LAUSR

We report a case of Strongyloides in a patient with advanced HIV-infection. A 45-year-old Latino man with diabetes mellitus type II and recent episode of pneumonia presented to the emergency center after one week of rectal pain. Physical examination was suggestive of a perirectal abscess. CT was interpreted as horseshoe perianal infection. Screening HIV test was positive with a T lymphocyte count of 2, a diagnosis previously unknown to the patient. He was admitted for debridement of necrotizing perianal tissue, which grew E. Coli, Klebsiella oxytoca, and coagulase-negative staphylococci. He was started on cefepime, which was switched to meropenem after developing a rash on torso and arms. Additionally, oral thrush was noted and he was started on fluconazole. The patient had difficulty breathing and was intubated for his increasingly altered mental status and airway protection. He underwent a bronchoscopy and bronchioalveolar lavage (BAL). BAL was negative for Pneumocystis jiroveci (PJP) and its culture did not grow any bacteria or fungi. Antimicrobials were transitioned to meropenem, amphotericin, Bactrim, and prednisone (for empiric PJP treatment). The patient was weaned off sedation but continued to worsen mentally, not even responding to pain. CT of the head was unrevealing and lumbar puncture was performed with normal cell counts and an opening pressure of 31 (while on a vent). CSF was clear with 425 RBC, 1 WBC, glucose of 230, protein of 36, VDRL was not reactive, and cytology was negative. Patient’s mental status continued to deteriorate and a repeat lumbar puncture was performed, which was hazy with 1,250 RBC, 1 WBC, glucose of 90, and protein of 134.6. A concurrent BAL was performed, which showed Strongyloides on Gram stain, and he was started on ivermectin. Strongyloides was found on cytologic evaluation of CSF (Figs. 1 and 2). Patient had erythematous skin macules, which also showed Strongyloides larvae on biopsy. Other cultures and results were negative (other than an elevated IgG for toxoplasmosis). The patient’s condition continued to deteriorate with multi-organ failure (shock liver, central diabetes insipidus, and renal failure) and he passed away. Strongyloides larvae were identified in cytospin preparations of CSF with routine Romanowski (Diff-Quik) and Papanicolaou stains. The direct examination of the filariform larvae in CSF is diagnostic for Strongyloides infection involving central nervous system.