strongyloides stercoralis is a human intestinal nematode that is considered a common parasitic disease in tropical and subtropical areas .
it is endemic in southeast asia , africa , west indies , south america , bangladesh , and pakistan .
the ability to replicate in the human host permits autoinfection of s. stercoralis leading to chronic infection .
hyperinfection occurs when the parasite load increases and the rhabditiform larvae penetrate the bowel mucosa and finally reaches the organs normally involved in pulmonary autoinfection cycle ( gi tract , peritoneum , and lungs ) .
dissemination is defined as larva migrating to end organs not usually involving the normal life cycle of the parasite such as brain and skin .
there are very few case reports of hyperinfection or disseminated s. stercoralis infection in immunocompetent patients .
we present a case of hyperinfected s. stercoralis infection in an adult male patient presenting with respiratory symptoms .
a 48-year - old farmer from eastern part of coastal india presented to the emergency department with complaints of low - grade fever for 15 days , cough with expectoration for 10 days , and gradually increasing breathlessness for 5 days .
the patient was suffering from cough with expectoration and breathlessness on and off for the past 2 years .
he was neither a diabetic nor a hypertensive . at the time of admission , the patient was confused , irritable , cyanosed , and tachypneic .
his pulse rate was 120/min , blood pressure was 90/60 mm of hg , temperature was 101 f , respiratory rate was 30/min , and oxygen saturation was 78% .
hb - 8.8 gm / dl , tlc - 10.8  10/cmm , dc - p 72% , l 22% , e 4% , and absolute eosinophil count - 480/cmm , tpc 
rbs was 96 mg / dl , bun - 28 mg / dl , serum creatinine - 1.2 , serum na - 128 mmol / l , serum k - 3.9 mmol / l .
abg analysis revealed ph - 7.44 , paco2  32 mm hg , pao2  67 mm hg , bicarbonate  24
a provisional diagnosis of bronchopneumonia , and septic shock was made , and the patient was shifted to icu .
blood and sputum were sent for aerobic culture along with sputum gram stain and zn stain before starting the antibiotic .
chest x - ray at the time of admission revealed bilateral interstitial pattern of opacities [ figure 1 ] . on the 2 day , he developed ards and was put on mechanical ventilator .
x - ray chest showing features of ards while examining the gram stain and zn stain smears of sputum , plenty of larvae were seen [ figure 2 ] . on wet mount , plenty of actively motile larvae of s. stercoralis were found [ figures 3 and 4 ; videos 1 and 2 ] .
s. stercoralis rhabditiform larvae in sputum on zn staining s. stercoralis larvae on wet film observation of sputum sample motile rhabditiform larvae of s. stercoralis on wet film observation of sputum .
rhabditiform larva of s. stercoralis in stool sample of patient the patient 's condition gradually deteriorated inspite of adding oral ivermectol and intravenous imipenam .
s. stercoralis is a unique intestinal nematode causing chronic asymptomatic infection , hyperinfection , and dissemination due to its ability to produce autoinfection in the intestine and due to penetration of the perianal skin by the filariform larvae .
hyperinfection and dissemination syndrome usually occur in immunocompromised patients includes those undergoing steroid therapy or chemotherapy , and those with hematologic malignancy , kidney and bone marrow transplant , hiv infection , and hypogammaglobulinemia .
hyperinfection and dissemination syndrome has a very high mortality rate ( up to 87% ) .
complications of hyperinfection and disseminated disease include bacterial and fungal infections , sepsis , and meningitis .
secondary bacterial infection occurs because of the leakage of gut flora from an ulcerative bowel mucosa or as a result of bacteria carried on the surface of the larvae when they migrate into the host 's circulation .
therefore , blood cultures commonly grow escherichia coli , klebsiella pneumoniae , proteus mirabilis , pseudomonas , and enterococcus fecalis . s. stercoralis hyperinfection has been documented in immunocompetent patients very rarely .
a case has been documented from puducherry in an elderly male who presented with fever , cough , breathlessness , and pain abdomen who responded to oral ivermectol . a study from sgpgims documented 15 cases of strongyloidiasis ( 7 in immunocompromised and 8 in immunocompetent patients ) .
but , eosinophilia is often absent in hyperinfection syndrome , as in our case . in conclusion ,
besides showing gastrointestinal symptoms , it may mimic acute exacerbation of underlying copd or new - onset asthma and be complicated with gram - negative bacteremia .
therefore , stool and sputum examinations are important when the clinical picture is suspicious for s. stercoralis hyperinfection .
 s. stercoralis infection is very common in south east asian countries including india . 
 chronic infection is very common with symptoms of diarrhea , abdominal pain , nausea , vomiting , anemia , and cough . 
 hyperinfection and dissemination usually occur in immunocompromised patients with symptoms mimicking asthma , copd , or aseptic meningitis . 
 very few cases of hyperinfection and dissemination have been documented in immunocompetent patients . 
 we report this case for its rarity and future references . 
INTRODUCTION
CASE REPORT
DISCUSSION
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