Methods: Diagnosis was made via History, Physical exam, Imaging, Lumbar puncture, CSF and Blood culture, Bronchoscopy, Urine analysis and stool studies.
Results: 49yo Caucasian male with a history of HIV presented to the Emergency Department with altered mental status presumed to be due to drug abuse. His temperature of 104F and abnormal urine analysis prompted empiric antibiotic therapy, however, his condition continued to deteriorate. Brain CT without contrast showed intraparenchymal hemorrhage with left temporal occipital horn and third ventricle compression. Subsequent lumbar puncture revealed a WBC count of 144,218 cells/μL, 78% PMNs, no RBCs, glucose of 50mg/dL and protein over 600mg/dL. Meningococcal meningitis was then suspected following maculo-papular exanthema on abdomen and thigh. However, CSF was negative for bacteria and fungi. Thorough investigation of CSF, bronchoalveolar lavage, and stool studies revealed Strongyloides stercoralis. Blood cultures were positive for Candida Parapsilosis and coagulase negative Staphylococcus. CT angiography of the chest revealed a thrombus in the right lower lobe. Patient was treated for disseminated Strongyloides infection, Pulmonary embolism, HIV, Candida fungemia and bacteremia. His respiratory function, however, failed to improve, necessitating mechanical ventilation. Several attempts at extubation were unsuccessful. Patient passed away from cardiac arrest.
Conclusion: This patient’s unfortunate case demonstrates the fundamental importance of thorough investigation into some of the rarest etiologies of disease. Although this patient had a classic presentation of bacterial meningitis, similar symptoms and findings were also present in disseminated strongyloidiasis. This is why it is never enough to rest on what is more common especially in cases with such significant past medical history and comorbidities.
C. Villania, None
W. Zeleznak, None
S. Gerasim, None
D. Casadesus, None