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A5446 - Strongyloides Hyperinfection After Glioblastoma Treatment Diagnosed with Bronchoalveolar Lavage
Author Block: R. Baalachandran, E. Britt; Division of Pulmonary and critical care medicine, Univ of Maryland Med Ctr, Baltimore, MD, United States.
Introduction: Strongyloidiasis is a soil-transmitted helminthic infection more common in tropical and sub-tropical climate. We report a case of Strongyloides hyperinfection (SHI) in a patient with glioblastoma treated with radiotherapy, bevacizumab and dexamethasone. Case Report: 37 year-old gentleman with history of brain stem glioma treated with radiotherapy, bevacizumab and dexamethasone taper presented to the hospital with sudden onset chest pain, dyspnea, cough, scanty sputum and hoarseness of voice. He emigrated from Honduras in 2001. On arrival temperature was 37.5 degree Celsius, heart rate was 88 beats per minute and blood pressure 106/65 mm Hg. His oxygen saturation was 90% on room air and respiratory rate 18 per minute. On examination he had centripetally distributed erythematous maculo-papular rash. White blood cell count was decreased to 2700 cells/cu.mm. CT chest showed right-sided aortic arch, bilateral ground glass opacities and bibasilar consolidation. Broncho-alveolar lavage (BAL) cytology revealed the diagnosis by demonstrating strongyloides filariform larva. Rhinovirus was detected on viral panel polymerase chain reaction (PCR) and blood culture was positive for Escherichia coli (E.coli). Fluconazole, ceftriaxone and ivermectin were started. In 24 hours patient became more hypoxemic, thus transferred to intensive care unit and intubated. Hypoxemia improved after 4 days and patient was extubated. According to family wishes, he was discharged to inpatient hospice care due to poor prognosis of cancer. Discussion: Steroid treatment is an important risk factor for Strongyloidiasis likely due to impaired cell mediated immunity. It is seen in patients who have received a cumulative prednisone dose of 200-20,000 mg and 50% develop infection after 1 month of therapy. Hematological malignancies are the usual culprit, but we found one case report of severe strongyloidiasis after glioblastoma. There have been no case reports of strongyloides infection associated with bevacizumab. The filariform larva penetrates the skin and reaches lung briefly via blood before being swallowed into the intestine. Diagnosis is usually made with stool exam, but occasionally with BAL cytology in hyperinfection and dissemination. The invasion of filariform larva through the intestinal wall is the reason for association of SHI with gram-negative bacteremia. Ivermectin and albendazole are drugs of choice for treatment. Conclusion: Strongyloidiasis should be considered in patients being treated for glioma, who have lived or traveled to high-risk areas. We present an unusual case of strongyloides diagnosed with BAL cytology in a patient treated for glioblastoma.