Re: Autoimmune system "attacking itself"

http://www.ncbi.nlm.nih.gov/pubmed/17662320


Strongyloides stercoralis septicaemia following steroid therapy for eosinophilia: report of three cases.
Ghosh K, Ghosh K.

Pravara Institute of Medical Sciences, Pravaranagar, Loni, Ahmednagar, Maharashtra, India.

Abstract
Three apparently immunocompetent patients died in the intensive care unit at Loni Hospital, Ahmednagar, Maharashtra, India, between 2001 and 2006 due to multiorgan failure and Strongyloides stercoralis septicaemia following a short course of corticosteroid (prednisolone) therapy of 6-17 days for peripheral blood eosinophilia associated with urticaria and angioneurotic oedema, bronchospasm, and generalised aches and pains, respectively. None of the patients had any obvious lymphoproliferative disorder, solid tumour or HIV 1+2 infection as an underlying immunosuppressive condition. These three patients highlight the extreme caution that must be exercised in administering a moderate dose of oral corticosteroid even for a short period of time as well as the high degree of suspicion that needs to be maintained if there is clinical deterioration following corticosteroid therapy.

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The other case concerns a forty-year-old Cambodian female with a four-year history of Systemic Lupus Erythematosis (SLE) with secondary nephritis, nephrosis, and vasculitis, and many exacerbations requiring hospital admission and chronic steroid therapy. This patient presented to the same emergency room following a two-day episode of nausea and vomiting with recent onset of abdominal pain and fever. Current medications included prednisone (50 mg daily), and plaquenil (200 mg twice daily).

On physical exam, the patient appeared in some distress, with a temperature of 102.2 and pulse of 104. The abdomen was soft, tender to palpation with positive tympany on percussion. Abdominal plain films were negative for free air. Ultrasound demonstrated ascitic fluid with possible ruptured appendix or ruptured ovarian cyst. An acute abdomen was assumed, but exploratory laparotomy showed mild non-purulent ascites with no evidence of acute appendicitis. Peritoneal Gram’s stain was negative, but cultures were positive for coagulase-negative staphylococcus. The patient tolerated appendectomy without complication and was placed on Antibiotics post-operatively. Pathology reported the appendix to have mild eosinophilic infiltration.

Four days post-operatively, the patient developed a fever and tachypnea. Pulmonary auscultation revealed crackles bilaterally in all lung fields. Chest X-ray demonstrated diffuse alveolar infiltration (figure 4). CBC showed a WBC count of 15,000, with a hemoglobin of 8.2 and hematocrit of 24.1. Sputum culture showed few Gram-positive cocci, and blood cultures were negative. The patient progressed to acute respiratory failure and was subsequently intubated. Arterial blood gas showed a pH of 7.28, pCO2 of 40, pO2 of 105 on 70% FIO2 assist control ventilation. Antibiotic regimen was expanded to cover anaerobic bacteria, as well as atypical and opportunistic respiratory pathogens. Sputum specimens were sent for staining and culture to evaluate for possible Pneumocystis, Strongyloides, Cryptococcus, or Mycobacterium infections. Serological analysis for cryptococcal antigens and coccidioidal antibodies was performed along with a urinary screen for Legionella species antigen.


Despite repeatedly negative sputum and serologic stains and cultures over the next three days, the patient progressed to respiratory failure, requiring sedation and an FIO2 level of 100% (figure 5). Bilateral lung fields showed increasing alveolar infiltration. As her condition deteriorated, the patient spontaneously developed hemorrhagic pulmonary secretions and an acute rash of the abdomen. Although she had a normal sedimentation rate, progression to lupus pneumonitis with cutaneous vasculitis seemed the only possibility. At this point, a sputum sample was positive for Strongyloides stercoralis larvae and the etiologic factor was finally revealed (figure 6). Unfortunately, it was too late and despite initiation of ivermectin (200 ug/kg daily) and thiabendazole (25 mg/kg daily) therapy, the patient developed cardiopulmonary arrest unresponsive to resuscitation. The terminal diagnosis was “Strongyloides hyperinfection syndrome” leading to peritonitis, respiratory failure, and death.

http://tinyurl.com/2a5me33