title: Strongyloides stercoralis Hyperinfection Syndrome Presenting as Severe, Recurrent Gastrointestinal Bleeding, Leading to a Diagnosis of Cushing Disease.
abstract: A 50-year-old male immigrant from Ethiopia presented for consultation after 3 years of hematochezia/melena requiring > 25 units of blood transfusions. Physical examination revealed severe proximal muscle wasting and weakness, central obesity, proptosis, and abdominal striae, accompanied by eosinophilia, elevated hemoglobin A1c, elevated 24-hour urinary cortisol, lack of suppression of 8 am cortisol levels by 1 mg dexamethasone, and inappropriately elevated random adrenocorticotropic hormone (ACTH) level. Histopathological examination of gastrointestinal biopsies showed large numbers of Strongyloides stercoralis, indicating Strongyloides hyperinfection. Treatment with 2 days of ivermectin led to resolution of gastrointestinal bleeding. This syndrome was due to chronic immunosuppression from a pituitary ACTH (corticotroph) microadenoma, of which resection led to gradual normalization of urine cortisol, improved glycemic control, resolution of eosinophilia, and no recurrence of infection.
authors.affiliation: Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Endocrinology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Department of Pathology, University of California San Diego School of Medicine, La Jolla, California; Department of Radiology, University of California San Diego School of Medicine, La Jolla, California; Department of Neurosurgery, University of California San Diego School of Medicine, La Jolla, California; Division of Gastroenterology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Instituto de Medicina Tropical "Alexander von Humboldt," Universidad Peruana Cayetano Heredia, Lima, Peru; Departamento de Ciencias Celulares y Moleculares, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru; Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Brittany
authors.initials: B
authors.lastname: Yee
authors.affiliation: Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Endocrinology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Department of Pathology, University of California San Diego School of Medicine, La Jolla, California; Department of Radiology, University of California San Diego School of Medicine, La Jolla, California; Department of Neurosurgery, University of California San Diego School of Medicine, La Jolla, California; Division of Gastroenterology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Instituto de Medicina Tropical "Alexander von Humboldt," Universidad Peruana Cayetano Heredia, Lima, Peru; Departamento de Ciencias Celulares y Moleculares, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru; Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Nai-Wen
authors.initials: NW
authors.lastname: Chi
authors.affiliation: Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Endocrinology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Department of Pathology, University of California San Diego School of Medicine, La Jolla, California; Department of Radiology, University of California San Diego School of Medicine, La Jolla, California; Department of Neurosurgery, University of California San Diego School of Medicine, La Jolla, California; Division of Gastroenterology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Instituto de Medicina Tropical "Alexander von Humboldt," Universidad Peruana Cayetano Heredia, Lima, Peru; Departamento de Ciencias Celulares y Moleculares, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru; Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Lawrence A
authors.initials: LA
authors.lastname: Hansen
authors.affiliation: Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Endocrinology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Department of Pathology, University of California San Diego School of Medicine, La Jolla, California; Department of Radiology, University of California San Diego School of Medicine, La Jolla, California; Department of Neurosurgery, University of California San Diego School of Medicine, La Jolla, California; Division of Gastroenterology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Instituto de Medicina Tropical "Alexander von Humboldt," Universidad Peruana Cayetano Heredia, Lima, Peru; Departamento de Ciencias Celulares y Moleculares, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru; Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Roland R
authors.initials: RR
authors.lastname: Lee
authors.affiliation: Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Endocrinology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Department of Pathology, University of California San Diego School of Medicine, La Jolla, California; Department of Radiology, University of California San Diego School of Medicine, La Jolla, California; Department of Neurosurgery, University of California San Diego School of Medicine, La Jolla, California; Division of Gastroenterology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Instituto de Medicina Tropical "Alexander von Humboldt," Universidad Peruana Cayetano Heredia, Lima, Peru; Departamento de Ciencias Celulares y Moleculares, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru; Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Hoi-Sang
authors.initials: HS
authors.lastname: U
authors.affiliation: Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Endocrinology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Department of Pathology, University of California San Diego School of Medicine, La Jolla, California; Department of Radiology, University of California San Diego School of Medicine, La Jolla, California; Department of Neurosurgery, University of California San Diego School of Medicine, La Jolla, California; Division of Gastroenterology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Instituto de Medicina Tropical "Alexander von Humboldt," Universidad Peruana Cayetano Heredia, Lima, Peru; Departamento de Ciencias Celulares y Moleculares, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru; Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Savides
authors.affiliation: Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Endocrinology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Department of Pathology, University of California San Diego School of Medicine, La Jolla, California; Department of Radiology, University of California San Diego School of Medicine, La Jolla, California; Department of Neurosurgery, University of California San Diego School of Medicine, La Jolla, California; Division of Gastroenterology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California; Instituto de Medicina Tropical "Alexander von Humboldt," Universidad Peruana Cayetano Heredia, Lima, Peru; Departamento de Ciencias Celulares y Moleculares, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru; Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Peru jvinetz@ucsd.edu.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Vinetz
mesh_terms: D000208:Acute Disease; D000818:Animals; D000871:Anthelmintics / Q000627:therapeutic use; D006471:Gastrointestinal Hemorrhage / Q000209:etiology* / Q000469:parasitology; D006801:Humans; D016867:Immunocompromised Host / Q000276:immunology; D007559:Ivermectin / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D047748:Pituitary ACTH Hypersecretion / Q000150:complications / Q000175:diagnosis* / Q000276:immunology / Q000469:parasitology / Q000473:pathology; D010903:Pituitary Gland, Anterior / Q000473:pathology; D017171:Strongyloides stercoralis; D013322:Strongyloidiasis / Q000150:complications / Q000175:diagnosis*
chemical_list: D000871:Anthelmintics; D007559:Ivermectin