Malnourished, Pneumonia, Strongyloides stercoralis.
INTRODUCTION
Strongyloidosis, an intestinal nema-
tode infection is prevalent in the tropi-
cal and subtropical regions especially in
low socio-economic countries where the
faecal contamination of soil or water is
common. The most common source
of infection is by contacting soil that is
contaminated with Strongyloides larvae.
Therefore, activities that increase con-
tact with the soil such as walking with
bare feet, contact with human waste or
sewage, occupations that increase con-
tact with contaminated soil such as farm-
ing and coal mining, increase the risk of
becoming infected which are all being
commonly practiced in India.1
Strongyloides infection in immunocom-
petent individual is usually asymptom-
atic. In the immunocompetent host, the
immune system regulates the population
density of adult worms in the intestine.2
Immunocompromised status is a predis-
posing factor for hyper infection. In the
era of increased use of corticosteroids
and anticancer drugs there is an absolute
chance for developing hyper infection
syndrome in a previously infected and
asymptomatic patient.
Autoinfection, hyper infection and dis-
seminated infections are the three related
entities shown by the parasite during
its course of infection. There is no clear
demarcation between autoinfection and
hyper infection where the hyper infec-
tion is an exaggerated mechanism of
autoinfection along with clinical signs
and symptoms related to GIT and pul-
monary system. Increased numbers of
larvae in stool and/or sputum is the hall-
mark of hyper infection. Whereas in dis-
seminated infection there is a deviation
of the course of larva from its routine
Nayakanti et al.: Case Report on Strongyloides Stercoralis
154 Indian Journal of Pharmacy Practice, Vol 10, Issue 2, Apr-Jun, 2017
cycle and it enters into various organs systems like
brain, kidneys etc causing devastating consequences.3
Auto-infective larvae can carry gut bacteria to the
other parts of the body. Many of the people with
hyper infection present with bacterial disease due
to enteric bacteria. Case reports of bacteremias and
meningitis with the enteric bacteria like Escherichia
coli and Klebsiella have been reported.4 The high
mortality rate associated with hyper infection syn-
drome and disseminated disease is frequently due to
secondary bacterial infections.5
Here we report a case of hyper infection syndrome lead-
ing to secondary bacterial pneumonia caused by mixed
infection of Klebsiella and Pseudomonas.
CASE REPORT
Female patient aged 45 years presented to the hospi-
tal with severe breathlessness and right sided chest
pain associated with 2 episodes of hemoptysis in
the morning. She had a history of cough since 2
months, associated with intermittent productive
sputum along with shortness of breath and right
sided chest pain which increased in the intensity for
the last 15 days and became intolerable on the day of
presentation to the hospital. She was admitted and
started with empirical antibiotic therapy.
Patient is not a known case of DM and HTN. She
had past h/o pneumonia 8 months back which was
relieved after the treatment. No past h/o pul TB /
asthma/ CAD/CVA
A panel of Investigations was done to identify the
underlying cause.
Sputum was sent for Gram’s staining and acid fast
staining. No Acid fast bacilli were observed in Aura
mine staining and the Gram’s stain showed plenty of
neutrophils along with many gram negative bacilli.
And round coiled hollow structures appearing like
larvae were also observed surrounded by neutro-
phils.
Wet mount of the sputum was made and plenty of
motile larval forms (3-4 parasites/ LPF) correspond-
ing with the morphology of lariform larvae were
observed.
Culture of the sputum was done on blood agar and
McConkeys agar.
X ray and other routine blood investigations were
done.
X ray chest showed diffuse inltrations in the right
lung with consolidation of right lower lobe. Blood
investigations showed signicant neutrophilia with
Figure 1: Diffuse infiltrations in the right lung with consolida-
tion of right lower lobe (Chest X-ray PA view).
Figure 2: gram staining of sputum showing larvae of strongy-
loides stercoralis.
>85% of WBC being neutrophils. Ig E levels were
slightly elevated.
Clinician was informed about the larvae and the
patient was started with additional ivermectin treat-
ment. Next day stool was asked for wet mount
examination and observed many sluggishly motile
and some non-motile larvae of strongyloides sterco-
ralis. Blood agar plate also showed serpiginous mark-
ings along with bacterial colonies because of the
surface movements of the larvae on the agar plate.
