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Strongyloides stercoralis Hyperinfection Syndrome Presenting as Severe, Recurrent Gastrointestinal Bleeding, Leading to a Diagnosis of Cushing Disease
A 50-year-old male immigrant from Ethiopia presented for consultation after 3 years of hematochezia/melena requiring > 25 units of blood transfusions. Physical examination revealed severe proximal muscle wasting and weakness, central obesity, proptosis, and abdominal striae, accompanied by eosinophilia, elevated hemoglobin A1c, elevated 24-hour urinary cortisol, lack of suppression of 8 am cortisol levels by 1 mg dexamethasone, and inappropriately elevated random adrenocorticotropic hormone (ACTH) level. Histopathological examination of gastrointestinal biopsies showed large numbers of Strongyloides stercoralis, indicating Strongyloides hyperinfection. Treatment with 2 days of ivermectin led to resolution of gastrointestinal bleeding. This syndrome was due to chronic immunosuppression from a pituitary ACTH (corticotroph) microadenoma, of which resection led to gradual normalization of urine cortisol, improved glycemic control, resolution of eosinophilia, and no recurrence of infection.
Author Notes
Authors' addresses: Brittany Yee, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA, E-mail: brittany.yee@gmail.com. Nai-Wen Chi, Division of Endocrinology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA, E-mail: nwchi@ucsd.edu. Lawrence A. Hansen, Department of Pathology, University of California San Diego School of Medicine, La Jolla, CA, E-mail: lahansen@ucsd.edu. Roland R. Lee, Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA, E-mail: rrlee@ucsd.edu. Hoi-Sang U, Department of Neurosurgery, University of California San Diego School of Medicine, La Jolla, CA, E-mail: hoisang@ucsd.edu. Thomas J. Savides, Division of Gastroenterology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA, E-mail: tsavides@ucsd.edu. Joseph M. Vinetz, Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA, and Instituto de Medicina Tropical “Alexander von Humboldt” and Departamento de Ciencias Celulares y Moleculares, Facultad de Ciencias y Filosofia, Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Peru, E-mail: jvinetz@ucsd.edu.