Navin Kuthiah BM, MSc(Diabetes and Endocrinology), MRCPE is an Internal Medicine Consultant at Woodlands Health Campus, Singapore. He has special interests in endocrinology and peri-operative medicine. He is also a core tutor for Lee Kong Chian School of Medicine, Singapore.
Haemoptysis And Pulmonary Strongyloidiasis
A 69-year-old Chinese gentleman with significant past medical history of hypertension and Stiffman syndrome presented to our hospital with 3 days of fever and cough. He was febrile and hypotensive at the emergency department. With antibiotic, dopamine infusion and hydrocortisone support, he recovered from the septic shock. On day 5 of admission he developed an episode of massive haemoptysis (200ml of fresh blood) and desaturation. Computed tomography (CT) of chest and CT pulmonary angiogram showed widespread bilateral lung ground glass changes and no evidence of pulmonary embolism. He was transferred to the high dependency unit. Blood culture, sputum culture and sputum acid fast bacilli stain were all negative. Bronchoscopy did not identify any mass. His bronchoalveolar lavage sample grew E. coli. Antineutrophil cytoplasmic antibodies (ANCA) were negative. Strongyloides stercoralis was however identified in his sputum but not in his stool. Our infectious disease physicians recommended a course of Ivermectin and Albendazole. Patient made an uneventfult recovery.
Haemoptysis can be caused by pulmonary infections, infarct, neoplasm, vasculitis, pulmonary hypertension, arteriovenous malformation and many other causes. Management includes immediate stabilisation focusing on airway, breathing, circulation and treating the underlying cause. To identify the cause of bleeding, basic coagulation profile, autoantibodies, chest X-ray, CT chest, CT pulmonary angiogram and bronchoscopy are important investigations.
Strongyloidiasis is common in tropical regions. Most infected patients are asymptomatic. Our patient was considered immunocompromised as he was on long term steroid for his Stiffman syndrome. Hyperinfection syndrome happens when there is dissemination of larvae to other organs of the infected patients. In our patient, the pulmonary strongyloidiasis led to the massive haemoptysis. He responded well to Ivermectin and Albendazole.
Pulmonary strongyloidiasis should be considered as a cause of haemoptysis in immunocompromised patients in the tropical regions.