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Infectious Diseases Unit, Civile Maggiore Hospital, and Section of Infectious Diseases, Department of Pathology, University of Verona, Verona, Italy
In their recent article [1], Viney et al. showed that relatively preserved immune function in HIV-1infected individuals favors disseminated strongyloidiasis and proposed longitudinal studies of the effect of highly active antiretroviral therapyinduced immune restoration on the development of helminths. We report one case that may shed some light on this thesis.
A 60-year-old HIV-1infected man from Eritrea was examined during March 2003, to investigate his progressive loss of weight during the past 6 months. He had never had any opportunistic infection or malignancy. His CD4 cell count was 135 cells/mL (11.5% of total lymphocytes), and his plasma HIV-RNA level was 342,978 copies/mL. He was leukopenic and had both absolute (930 cells/mL) and relative (13% of white blood cells ) increases in eosinophils. Four examinations of stool specimens did not show helminths; results of chest x-ray and abdominal ultrasound were normal. Antiretroviral therapy with zidovudine, lamivudine, and abacavir and primary prophylaxis with cotrimoxazole were started.
On 1 May 2003, the patient was again admitted to our unit, with a 10-day history of nausea, vomiting, weakness, epigastric pain, diarrhea, and itching. Eosinophils had considerably increased in peripheral blood (1820 cells/mL; 41% of WBCs), and mild anemia was present. His CD4 cell count had increased to 368 cells/mL (22.9% of total lymphocytes), and his HIV-RNA level had decreased to 1208 copies/mL. Four days later, the patient was febrile and had a cough. Results of chest x-ray showed bilateral pulmonary infiltrates, Escherichia coli was present in blood cultures, and numerous larvae of Strongyloides stercoralis were found in stool specimens. Treatment with ceftriaxone and thiabendazole was started. After 10 days of treatment, the patient was afebrile and asymptomatic. Examination of stool specimens collected for 6 consecutive days did not show any helminths.
In conclusion, in our patient, antiretroviral therapyinduced immune restoration was associated with dissemination of S. stercoralis. We recommend careful monitoring for this infection in HIV-1infected individuals receiving antiretroviral therapy who live in or come from countries where this organism is endemic.
Reference
1. Viney ME, Brown M, Omoding NE, et al. Why does HIV infection not lead to disseminated strongyloidiasis J Infect Dis 2004; 190:217581. First citation in article