Rapid Respiratory Failure after Heart Transplant

Introduction Strongyloides is a helminthic intestinal parasite that is common in tropical regions. In immunosuppressed individuals it may cause a hyperinfection syndrome with fatal complications. We present one such case. Case Report A 60 year old Hispanic male presents 2 months after heart transplantation (HT) with fatigue. His post transplant course was complicated by recurrent rejection requiring intravenous steroids. His immunosuppression included tacrolimus, mycophenolate mofetil and prednisone. On presentation, he underwent endomyocardial biopsy which demonstrated 1R rejection. Echocardiography revealed normal allograft function. He developed respiratory distress requiring intubation, followed by profound hypotension necessitating vasopressor and broad spectrum antimicrobial support. Due to difficulty with oxygenation, he underwent urgent bronchoscopy. Over the next 72 hours, he became increasingly unstable. On hospital day 4, Papanicolaou staining identified Strongyloides in the bronchoalveolar lavage specimen. [ figure 1 ] Ivermectin 200mg was initiated and on hospital day 7 with the patient continuing to do poorly, albendazole was added. This resulted in improvement in his hemodynamic and respiratory status, however, his mental status failed to recover. Lumbar puncture revealed Strongyloides in the cerebro-spinal fluid. On hospital day 26 life sustaining support was withdrawn and the patient passed away. Summary Atypical symptoms and rapid deterioration in HT patients without a clear cause should prompt an early investigation for strongyloides. Screening of high risk populations, such as those from endemic areas, of both potential donors and recipients should be discussed as pre-treatment may prevent catastrophic complications.