Fatal strongyloidiasis in three kidney recipients in Kuwait.

OBJECTIVE: It was the aim of this study to report 3 rare fatal cases of strongyloidiasis in Kuwaiti renal transplant patients.

CLINICAL PRESENTATION AND INTERVENTION: All 3 cases received allografts from cadaveric donors of Asian origin, the first 2 from an Indian (transplanted on the same day) and the third from a Bangladeshi. In all 3 cases, Strongyloides stercoralis larvae were first isolated from bronchoalveolar lavage. All 3 patients were on immunosuppressive therapy which included prednisolone, thereby leading to the hyperinfection syndrome. All patients presented with gastrointestinal symptoms (abdominal pain, vomiting, diarrhea, constipation and paralytic ileus), as well as pulmonary symptoms (cough, dyspnea and blood-stained sputum). Albendazole 800 mg twice daily orally was started. Cyclosporine A was started after discontinuing prograf. The patients continued to deteriorate with a fall in blood pressure and platelets. All 3 patients died from adult respiratory distress syndrome following hyperinfection with S. stercoralis.

CONCLUSION: Hyperinfection with S. stercoralis is a rare but preventable complication of immunosuppressive therapy. A high index of suspicion is required for the diagnosis of this infection. Persistent examination of sputum, bronchial washings and upper intestinal aspirates should be done as part of surveillance following cadaveric renal transplantation. Adult respiratory distress syndrome is indeed a red flag in patients who are on steroids, not on cyclosporine and receiving a kidney from donors in endemic countries of S. stercoralis.