Resistant and disseminated Strongyloides stercoralis infection in a young patient with adult T-cell leukemia/lymphoma

Adult T-cell leukemia/lymphoma (ATLL) is a mature T-cell malignancy associated to the human T-cell lymphotropic virus type 1 (HTLV-1). There are between 10 and 20 million HTLV-1 carriers worldwide, particularly in Southwest Japan, the Caribbean, Central Africa, South America and Papua New-Guinea. In developed countries the median age of patients with ATLL is 60 years, however this is lower in developing countries. In Brazil rare cases have been described in infancy. This earlier incidence of ATLL may be linked to an excess of antigenic stimuli caused by chronic and multiple parasitic infections commonly seen in poor countries(1). This article reports on an ATLL case in a young woman with massive and refractory Strongyloides stercoralis infection. A 17-year-old woman came to the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo with abdominal pain and diarrhea that caused a 13 kg weight loss. Strongyloidiasis, giardiasis and esophageal candidiasis were identified. Despite of several different therapies including specific treatment, the intestinal strongyloidiasis had persisted for one year when the patient returned to the hospital with sepsis and aseptic meningitis and a HTLV1 infection was detected. A computerized tomography showed enlargement of mesenteric and lung hilum lymph nodes and a lymph node biopsy revealed reactive lymphoid hyperplasia. Three months later wart-like lesions were noticed on the hands and right knee and blood counts showed hemoglobin was 14 g/L, platelet count 156 x 109/L, the white blood cell count was 5 x 109/L, lymphocytes were 1.5 x 109/L and flower cells were identified in the blood smear. The immunophenotype by flow cytometry showed abnormal CD3dim, CD4bright, CD25dim and CD7T-cell lymphocytes (Figure 1). A monoclonal pattern of HTLV-1 insertion into the neoplastic cells was identified by inverse long polymerase chain reaction (ILPCR) (Figure 2). A smoldering ATLL was diagnosed and treatment with 3 million units of interferon alpha twice per week and zidovudine 900 mg/day was started. The patient remained with itching and intermittent diarrhea, despite of the treatment for strongyloidiasis. After one year the disease progressed with neck, axillary and inguinal lymphadenopathy and splenomegaly. Finally, the patient was admitted to the emergency department in a bad health state with cough, fever, tracheobronchitis and hypercalcemia. Regardless of treatment the patient died after four days due to disseminated Strongyloides stercoralis infection. Luís Alberto de Pádua Covas Lage Renata de Oliveira Costa Livia Caroline Barbosa Mariano Erick Menezes Xavier Juliana Pereira