A 45 year-old Haitian man with AIDS (CD4=36, VL<50) on HAART with a history of T-cell lymphoma on chemotherapy (EPOCH x1, then CHOP x4) presented with a ten day history of fever and diarrhea. His physical examination was significant for a rectal temperature of 102.8°F, shotty cervical lymphadenopathy, oral thrush, and a soft, non-tender, mildly protuberant abdomen. Laboratory evaluation was remarkable for mild anemia and renal insufficiency. Diarrhea resolved after week but fevers persisted on broad-spectrum antibiotics. Abdominal CT revealed pan-colitis, multiple small liver & spleen lesions, adenopathy, ascites, and ileus. Ascitic fluid analysis revealed 8000 WBC (43% neutrophils). Flexible sigmoidoscopy revealed edema and small ulcers. The patient remained febrile and refused additional work-up. The patient was transferred to a nursing home. Eight days later he was readmitted with fever to 105°F and confusion, ill-appearing, with thrush and abdominal tenderness. Repeat ascetic fluid analysis revealed 788 WBC (45% neutrophils), Gram stain (-). Blood cultures grew Candida glabrata and Enterococcus faecium . Cytologic evaluation of ascitic fluid was consistent with Strongyloides stercoralis .
Stongyloides stercoralis has been very rarely reported in the ascitic fluid of patients with AIDS, renal transplant and alcoholism. The patient in this case developed sepsis and died in the medical ICU. Pleural fluid cultures grew Mycobacterium tuberculosis.
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V. McAuliffe MD and K. Javaly MD, Attending
Bellevue Hospital and the VA Medical Center
New York, NY, 10016
