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S stercoralis is an intestinal parasite that normally causes a chronic, low-grade, mostly asymptomatic infection. Hyperinfection syndrome and dissemination, with secondary sepsis, may occur in immunosuppressed patients, especially those on corticosteroid therapy. We present a case of fatal strongyloidiasis occurring in a patient 1 month after orthotopic heart transplantation (OHT). We assess the diagnostic challenges in these patients where pulmonary and gastrointestinal symptoms predominate as presenting clinical manifestations. We also investigate the role of screening and prophylactic anti-helmintic therapy in patients at high risk of harboring the occult intestinal infection. [Copyright &y& Elsevier]