A 46-year-old female presented with complaints of fever, breathlessness on minimal exertion, vomiting, abdominal pain, and reduced appetite since 10 days. She also complained of weight loss of 10 kilograms in the last 6 months. She was diagnosed with HIV-1 infection, 1 month prior, and was prescribed tenofovir, lamivudine, and efavirenz fixed-dose combination single-pill regimen. Her baseline CD4 count was 68 cells/mm3, and plasma HIV-1 viral load was 867,000 copies/ml. She had no comorbidities or prior significant medical history. On examination, she was febrile (temperature: 100 degrees Fahrenheit) with pulse (100/min), blood pressure (110/60 mm Hg), and respiratory rate (24/min). Respiratory examination revealed crepitations in bilateral inframammary, infraaxillary, and infrascapular areas. There was diffuse abdominal tenderness but no organomegaly. Rest of the examination including fundoscopy was unremarkable. Hemoglobin was 8.3 g/dl while rest of the biochemical investigations was normal. CD4 count and plasma HIV-1 viral load after 1 month of ART was 190 cells/mm3 and 9,500 copies/ml, respectively, suggesting satisfactory immune reconstitution. The arterial blood gas (ABG) was suggestive of hypoxia (pO2-63 mm Hg) on room air. Chest X-ray was suggestive of bilateral, extensive, and patchy consolidation suggestive of infective etiology (Figure 1). Sonography of abdomen showed multiple mesenteric nodes with the largest size of 21 mm by 17 mm, grade 2 fatty liver, and dilated portal vein. The CT scan of chest revealed bilateral ground glass haziness suggestive of pneumocystis carinii pneumonia (PCP). CT abdomen showed biliary dilatation due to distal CBD stricture, mesenteric lymphadenopathy and mild diffuse thickening of the caecum, and ascending and transverse colon. 2D echocardiography of the heart was normal. Blood culture was sterile, and serum procalcitonin was normal. Keeping a provisional diagnosis of IRIS to Pneumocystis jirovecii or Mycobacterium tuberculosis in mind, she was started on high-dose trimethoprim-sulphamethoxazole (TMP-SMX), oral steroids, and empirical antitubercular therapy (ATT) in addition to ART. She had diarrhea on admission, which subsided in 2 days after taking loperamide. Stool routine and modified Ziehl-Neelsen (ZN) examination was unremarkable. Due to a suspicion of CMV enterocolitis, she was also started on empirical oral valgancyclovir. Bronchoscopy with BAL was attempted but had to be aborted in view of worsening hypoxia during procedure. For establishing diagnosis, upper GI endoscopy and colonoscopy were attempted. Upper GI endoscopy revealed diffuse gastroduodenitis. Colonoscopy showed patchy colitis. Duodenal biopsy revealed focal blunting, ulceration, and neutrophilic exudates (Figure 2). The surface epithelium showed several eggs, larvae, and adult forms of S. stercoralis (Figure 3). Lamina propria showed moderate mononuclear inflammatory infiltrate with lymphoid follicle formation and many admixed eosinophils (Figures 2 and 3). There was no evidence of tuberculosis or malignancy. Induced sputum also demonstrated larvae of S. stercoralis. As a result, diagnosis of SHS as a manifestation of IRIS was made, and she was started on an oral combination of albendazole (400 mg twice a day) and ivermectin (200 microg/kg). Inspite of antihelminthic treatment, her dyspnea worsened. Her repeat ABG showed hypoxia (PO2 -47 mm Hg, Spo2 89%) and respiratory alkalosis. She developed hypotension (blood pressure 80/60 mm Hg) and altered sensorium in the form of increasing drowsiness (Glasgow Coma Scale 12/15). She was shifted to the Intensive Care Unit (ICU) for the same. MRI brain and CSF examination were normal while serum sodium level had dropped to 125 mEq/L. Noradrenaline infusion and noninvasive BIPAP ventilation were started. She was initiated on intravenous (i.v.) meropenem, i.v. teicoplanin, and i.v. fluconazole in addition to antihelminthic agents, steroids (in tapering doses), and ART. ATT and valganciclovir were withdrawn while TMP-SMX was reduced to prophylactic dose. She gradually started improving over the next 7 days with improvement in sensorium and reduction in breathlessness. She was shifted out of the ICU by day 21 of admission. Her CXR showed complete resolution of pneumonic consolidation. She was discharged on oral antihelminthic treatment which she continued for another 8 weeks. Follow-up endoscopy studies showed complete clearance of S. stercoralis.