We describe a North American human immunodeficiency virus (HIV)-positive patient with Strongyloides stercoralis infection of the gastrointestinal tract.

We describe a North American human immunodeficiency virus (HIV)-positive patient with Strongyloides stercoralis infection of the gastrointestinal tract, who required repeated "standard" courses of thiabendazole. Pulmonary infection with numerous roundworms exhibited as suspected by bronchoalveolar lavage, and while he was receiving therapy, dissemination occurr in succession autopsy, S stercoralis was regained in the gastrointestinal tract, liver, lung and heart. After a literature review, we decide that HIV-positive patients have a higher risk of dissemination and "standard" treatment failure. This may come to pass without elevation of IgE or eosinophilia. Those patients may require put offed courses of thiabendazole or alternatively ivermectin therapy.

Strongyloides stercoralis is an intestinal parasite in humans that may be asymptomatic or cause mild to moderate abdominal symptoms. It may spread to pulmonary tissue and finally disseminate in immunocompromised patients. Accepted therapy for intestinal involvement is thiabendazole, 25 mg/kg twice a day for 2 to 3 days.[1,2]

We describe a human immunodeficiency virus (HIV)-infected patient who, after receiving couple courses of "standard" thiabendazole therapy, make knowned pulmonary spread and died while receiving treatment. The postmortem examination revealed systemic dissemination. To our knowledge, this is the first described HIV-positive patient, without a history of opportunistic infection, who despite repeated accepted therapy, failed to suit and died of dissemination while receiving therapy. After a literature review, we determine that dissemination may be more customary than previously recognized.[3]

CASE REPORT

The patient is a North American 60-year-old white homosexual male journalist who was known to be HIV seropositive for 2 years with a [CD4sup+] lymphocyte judge of 194 x [10.sup.6]/L without a history of opportunistic infections; he was receiving zidovudine and low-dose sulfamethoxazole/trimethoprim prophylaxis. He had travelled from head to foot the world for the last 20 years, including Southeast Asia, Mediterranean countries, southerly America, and southeast and southwest United States. In December 1991 he existinged to his physician with epigastric pain and mild diarrhea. A gastroduodenoscopy was performed because of suspected peptic sore disease. Two duodenal biopsy specimens showed several s stercoralis. Thiabendazole therapy (50 mg/kg/d orally for 3 days) was complet couple months later, his symptoms recurr and a repeated duodenoscopy with biopsy specimens again revealed s stercoralis. A second course of thiabendazole, at the same dosage, combined with pyrantel pamoate (11 mg/kg orally, undivided dose) was instituted and his symptoms disappeared. Stool studies were at no time performed during his out-patient visits.

Three weeks later, he was referr to the hospital because of rapid clinical deterioration. His vital signs were a heart rate of 136/min, kindred pressure of 98/60 mm Hg and respiratory rate of 16/min. He was afebrile with a temperature of 372 [degrees] C pale, and dehydrated, unless otherwise results of his physical examination were unremarkable. Laboratory data included a mild macrocytic anemia with a hemoglobin flat of 116 g/L (normal, 120 to 150) probably secondary to zidovudine, a leukocyte judge of 7.0 x [10.sup.9]/L (normal) with 3 percent eosinophils, and mildly elevated liver function touchstone results with alanine aminotransferase of 67 U/L (normal <35) aspartate aminotransferase of 59 U/L (normal <35) and alkaline phosphatase of 253 U/L (normal <115) The chest radiograph showed mild bilateral interstitial infiltrates in the two lower lung zones. On the third hospital day, he suddenly

develop febrile affection (39.5 [degrees] C), dyspnea, and tachypnea (40/min). Lung auscultation disclosed bilateral diffuse rales and the patient required intubation and mechanical ventilation. The arterial [POsub2] was 102 mm Hg in succession a [FIO.sub.2] of 0.65 with a positive end-expiratory squeezing 15 cm [H.sub.2]O. Bilateral diffuse alveolar and interstitial infiltrates were seen forward chest radiograph with left midlung field patchy alveolar consolidation (Fig 1) A diagnostic fiberoptic bronchoscopy was performed and demonstrated sharp hyperemic bronchial mucosa and feculent hemorrhagic secretions. The bronchoalveolar lavage showed numerous s stercoralis larvae. One of three stool studies with a "wet mount" technique revealed the organism. The third course of thiabendazole (25 mg/kg/twice a day) was started upon day 5, and pyrantel pamoate (11/mg/kg single dose) was added. No clinical answer was noted and his oxygenation deteriorated. He cause to growed multiple organ system failure with adult respiratory distress syndrome acute renal failure, acute gastrointestinal tract bleeding, and cardiopulmonary arrest forward day 11.

The autopsy showed overwhelming s stercoralis infection in liver, lung duodenum jejunum ileum, and myocardium (Fig 2 and 3) He had no additional infection and all refinements for bacterial and fungal organisms were negative.

...