Answer to the last #DiagnosticDilemma
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The answer to the last Diagnostic Dilemma (A worm identified in an endotracheal aspirate of a patient with pulmonary infiltrates) is D. Strongyloides stercoralis.

A 46-year-old man with raynaud’s disease who emigrated from cambodia 30 years ago presented with a 2-month history of myalgias, exertional dyspnea, and an elevated level of creatine kinase. An extensive evaluation was notable for the ground-glass infiltrates detected in the lower lobes on a CT scan of the thorax. Serologic tests and bronchoalveolar lavage were unrevealing. A specimen from a muscle biopsy showed necrotizing myopathy. Empirical therapy with oral corticosteroids was begun for treatment of an inflammatory condition that was presumed to be noninfectious.

4 weeks after therapy was initiated, the muscle weakness and dyspnea were worse and there was progression of the pulmonary infiltrates. While the patient was waiting to undergo an open-lung biopsy, pulmonary hemorrhage, hypoxemic respiratory failure, and fulminant septic shock with E coli occurred. Many larvae of Strongyloides stercoralis were identified in an endotracheal aspirate. Despite treatment with ivermectin and albendazole and therapy for septic shock, the patient’s condition deteriorated rapidly, and he died.

Subclinical infection with this nematode (roundworm) may persist for decades through an autoinfection cycle in which there is low-level hematogenous migration from the gastrointestinal tract to the lungs and then, through reverse aspiration, back to the GI tract. When a patient with latent S. stercoralis infection is given corticosteroid therapy, a severe, life-threatening hyperinfection syndrome may occur; this syndrome is often associated with sepsis from enteric flora. As in this case, the presence of visible filariform larvae in the respiratory tract is a manifestation of disseminated infection.

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Source: NEJM