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A 57-year-old male Mexican immigrant living in Dallas presented with altered mental status, progressive confusion, mild headache and fevers. He was diagnosed with embryonal liver sarcoma one year prior to admission and had recently started dexamethasone therapy for metastatic spinal lesions. Blood and cerebrospinal fluid cultures from a lumbar puncture were both positive for Escherichia coli. He was diagnosed with spontaneous gram negative rod (GNR) meningitis. Given his travel history, immunosuppression and GNR meningitis, a stool ova and parasite sample was obtained to screen for Strongyloides stercoralis. His stool was markedly positive for Strongyloides stercoralis larvae and he was further diagnosed with Strongyloides hyperinfection syndrome. Strongyloides is capable of chronically re-infecting human hosts without an external life cycle via autoinfection. In chronic infections, hyperinfection can be triggered with immunosuppressive medications, especially steroids. Disseminated Strongyloides should be considered as the source for unexplained GNR bacteremia or meningitis especially in immunosuppressed patients. Our patient likely had a chronic asymptomatic Strongyloides infection acquired in Mexico that became a hyperinfection resulting in GNR meningitis after starting high doses of dexamethasone.

A 28-year-old visiting from Central America presented with twenty-four hours of lower extremity swelling, dyspnea and orthopnea. Clinically, she was diagnosed with acute heart failure requiring inotropes with a transthoracic echocardiogram revealing severe mitral regurgitation with a normal ejection fraction. Subsequent transesophageal echocardiogram confirmed severe mitral regurgitation with aortic root dilatation (Z-score: 3.9). She was also found to have arachnodactyly, scoliosis on X-ray and severe mitral valve prolapse. Given her clinical features she was assessed for Marfan syndrome with the modified Ghent nosology systemic score and met diagnostic criteria. A FBN1 genetic test confirmed the diagnosis of Marfan syndrome discovering a frameshift mutation resulting in an inappropriate stop codon and peptide truncation. For patients presenting with heart failure at an atypical age without typical risk factors, rare conditions such as Marfan syndrome should be considered. Marfan syndrome can accurately and quickly be screened for and diagnosed using the systemic score from the modified Ghent nosology.