Strongyloides hyperinfection in a case of post- cadaveric solid organ transplantation

With cadaveric solid organ transplants becoming more common, the number of cases of infections transmitted from the donor to the recipient is increasing. This raises new questions regarding screening for infections in donors, particularly less common or rare infections. A Caucasian, CMV-positive 64-year-old male with end-stage renal disease secondary to type I diabetes mellitus received a simultaneous left kidney/pancreas cadaveric transplant from a 24-year-old Hispanic, CMV-positive, HTLV-1 negative donor. The donor blood work was negative for eosinophilia, but he did receive steroids prior to organ procurement. Small bowel obstruction and gastrointestinal bleeding complicated the recipient’s post-operative course. The patient had persistent nausea, bilious emesis, anorexia, and weight loss for months after his transplant. Endoscopy revealed confluent ulceration throughout the second portion of the duodenum with a heavy burden of the adult Strongyloides stercoralis on microscopic examination, consistent with hyperinfection. Urine and stool studies also confirmed the presence of Strongyloides infection. The patient was treated with ivermectin and immunosuppression changed to cyclosporine with resolution of the infection. Asymptomatic carriage was isolated to the donor (IgG positive status), while the archived recipient pre-transplant serum was negative for Strongyloides IgG. The other organ (liver, heart, and kidney) recipients were identified. The liver recipient died secondary to cardiopulmonary arrest post operative day 4. The heart recipient developed episodes of organ rejection, was treated with steroids, and subsequently developed Strongyloides hyperinfection with pulmonary involvement. The recipient of the right kidney was asymptomatic. This case highlights the need for enhanced screening protocols for cadaveric solid organ donors and recipients, based on infections endemic to the region of interest. In this circumstance, the identification of Strongyloides carriage may have reduced morbidity and mortality in the organ recipients.