A 56-year-old woman with rash, paralytic ileus, and massive gastrointestinal bleeding.

Figure 1. Diffuse maculopapular rash that appeared simultaneously with high fever, progressive abdominal distention, and massive gastrointestinal bleeding. Diagnosis: Strongyloides stercoralis hyperinfection syndrome in a patient with human T lymphotropic virus type 1 (HTLV-1) infection. The duodenal sample obtained through a nasogastric tube showed multiple filariform larvae of Strongyloides stercoralis (figure 1; figure 2). Enzyme-linked immunosorbent assay (ELISA) test for toxins of Clostridium difficile had negative results, and stool cultures for bacteria showed no growth. Cultures of blood samples obtained during the abdominal catastrophe were positive for Escherichia coli. Strongyloidiasis is a parasitic disease that is caused by the soil-transmitted nematode S. stercoralis, which is estimated to affect almost 300 million people worldwide. Once infected, humans may harbor the parasite for decades. Most of the infections due to S. stercoralis are asymptomatic or mildly symptomatic. However, in the presence of immunosuppressive conditions (such as high-dose steroid use, use of cytotoxic drugs, malignancies, human immunodeficiency virus infection, malnutrition , and more recently, HTLV-1 infection), an autoin-fective cycle may ensue that amplifies the infection and leads to the hyperinfection syndrome [1]. Multiple erosions in the colonic mucosa result from the migration of the filariform larva across the intestinal wall and may induce massive bleeding , which is associated with significant mortality [2]. The family history of T cell leukemia lymphoma in this patient raised the suspicion of HTLV-1 infection, which was confirmed by means of an ELISA and Western blot tests. The patient recalled that her sister had also been infected with HTLV-1. Further evaluation of her relatives revealed that 2 of her 3 sons were also HTLV-1 positive, as were 3 of her 5 brothers. Acquisition through breast feeding may explain the high attack rate of infection observed in this family. A marked T cell activation with predominance of Th1 response (characterized by increased production of interferon g and tumor necro-Figure 2. Multiple filariform larvae of Strongyloides stercoralis are observed in the duodenal sample. sis factor a) over Th2 response (characterized by production of interleukin [IL]–4, IL-5, IL-10, and IL-13, high eosinophil response, and elevated levels of immunoglobulin E) is the immunological hallmark of HTLV-1 infection [3]. The blunted Th2 response observed in patients with HTLV-1 infection is associated with severe helminthic infections, in particular with S. stercoralis infection. The association between HTLV-1 infection and S. stercoralis was recognized initially in Japan 12 decades ago [4], with further recognition in other …