Strongyloides hyperinfection syndrome due to corticosteroid therapy after resection of meningioma: illustrative case

Abstract

Background: Strongyloidiasis is an underdiagnosed and preventable life-threatening disease caused by infection with the helminth Strongyloides stercoralis. Chronic asymptomatic infection can be sustained for decades, and immunosuppression can lead to disseminated infection, with a mortality rate of 70%-100%. In the neurosurgical population, corticosteroids are the most consistent cause of hyperinfection.

Observations: The authors present the case of a 33-year-old woman of Paraguayan origin who was diagnosed with sphenoid planum meningioma and treated with a high dose of corticosteroids on the basis of the diagnosis. She underwent surgery, and pathological anatomy reflected grade I meningioma. After the surgery, she started with a history of dyspnea, productive cough, fever, and urticarial rash. Later, she presented with intestinal pseudo-obstruction and bacterial meningitis with hydrocephalus. Serology was positive for Strongyloides (enzyme-linked immunosorbent assay), and she was diagnosed with hyperinfection syndrome. Ivermectin 200 µg/kg daily was established.

Lessons: It may be of interest to rule out a chronic Strongyloides infection in patients from risk areas (immigrants or those returning from recent trips) before starting treatment with corticosteroids.

Keywords: CSF = cerebrospinal fluid; CT = computed tomography; ELISA = enzyme-linked immunosorbent assay; IgG = immunoglobulin G; MRI = magnetic resonance imaging; Strongyloides stercoralis; corticosteroids; hydrocephalus; meningioma; meningitis.

FIG. 1.

Expansive suprasellar lesion that spares the pituitary gland (arrowhead) and presents with a dural tail (arrow), compatible as a first possibility with sphenoid planum meningioma. Axial head CT with contrast (A). Preoperative coronal (B) and sagittal (C) T1-weighted MRI scans with contrast.

FIG. 2.

Axial noncontrast MRI. Bilateral small foci of diffusion restriction compatible with acute ischemia in the deep white matter (arrows). A: Diffusion-weighted sequence (b = 1,000). B: Apparent diffusion coefficient map.

FIG. 3.

Axial noncontrast head CT. Marked dilatation of lateral ventricles with periventricular hypodensity, in keeping with transependymal edema (arrow), compatible with communicating hydrocephalus.

FIG. 4.

Most prevalent areas of strongyloidiasis worldwide: Latin America, sub-Saharan Africa, and Southeast Asia.^,,

FIG. 5.

Management algorithm proposed by our team.