Strongyloides stercoralis Hyperinfection Presenting As Ascending Cholangitis and Escherichia coli Bacteremia in a Patient With Metastatic Pancreatic Cancer

<i>Strongyloides stercoralis</i> is a nematode capable of persisting in humans for years to decades, or even lifelong, through an autoinfection cycle. In immunocompromised individuals, this can lead to uncontrolled proliferation and hyperinfection syndrome. We report the case of a 56-year-old Jamaican man with metastatic pancreatic cancer status post-Whipple procedure who presented with fever, sepsis, and signs of ascending cholangitis. Imaging revealed the progression of hepatic metastases, biliary obstruction, and new intrahepatic cystic lesions. Blood cultures grew <i>Escherichia coli</i>, and bile cultures unexpectedly revealed motile <i>S. stercoralis</i> larvae, confirming hyperinfection. Notably, the patient had no eosinophilia. He was treated with a two-week course of ivermectin and albendazole, along with intravenous antibiotics. Given the altered gastrointestinal anatomy from prior surgery, we propose that larvae accessed the biliary system via the choledochojejunostomy. While biliary involvement was present, the migration pathway was anatomically continuous, and this presentation was considered hyperinfection rather than disseminated disease. This case underscores the importance of considering strongyloidiasis in immunocompromised patients with sepsis of unclear origin, even when eosinophilia is absent, given the high morbidity and mortality associated with hyperinfection.