Iranian Journal of Medical Microbiology

Case Presentation

A 70-year-old man was admitted to the emergency ward of the Ayatollah Rouhani Hospital, Babol, Iran, on September 1, 2020, with a history of chest discomfort, nausea, and loss of appetite for 10 days.
He had a history of mitral valve replacement and atrial fibrillation (AF) 13 years prior to his referral; and heart failure for 3 years. He was hospitalized due to severe COVID-19 about three weeks before the admission mentioned above, where he received 6 mg/day dexamethasone intravenously for 10 days. His vital signs were stable on admission, and oxygen saturation was 96% without supplemental oxygen. His physical examination was unremarkable except for AF arrhythmia.
Laboratory findings were as follows: white blood cell count (WBC): 17,600/µL (absolute neutrophil count: 7568/µL, absolute lymphocyte count: 2464/µL and absolute eosinophil count (EAC): 7040/µL), high sensitive C-reactive protein (h-CRP): 1 mg/L, ESR: 20 mm/h. Troponin I and CK-MB were negative. An electrocardiogram (ECG) showed AF rhythm with no ST–T wave changes.
After consultation with a gastroenterologist, a gastroduodenoscopy was performed. Gastroduoden-oscopy revealed slight erythema in the gastric antrum, inflammation and few erosions in the distal part of the duodenum bulb, and a notable inflammation in D2. Multiple biopsies were taken from the gastric antrum and duodenal mucosae and sent for histopathologic examination.
Histopathologic examination of the biopsies showed numerous eggs and filariform larvae of S. stercoralis in the gastric and duodenal mucosae with increased eosinophilic infiltration in lamina propria (Figures 1).
 

 
Figure 1. A. H & E slides (400x) of gastric antral mucosa show many rhabditiform larvae of S. stercoralis. B. H & E slides (400X) of duodenal mucosa show a large number of rhabditiform larvae of S. stercoralis

 
These findings confirmed the diagnosis of SHS syndrome. Therefore, 200 µg/kg Ivermectin was administered to the patient for two days. After 2 weeks, the patient's symptoms did not change, and the WBC: 10640/µL with EAC of 4117/µL were reported in the laboratory evaluation. Therefore, ivermectin was administered at a dose of 200 µg/kg for 5 days, accompanied by albendazole at a dose of 400 mg every 12 hours for 10 days.
Serial EAC revealed a decreasing trend in eosinophil count. The patient's symptoms, including chest discomfort, nausea, and anorexia, also disappeared.

Follow-up and Outcomes:

Currently, after about eight months, the patient is in good general condition without any complaints or adverse events.

Strongyloides infection is common in tropical and subtropical regions and in passengers, migrants, and prisoners of war who have spent time in these areas. Strongyloidiasis is mainly an asymptomatic or mildly symptomatic disease (7). However, in the case of immunosuppression, strongyloidiasis can cause hyperinfection syndrome or disseminated infection with a mortality rate of 70 to 100% (9).
Asymptomatic Strongyloides infection in patients undergoing immunosuppression with dexamethasone should be considered to avoid precipitating SHS.
Clinical observational studies described improved clinical symptoms and oxygenation after steroid administration in patients with severe COVID-19 (10, 11, 12). We found two published case reports of SHS in COVID-19 patients who became immune-suppressed due to dexamethasone and tocilizumab administration.
For the first time, Marchese et al. reported a case of a 59-year-old Italian patient treated with high dose intravenous dexamethasone and two intravenous doses of tocilizumab for bilateral interstitial pneum-onia associated with SARS-CoV-2 infection who developed itching, abdominal pain, and an increased eosinophil count. Stool examination confirmed the presence of S. stercoralis larvae. The patient was treated with a 4-day course of ivermectin that resulted in full recovery (13).
Furthermore, Lier et al., on October 2020, reported a case of a 68-year-old man with COVID-19 infection who developed disseminated strongyloidiasis follo-wing treatment with high-dose corticosteroids and tocilizumab. The authors suggested Strongyloides infection be screened in individuals with COVID-19 who come from S. stercoralis endemic regions before initiating immunosuppressive therapy (14).
In this case presentation, we reported a 70-year-old-man with SHS following a 10-day treatment with intravenous dexamethasone for severe COVID-19 who presented with a significantly increased EAC on admi-ssion.
In this context, the risk assessment should be performed for Strongyloidiasis in patients who live or have visited areas where the organism is endemic before and during corticosteroid therapy for COVID-19, and Strongyloidiasis should be considered in cases of unexplained hypereosinophilia.

 

Early diagnosis and appropriate treatment of SHS significantly reduce the mortality rate in SHS. Clinicians should be aware of the risk of SHS syndrome in COVID-19 patients undergoing corticosteroid therapy. Furthermore, unexplained hypereosinophilia in immunosuppressed patients should be an alarming sign of SHS, especially in S. stercoralis endemic areas.

 

The authors would like to thank all the Babol Ayatollah Rouhani Hospital staff for their valuable help.

 

The authors declared no conflict of interest.

 

Conflicts of Interest

Funded for this study, provided by the authors.