LAUSR

A 74-year-old male with poorly-controlled type 2 diabetes mellitus (recent hemoglobin A1c 11%) presented in the emergency department complaining of abdominal pain and fever for two weeks. He immigrated from Cambodia in 1970 but has traveled back frequently, being his last trip two years prior to this presentation. On presentation, patient was febrile, hypotensive, with tenderness on palpation in the right upper quadrant. Laboratory testing was remarkable for white blood cell count 18,000 cells/uL, absolute neutrophil count 16,000 cells/uL, absolute eosinophils count 70 cells/uL, hemoglobin 15 g/dL, alanine aminotransferase 232 IU/L, aspartate aminotransferase 242 IU/L, alkaline phosphatase 193 IU/L, glucose 267 mg/dL, creatinine 0.8 mg/dL. A computed tomogram of the abdomen revealed multiple hypo-enhanced lesions in the liver concerning for abscesses (Fig. 1). The patient was admitted to the hospital and received empiric ceftriaxone. Eight hours later, blood cultures resulted positive for a gram-negative bacterium that was later identified as a susceptible mucoid strain of Klebsiella pneumoniae (Fig. 2). Fine needle liver aspiration revealed an organizing abscess with prominent eosinophils (Fig. 3), and tissue culture resulted positive for Klebsiella pneumoniae. Per chart review, it was noted that patient had previous episodes of intermittent eosinophilia without further evaluation. Given this finding, epidemiological background, and gram-negative bacteremia, the diagnosis of strongyloidiasis was considered. Strongyloides IgG antibody resulted positive, and larvae of Strongyloides stercoralis were detected in stool culture (Fig. 4). Patient received ceftriaxone while in the hospital with rapid clearance of bacteremia and two doses of oral ivermectin. After dismissal, the patient received levofloxacin completing three weeks of treatment with resolution of liver abscesses in follow-up imaging and no evidence of eosinophilia in repeat hemogram. Strongyloidiasis is a soil-transmitted helminthiasis endemic in tropical and subtropical countries [1]. It has a broad clinical spectrum, ranging from asymptomatic infection with transient eosinophilia to life-threatening forms, hyperinfection or disseminated disease [2]. During hyperinfection syndrome, invading filariform larvae can transport luminal enteric bacteria to the bloodstream and central nervous system leading to bacteremia and meningitis, respectively [3]. Serology is highly sensitive, and stool culture in agar plate can confirm the diagnosis [1]. Oral ivermectin is the treatment of choice, but subcutaneous ivermectin can be used in patients unable to tolerate the oral route [3]. This case highlights the importance of considering strongyloidiasis in the differential diagnosis of patients with epidemiological exposure presenting with enteric gram-negative bacteremia without a clear source.