Strongyloides Stercoralis Autoinfection

INTRODUCTION: Strongyloides stercoralis is an intestinal roundworm that infect humans through contact with soil that is contaminated with free-living larvae. The larvae penetrate the skin and migrate through the body to the small intestine to lay their eggs. It is associated with immigrant populations from tropical regions such as Southeast Asia and the south pacific. Strongyloidiasis is often mild or asymptomatic in over 50%-60% of cases, but may present with cutaneous and gastrointestinal symptoms like abdominal pain, bloating and diarrhea. The rise in blood eosinophils count could be the only finding. Strongyloides is able to re-infect the host through the wall of gastrointestinal tract, a process described as autoinfection. This is why it may be detected decades after original exposure. CASE DESCRIPTION/METHODS: We encounter a 64-year old Hispanic male with PMH of Multiple Myeloma, who was admitted to our hospital due to fatigue and spiking fever. Patient was recently diagnosed with Multiple Myeloma and was on Bortezomib, Cyclophosphamide and Dexamethasone for the last 22 days. During the presentation, maculopapular rash was noted on his right inner thigh that later on got more diffused and affected the bilateral thigh and right forearm. Laboratory results shows Leukocyte 6.8 thousand/uL, hemoglobin 7.3 g/dL, platelet 35 thousand/uL, eosinophil 34 cells/uL, and plasma cell 2 cells. Patient had Tmax of 103 and empiric antibiotic was started. All blood cultures, urine cultures and chest X-ray was negative for any source. His liver enzymes and direct bilirubin trended up without any sign of cholecystitis on ultrasound and Cholescintigraphy scan. During the hospital course, the rash got more characteristic of reticulated purpuric patches. EBV, HSV, Varicella, Spotted fever, Typhus fever, ANA, IGG and hepatitis panel back negative. Due to reticular rash development, suspicion of Strongyloidiasis increased and IGG antibody came back positive. Patient started on Stromectol 15 mg for 2 doses and the rash resolved following the second dose of the medication. DISCUSSION: Strongyloides stercoralis is a challenging diagnosis in immunocompromised patients. It is important to screen for helminth diseases in patients with high blood eosinophils count, especially before starting chemotherapy.