1393: Donor-Derived Strongyloidiasis in a Post-Heart Transplant Patient With Neurologic Recovery

Introduction: Disseminated strongyloidiasis is a rare hyperinfection syndrome most commonly seen in immunosuppressed patients, including transplant recipients. Neurological manifestations of strongyloidiasis vary significantly, and are often diagnosed post-mortem with variable evidence for improvement. We present a case of donor-derived strongyloidiasis with severe manifestations after orthotopic heart transplant (OHT) in a patient with no relevant personal history. The timing of post-transplant infection, severe disease course, and subsequent recovery make this case unique. We outline novel approaches to anthelmintic treatment and monitoring, advocate for more rigorous donor/recipient testing, and show that severe neurological manifestations can improve. Description: An 18-year-old female status post orthotopic heart transplant five months prior presented with two weeks of epigastric pain, nausea and weight loss. She exhibited progressive hypoxemic respiratory failure and profound anemia. The patient had a rapid decompensation with diffuse alveolar hemorrhage, cerebral edema, multi-organ failure, and hypotension requiring intubation, ECMO and continuous hemodialysis. Plasma metagenomics testing showed Strongyloides stercoralis, later found to have derived from donor, not recipient. The patient had contraindications to oral ivermectin, so the Food and Drug Administration granted emergency approval for subcutaneous ivermectin. A parasitology expert guided treatment and a third-party lab monitored drug levels. The patient had minimal to no purposeful movements off all sedating medications for weeks. After three months, patient began to show recovery of mental status, returning to near-baseline with rehabilitation. Discussion: Diagnosis and management of disseminated strongyloides poses a challenge in the absence of trials. This case illustrates that donor-derived Strongyloides can manifest after the initial three months post-transplant. Strongyloidiasis should be considered in any transplant patient, as organ procurement organizations have varying testing practices. Subcutaneous ivermectin was successfully used as salvage therapy despite no current treatment or monitoring guidelines. Our case also describes recovery to neurological baseline after severe manifestations were thought to be irreversible.