Purpose To report a unique case of a delayed diagnosis of stronglyoidasis hyperinfection in a patient with systemic lupus erythematotus (SLE), lymphoplasmatic lymphoma and proteinuria with microhaematuria. Stronglyoidasis stercoralis is a rare nematode endemic to the tropical and sutbtropic regions and immunocompromised patients are at risk of infection. Stronglyoidasis hyperinfection has been described in SLE cases previously, yet not also co-occurring with lymphoplasmacytic lymphoma.
Methods A 67-year-old female with a fifteen year history of SLE was referred to the immunology outpatient clinic due to malaise and ataxia progressing over several months. Before the referral, neurological, radiological, and hematological workup was performed, which objectified the clinical symptoms, showed CNS affection, and confirmed remission of a lymphoplasmacytic lymphoma treated using an B-R protocol over the previous year. Physical examination findings were consistent with previous chronic SLE sequelae, yet a decrease in body weight was noted, as well as a mild anemia, proteinuria (175 mg/dU) with microhaematuria, and increased eosinophile count. Workup was broadened, including kidney biopsy, bone marrow biopsy, parasite serology, and stool ova and parasite test.
Results Follow-up laboratory showed a further increase in eosinophile count (25%), positive Stronglyoides stercoralis serology (immunoglobulin G ELISA), and strongyloides larvae in stool samples. Bone marrow biopsy showed no abnormalities and kidney biopsy analysis ruled out lupus nephritis as a cause of proteinuria and haematuria. Single oral dose of ivermectin (200 µg/kg) was administered. One month after treatment the eosinophile count normalized and follow-up stool sample was free of larvae. Proteinuria and haematuria had resolved and other chronic morbidity remains under remission.
Conclusion Stronglyoidasis stercoralis hyperinfection should be considered when differentiating between possible causes of general deterioration in multi-morbid SLE cases, presenting even in areas not considered endemic. Paraneoplastic syndrome remains a possible etiology of the observed kidney injury.
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