Clinical Images

Failure to Thrive and Meningitis

Authors: Kristi Michelle Moore, M.D. and Scarlett Olivia Murphy, B.S.

            A 54-year-old man presented with anorexia, fatigue, and a 50-pound weight loss over several months.  Past history included chronic hepatitis C, non-specific inflammatory bowel disease, pulmonary sarcoidosis, and long-term steroid use. Review of systems was only notable for generalized malaise, constipation, and pruritus.  Recent imaging revealed mesenteric lymphadenopathy, although subsequent lymphoma workup was negative. He denied any international travel, but noted frequent visits to southern Louisiana.

On physical examination, the patient was cachectic with mild, diffuse abdominal tenderness. Findings on neurological examination were normal. Testing for HIV, tuberculosis, histoplasmosis, cytomegalovirus, and syphilis was negative.  Endoscopy revealed diffuse friable, nodular, and ulcerated mucosa (Image 1). Biopsies identified the causative pathogen (Image 2), and he began oral ivermectin.  Three days later, the patient became obtunded with meningeal signs. Cerebrospinal fluid (CSF) analysis revealed a culture-negative neutrophilic pleocytosis.  He received broad-spectrum IV antibiotics and continued antihelminthic therapy with remarkable clinical improvement. 

MCQ 1: What is the most likely pathogen responsible for the patient’s symptoms?

1. Onchocerca volvulus

2. Enterobius vermicularis

3. Echinococcus granulosus

4. Strongyloides stercoralis
   

MCQ 2: What is this patient’s biggest risk factor for infection?

1. Hepatitis C

2. Inflammatory bowel disease

3. Glucocorticoid use

4. Malnutrition

Click here for multiple choice answers

References:

1. Keiser PB, Nutman TB. Strongyloides stercoralis in the immunocompromised population.  Clin Microbiol Rev. 2004;17(1):208-17.

2. Zammarchi L, Montagnani F, Tordini G, et al. Persistent strongyloidiasis complicated by recurrent meningitis in an HTLV seropositive Peruvian migrant resettled in Italy. Am J Trop Med Hyg. 2015;92(6):1257-60.

Author Bios:

Scarlett Murphy is a 4^th year medical student at UNC Chapel Hill planning on a career in internal medicine.  Her interests include global health, infectious diseases, nephrology and cardiology.  She became interested in tropical diseases while working in a pediatric ICU during malaria season in Malawi.

Dr. Kristi M. Moore is an assistant professor of medicine and serves as an Associate Program Director for the Department of Internal Medicine at Carolinas Medical Center in Charlotte, North Carolina.