A 48 year-old man with no past medical history was sent to our emergency department (ED); from a primary care clinic for
hypertensive urgency of 200/130. The man reported an intermittent non-productive
cough of approximately one year's duration and worsening
dyspnea on exertion and
orthopnea over the last month with lower extremity swelling. Of note, he emigrated from Honduras twenty years ago. Blood pressure normalized with administration of
Lasix in the ED. Physical exam revealed
rales in lung bases bilaterally, jugular venous distension, lower extremity pitting
edema with serpiginous patches of
erythema and excoriation, and a cardiac gallop. Labs showed peripheral
eosinophilia,
thrombocytopenia, elevated
creatinine,
hyperbilirubinemia,
hyperglycemia, and mild transaminitis. Transthoracic echocardiogram revealed a dilated left ventricle with global hypokinesis and severely depressed systolic function with an ejection fraction less than 15 percent . The patient was diuresed, and subsequent left and right heart catheterizations were normal. CT chest showed a small nodule in the right upper lobe. Tests for
Coccidiosis, Trypanosoma cruzi, and Mycobacterium tuberculosis were negative; however the
acid fast bacilli culture grew Mycobacterium fortuitum. A Strongyloides stercoralis antibody test was positive, and the patient was treated with two doses of oral
ivermectin with one dose of intravenous
ceftriaxone, and discharged. Two months later, his
eosinophilia resolved, but he remained symptomatic with productive
cough and
weight loss, and was started on an outpatient course of oral
ciprofloxacin and
trimethoprim-sulfamethozole for M. fortuitum.
DISSCUSION: Strongyloides-infected patients may carry the parasite for years without prominent symptoms. Endemic throughout South America, Strongyloides persists in its hosts through a lifecycle of autoinfection, which, over time, increases parasite burden and can lead to a hyperinfection syndrome whereby filiariform larvae penetrate organ tissue, most commonly: heart, central nervous system, lungs and liver. We suspect chronic
eosinophilia and disseminated filiaria to be the etiology of the non-ischemic
dilated cardiomyopathy in this patient. Standard treatment of
strongyloidiasis is
ivermectin, however, mortality owing to transient
bacteremia in the setting of hyperinfection syndrome is high. Therefore,
bacteremia prophylaxis with gram negative rod coverage should be considered before
antiparasitic agent initiation.