Strongyloides hyperinfection syndrome, Cytomegalovirus enteritis with viremia and recurrent gram-negative sepsis in a patient with recurrent thymoma: a case report

Abstract

Strongyloides stercoralis is an intestinal nematode which is endemic in tropical and subtropical countries. It may cause asymptomatic infections, mild eosinophilia or hyperinfection syndrome in the most severe form. We are reporting a case of Strongyloides hyperinfection syndrome in an immunosuppressed patient with recurrent thymoma and myasthenic crisis. This patient is a 51-year-old man with myasthenia gravis on long term pyridostigmine and prednisolone and mycophenolate. He presented with copious diarrhoea and was in septic shock. His blood and urine cultures grew Klebsiella pneumoniae and Pseudomonas aeruginosa. Oesophago-gastro-duodenoscopy (OGD scopy) and biopsy showed severe active duodenitis with strongyloidiasis and moderate active antral gastritis with strongyloidiasis. He was diagnosed to have Strongyloides hyperinfection and was treated with oral Ivermectin. He recovered well. He was subsequently diagnosed to have CMV enteritis with viraemia and was treated with intravenous Ganciclovir. Our case emphasizes the association of Strongyloides hyperinfection with superimposed CMV infection and gram-negative sepsis due to prolonged immunosuppression and autoimmunity in Thymoma patients. Recurrent thymoma and high-grade infiltrative thymoma often poses difficulty in the management of myasthenia patients. A high index of suspicion and aggressive treatment is paramount in approaching a patient with multiple risk factors of hyperinfection syndrome and autoimmunity. This case is reported in view of its rarity and significance regarding the multidisciplinary approach in decreasing morbidity and mortality in hyperinfection syndrome with an autoimmune background.