A 29-Year-Old Renal Transplant Recipient with Acute Respiratory Failure

A 29-year-old woman was admitted with a 2-day history of fever, cough, hemoptysis, abdominal pain, and diarrhea. She had received a renal transplantation 4 months before and was receiving mycophenolate mofetil, tacrolimus, and prednisone. Two days after admission, she developed a petechial rash on the abdomen (Figure 1), paralytic ileus, and progressive respiratory distress requiring mechanical ventilation. The white blood cell count was 4,300, with 12% eosinophils, blood cultures were negative, serological tests for human immunodeficiency virus (HIV), human T-cell lymphotropic virus type 1 (HTLV-1), and cryptococcal antigen were negative, and plasma viral load for cytomegalovirus (CMV) was negative. The chest X-ray showed bilateral interstitial infiltrates (Figure 2). A bronchoalveolar lavage tested negative for bacteria, galactomannan antigen, mycobacteria, and fungi, but it disclosed rabditiform larvae of Strongyloides stercolaris (Figure 3), which were also found in the stools. She was started on ivermectin and broad antibiotic coverage but died of multiorgan failure 4 days later. Strongyloidiasis is a well-known complication of severe immunosupression. Conditions such as HIV and HTLV-1 infections, chronic use of steroids, chemotherapy, diabetes, hematologic malignancies, and malnutrition pre-dispose to the hyperinfection syndrome, which carries high mortality rates. Pre-transplant patients and donors in endemic areas should always be investigated for