Recurrent Streptococcus bovis meningitis in Strongyloides stercoralis hyperinfection after kidney transplantation: the dilemma in a non-endemic area.

Post transplant parasitic infections are a rarity and occur in around 2% of transplant recipients; the intestinal helminth Strongyloides stercoralis (Ss) is found in contaminated soil in hot and humid tropical and subtropical regions of Africa, South and East Asia, and South America. Infective larvae from contaminated soil enter the host venous system from the skin to end up in the lungs and are then ingested into the GI tract by the pharynx where they mature into adults. Approximately half of the immune competent hosts become carriers and the remainder usually present with mild abdominal and respiratory symptoms. Transplant recipients receive steroids, have altered cellular immunity, and are at increased risk for hyperinfection syndrome because of an accelerated auto-infective cycle, rapid multiplication, and systemic larval dissemination. This can result in serious complications including GI bleeding, bacteremia, meningitis, liver abscesses, pneumonia, and death. We report a Strongyloides hyperinfection syndrome in a Saudi kidney recipient with recurrent Streptococcus bovis bacterial meningitis and significant weight loss 2 months after deceased donor kidney transplantation.