A case of apparent ART-associated immune reconstitution inflammatory syndrome in a patient with Strongyloides stercoralis infection

Abstract

Introduction: Strongyloides infection is most commonly caused by Strongyloides stercoralis (S. stercoralis). It often causes asymptomatic chronic infection but through the translocation of the parasite into the bloodstream, it can lead to disseminated strongyloidiasis (DS). We describe a case of a patient with human immunodeficiency virus (HIV) who developed Strongyloidiasis with the complication of vancomycin-resistant Enterococcus (VRE) meningitis. Notably, the clinical condition of the patient worsened after commencing anti-retroviral therapy (ART), raising concern for ART-associated immune reconstitution inflammatory syndrome (IRIS) to S. stercoralis. Case Report: A 51-year-old African female with a past medical history of HIV presented with a 1-week history of abdominal pain and a 2-month history of generalized malaise, constipation, and weight loss. She improved with symptomatic management and commenced Biktarvy. She re-presented one month later with worsening gastrointestinal symptoms. Her hospital course was complicated by septicemia with worsening mentation. Her repeat abdominal imaging showed ascending and transverse colitis and cerebrospinal fluid analysis was positive for vancomycin-resistant Enterococcus faecium (VRE). During her re-admission, the patient developed persistent watery diarrhea which was found to be positive for S. stercoralis. Despite medical therapy she demised on day 28 of admission. Conclusion: Literature is very scarce concerning the progression of S. stercoralis infection to Strongyloides disseminated strongyloidiasis (DS) as a result of IRIS. As clinicians, we must have a high index of suspicion in our HIV population as DS can lead to fatal complications. It can also help guide management decisions concerning ART until complete eradication of S. stercoralis infection is obtained.