1971 Strongyloides Infection Presenting as a Massive GI Bleeding Without Eosinophilia

INTRODUCTION: Nematode hyperinfection classically presents with eosinophilia. However, immunosuppressed patients on corticosteroid therapy or with chronic HTLV 1-2 infection do not necessarily express the eosinophilic pattern. This case of GI massive bleeding in a patient with T cell lymphoma and HTLV 1-2 infection illustrates this atypical scenario. CASE DESCRIPTION/METHODS: A 60 year-old male with a recent diagnosis of C. difficile colitis was admitted to the ED with syncope and failure to thrive. His past medical history was notable for peripheral T cell lymphoma on azacitidine and CHOP, and chronic HLTV 1-2. The patient reported 6 days of nausea, vomiting, diarrhea, and chest pain. Patient was born in the Dominican Republic and moved to the US more than 10 years ago. On examination he was tachycardic and hypovolemic and responded to fluid resuscitation. The patient was in no acute distress. His labs were notable for hyponatremia, mild anemia without eosinophilia, cholestasis, hypoalbuminemia, increased PT and mild troponinemia. EKG was normal for acute coronary syndrome, and CT chest was significant for new small right and trace left pleural effusions with atelectasis. Abdominal US revealed gallbladder sludge and biliary duct dilatation. MRCP was normal. His course was complicated by melena and hematochezia. Given hemodynamic instability, he was managed with IV vancomycin and piperacillin/tazobactam in addition to vasopressors and blood products. EGD and flexible sigmoidoscopy showed diffuse mucosal oozing in the upper and lower GI tracts with targetoid, punched out duodenal lesions. Biopsy demonstrated worms suggestive of strongyloides on histopathologic evaluation. The patient was started on Ivermectin which was then switched to Praziquantel given concern of inadequate absorption due to ileus. DISCUSSION: Strongyloides infections usually present with variable grade of eosinophilia. However, eosinophilia may be suppressed or absent in disseminated disease because of concomitant pyogenic infection or steroid administration as we can see in this patient. 3 Additionally, patients with HTLV-1 infection express high levels of interferon-gamma production, which decreases the production of interleukin (IL)-4, IL-5, IL-13, and IgE, important molecules in host defense against Strongyloides. 4 Strongyloides is typically diagnosed via serology, but was made after EGD was done for GI bleeding. Thus, Strongyloides infection should be on the differential for GI bleeding in an immunocompromised patient.