A Canadian immigrant with coinfection of Strongyloides stercoralis and human T-lymphotropic virus 1

• Published in: Canadian Medical Association journal (CMAJ) Vol. 177; no. 5; pp. 451 - 453
• Main Authors: Lagacé-Wiens, Philippe R S, Harding, Godfrey K M
• Format: Journal Article
• Language: English
• Published: Canada CMA Impact Inc 28.08.2007; CMA Impact, Inc; Canadian Medical Association
• Series: Teaching Case Report
• Subjects: Albendazole; Animals; Antiretroviral drugs; Care and treatment; Case studies; Comorbidity; Diagnosis; Diagnosis, Differential; Dosage and administration; Drug therapy; Emigration and Immigration; Fatal Outcome; HTLV-I (Virus); Human T-lymphotropic virus 1; Human T-lymphotropic virus 1 - isolation & purification; Humans; Ivermectin; Leukemia-Lymphoma, Adult T-Cell - complications; Leukemia-Lymphoma, Adult T-Cell - diagnosis; Male; Manitoba; Medical diagnosis; Medical treatment; Middle Aged; Nematodes; Noncitizens; Parasites; Patient outcomes; Physiological aspects; Practice; Strongyloides stercoralis; Strongyloides stercoralis - isolation & purification; Strongyloidiasis; Strongyloidiasis - complications; Strongyloidiasis - diagnosis; United States Virgin Islands; Viruses; United States Virgin Islands; Manitoba; Canada
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.070126

Initial investigations revealed ascites, abdominal lymphadenopathy, acute renal failure (creatinine 320 µmol/L) and hypercalcemia (calcium 2.8 mmol/L), and he had no eosinophils. The results of a lymph node biopsy suggested a diagnosis of adult T-cell lymphoma. The results of immunophenotyping revealed the presence of CD2 and CD3 (T-cell markers) and CD25 (IL-2 receptor, activated T-cell marker) and the absence of CD5 (B-cell marker) and CD7 (immature T-cell marker). The presence of CD7 is common in cases of acute lymphocytic leukemia; however, this marker is not usually present in cases of adult T-cell lymphoma. The presence of CD25, hypercalcemia and persistent strongyloidiasis and the absence of CD7 were consistent with a diagnosis of T-cell lymphoma caused by human T-cell lymphotropic virus 1 (HTLV-1). The results of serologic investigations were positive for HTLV-1, and the results of a polymerase chain reaction test showed the presence of HTLV-1 proviral DNA. Dialysis was ordered to treat the patient's renal failure and hypercalcemia. After a week of dialysis, his calcium and creatinine levels normalized at 2.1 mmol/L and 86 µmol/L respectively. The patient's lymphoma was treated with cyclophosphamide, hydroxydaunorubicin, vincristine and prednisone (CHOP therapy). In addition, the patient was given a single dose of ivermectin (15 mg) for treatment of strongyloidiasis, which had been diagnosed by the presence of numerous rhabditiform larvae in a duodenal aspirate (Figure 1) 4 weeks before presentation at hospital. The patient's renal function and ascites improved after chemotherapy; however, 8 days after receiving the chemotherapy, fever, diaphoresis and hypotension developed. Blood cultures were positive for Escherichia coli and Citrobacter freundii, and a culture from the patient's central venous catheter was positive for E. coli, C. freundii, Staphylococcus epidermidis, Pseudomonas aeruginosaand α-hemolytic streptococci. Ciprofloxacin, piperacillin- tazobactam and vancomycin therapy were initiated; however, the patient's condition further deteriorated and upper and lower gastrointestinal hemorrhage and cytomegalovirus colitis developed. The patient received blood products, ganciclovir therapy, endoscopic cautery of varices and injection of anhydrous alcohol as a sclerosing agent. Supportive treatments were continued, and the patient was given a second course of ivermectin (15 mg/d for 2 days). Six cycles of chemotherapy were completed; however, a follow-up CT scan of the abdomen showed progressive lymphoma. The patient was given a trial of zidovudine and α-interferon for HTLV-1-associated lymphoma; however, his condition continued to deteriorate, and he died about 6 months after his initial presentation. The most important aspect of the management of S. stercoralis and HTLV-1 coinfection is the timely diagnosis and treatment of S. stercoralis. Those at risk for HTLV-1 infection, such as people from HTLV-1-endemic areas and those with compatible exposure (e.g., intravenous drug use, recipient of blood products, HTLV-1 infected partner or family member) should be tested for HTLV-1 and, if positive, screened for S. stercoralis.1,3 People with persistent S. stercoralisinfections should be evaluated for a predisposing condition such as HTLV-1 infection, and people from HTLV-1-endemic areas should be tested for S. stercoralisbefore the initiation of immunosuppressive therapy.1,3