Two types of colonies were isolated from the spu-
tum. The predominant organism was Pseudomonas
and the other organism being Klebsiella. Antibiotic
Nayakanti et al.: Case Report on Strongyloides Stercoralis
Indian Journal of Pharmacy Practice, Vol 10, Issue 2, Apr-Jun, 2017 155
sensitivities were determined for both the organ-
isms.
Empirical antibiotic therapy was changed to cipro-
oxacin after receiving the sensitivity report as both
the organisms were sensitive to it. Patient recovered
uneventfully in course of time and the pneumonia
was resolved.
DISCUSSION
In the present case, though the exact immunosup-
pressive condition could not be made out with the
available clinical and diagnostic measures, we cannot
rule out the hidden foci of such conditions which
may be expressed out in course of time. In this case
the preference is given to the malnutrition status of
the patient which might have played a role in the
causation of hyper infection. And the presence of
Pseudomonas super infection indicates an underly-
ing compromised status as this bacterium is a known
opportunistic pathogen.
There is quiet a high chance of misdiagnosing the
hyper infection with the bacterial pneumonias, SLE
and other inammatory conditions. As there are
only very few case reports of this condition came
as literature in Indian context, clinicians rarely sus-
pect this condition and they may not even include
it in their routine differential diagnosis panel. At
least in endemic areas of S. stercoralis, strongyloi-
diasis should be included as a possible cause of pul-
monary disease in differential diagnoses, especially
in patients with immunodeciencies and abnormal
chest imaging ndings, like alveolar and interstitial
shadow patterns or lobar pneumonia.6
High suspicion and thorough clinical and micro-
biological examination is necessary to identify this
condition and to treat the patient with appropriate
therapy otherwise the patient condition will be dete-
riorated which ultimately leads to bad outcome.
ACKNOWLEDGEMENT
The authors would like to thank Dr. Gerardo Alva-
rez-Uria, Head - Care and Supportive Center, Rural
Development Trust (RDT) Hospital, Bathalapalli,
Ananthapuramu, Andhra Pradesh for his constant
support and guidance throughout the study.
CONFLICT OF INTEREST
The author declares no conict of interest.
FUNDS AND GRANTS
Nil
ABBREVIATIONS
HIV: Human immunodeciency virus; HTLV-1:
Human T cell lymphotropic virus type 1; GIT: Gas-
tro Intestinal Tract; DM: Diabetes Mellitus; HTN:
Hypertension; TB: Tuberculosis; CAD: Coronary
Artery Disease; CVA: Cerebro Vascular Acci-
dent; Ig: Immunoglobulin; LPF: Low Power Field;
SLE:Systemic Lupus Erythematosus; WBC: White
Blood cell Count; PA: Posteroanterior.
REFERENCES
1. CDC. Parasites—Strongyloides: epidemiology and risk factors. Atlanta, GA:
US Department of Health and Human Resources, CDC; 2012.
2. Genta, RM. Strongyloidiasis. In: Guerrant, RL. Editor. Tropical Infectious
Diseases. Philadelphia: Elsevier; 2005. p. 1274-82.
3. Ramanathan R, Nutman TB. Strongyloides stercoralis infection in
the immunocompromised host. Current Infectious Disease Reports.
2008;10(2):105-10. https://doi.org/10.1007/s11908-008-0019-6;
PMid:18462583 PMCid:PMC3401551.
4. Keiser PB, Nutman TB. Strongyloides stercoralis in the immunocompromised
population. Clinical Microbiology Reviews. 2004;17(1):208-17. https://doi.
org/10.1128/CMR.17.1.208-217.2004; PMCid:PMC321465.
5. Link K, Orenstein R. Bacterial complications of strongyloidiasis: Streptococcus
bovis meningitis. Southern Medical Journal. 1999;92(7):728-31. https://doi.
org/10.1097/00007611-199907000-00016; PMid:10414486.
6. Jayaprakash B, Sandhya S, Kumari AK. Pulmonary strongyloidiasis. J Assoc
Phys India. 2009;57:535-36 PMid:20329418.