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Bart J. Currie, J. S. McCarthy, Strongyloides stercoralis Infection as a Manifestation of Immune Restoration Syndrome?, Clinical Infectious Diseases, Volume 40, Issue 4, 15 February 2005, Page 635, https://doi.org/10.1086/427757
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SIR—Kim and Lupatkin [1] describe a patient with fever, eosinophilia, hepatitis, and Strongyloides stercoralis larvae in stool, as revealed by microscopy. These clinical features developed after diagnosis of HIV-1 infection and commencement of HAART and are attributed by the authors to immune restoration. Empirical therapy for cerebral toxoplasmosis was also initiated with pyrimethamine and sulfadiazine, as was therapy with dexamethasone. The patient's condition responded to standard therapy with ivermectin.
A more likely explanation for this case is that the patient experienced an exacerbation of subclinical S. stercoralis infection following the institution of high-dose corticosteroid therapy. Corticosteroid therapy has long been recognized as the major risk factor for development of severe disease and disseminated strongyloidiasis in people with asymptomatic carriage of S. stercoralis [2, 3]. Furthermore, it has been noted that it is rare to develop disseminated strongyloidiasis in the absence of corticosteroid therapy. Although it was initially hypothesized that the immunosuppression secondary to HIV infection would result in an increased incidence of disseminated strongyloidiasis, such a rise in incidence has not been observed. For example, a general lack of correlation between HIV infection and strongyloides hyperinfection has been observed in regions where both are endemic, such as sub-Saharan Africa and Brazil [4]. We, therefore, suggest that the case presented may merely reflect S. stercoralis carriage progressing to clinical disease following the use of dexamethasone.
