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CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 2  |  Page : 127-129

A case report of Strongyloides stercoralis duodenitis in an immunocompromised patient


Department of Pathology, Super Speciality Hospital & GMC, Nagpur, Maharashtra, India

Date of Submission27-Feb-2015
Date of Acceptance06-Jul-2015
Date of Web Publication27-Jan-2016

Correspondence Address:
Archana Randale
MBBS, DPB, DNB (Pathology), 301, Siddhesh-Pratiksha, 29 Ganesh Colony, Ring Road, Pratap Nagar, Nagpur 440022, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7942.175011

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  Abstract 

Strongyloides stercoralis can cause hyperinfection syndrome and disseminated disease with high mortality, particularly in an immunocompromised patient. With the low diagnostic rate of S. stercoralis on stool examination, early endoscopic biopsy and histopathologic diagnosis of strongyloidiasis must be taken into consideration when examining duodenal biopsies from immunocompromised patients, to avoid the development of life-threatening infection.

Keywords: duodenal biopsy, immunocompromised host, stool examination, Strongyloides stercoralis, strongyloidiasis


How to cite this article:
Randale A, Dani A, Chawhan S, Meshram S, Tathe S, Kumbhalkar D. A case report of Strongyloides stercoralis duodenitis in an immunocompromised patient. Parasitol United J 2015;8:127-9

How to cite this URL:
Randale A, Dani A, Chawhan S, Meshram S, Tathe S, Kumbhalkar D. A case report of Strongyloides stercoralis duodenitis in an immunocompromised patient. Parasitol United J [serial online] 2015 [cited 2021 May 12];8:127-9. Available from: http://www.new.puj.eg.net/text.asp?2015/8/2/127/175011


  Introduction Top


Strongyloides stercoralis is an intestinal nematode that infects about 100 million people worldwide and is a common cause of abdominal pain and diarrhea [1] . The true prevalence of S. stercoralis is likely underestimated because infection is often subclinical. Only few cases have been reported from India, where its prevalence appears to be low [2] . Strongyloidiasis is a chronic and limited disease; however, in immunocompromised patients, hyperinfection syndrome and disseminated disease can occur [3] . Diagnosing strongyloidiasis early is important, as a high rate of mortality and morbidity is associated with S. stercoralis hyperinfection or disseminated disease [3],[4],[5] . As S. stercoralis colonize in the duodenum, implementation of endoscopy and histopathologic evaluation of biopsies is important for the diagnosis of strongyloidiasis [5] . Here, we report a case of an immunocompromised patient with involvement of the duodenum by S. stercoralis.


  Case history Top


A 28-year-old man, a known case of Hansen's disease with erythema nodosum leprosum, not responding to treatment with steroids since 2 years, was referred to the Gastroenterology Department for further evaluation as he complained of vague abdominal pain and vomiting since 1 month. On general examination, the patient was afebrile. Systemic examination, including abdominal examination, was unremarkable. His complete blood count was unremarkable. He was subjected to endoscopy with proper written informed consent. Endoscopy revealed a small whitish patch in the second part of the duodenum. Clinical diagnosis of malabsorption syndrome was considered. Multiple biopsies were taken from the lesion and subjected to routine histopathological examination. Hematoxylin and eosin-stained sections showed S. stercoralis larvae, several eggs, and adult worms located in the crypts and within glands ([Figure 1] and [Figure 2]). The lamina propria showed inflammatory infiltration comprising eosinophils, lymphocytes, and plasma cells. The case was diagnosed as chronic duodenitis due to strongyloidiasis. Corresponding stool examination for S. stercoralis larvae was negative.
Figure 1: Several e ggs and larvae present in crypts (×10).

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Figure 2: Rhabditoid larva seen within glands along with infl ammatory infiltrate (×100).

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  Discussion Top


S. stercoralis is a parasite that is very prevalent in the tropical and subtropical regions of the world [6],[7],[8] . Humans are generally infected transcutaneously with filariform larvae from the soil. The infection is usually asymptomatic but can present with cutaneous, gastrointestinal, or pulmonary symptoms. Eosinophillia may be the only sign, but eosinophilic count is not a reliable indicator of parasitic infections [9] .

The eosinophilic blood count in our patient was not high, possibly due to the prolonged corticosteroid therapy, but eosinophils were involved in the local inflammatory response. Strongyloidiasis is particularly important in immunocompromised patients receiving immunosuppressive drugs such as corticosteroids and chemotherapy for cancer and hematologic malignancies and also in those with organ transplantation, human T lymphotropic virus type 1, and HIV infections. Under such immunocompromising conditions the filariform larvae can be disseminated by autoinfection and progress to hyperinfection syndrome or disseminated strongyloidiasis [5] . Corticosteroids not only have a well-known effect on impairing human immunity but also directly induce female worms to increase the output of infective larvae with a structural similarity to larval ecdysteroids [4],[5] .

In the hyperinfection syndrome, the classic life cycle of S. stercoralis from skin to lungs and gastrointestinal tract is accelerated with increased reproduction leading to excessive worm burden, whereas in disseminated strongyloidiasis, there is a widespread dissemination of larvae outside the gut and lungs, often involving the liver, brain, heart, and urinary tract [10],[11],[12],[13] . Our patient who was also on steroid therapy for the last 2 years suffered from hyperinfection. Definitive diagnosis of strongyloidiasis is generally made based on detection of larvae in stool, sputum, and duodenal fluid/biopsy. However, strongyloidiasis is difficult to diagnose only on stool examination as the parasite load is low and the larval output is irregular in the majority of patients [14] . Although most studies focus on finding the parasite by means of stool examination, single stool examinations are unrewarding in up to 50-70% of cases [15] . Even after three stool examinations, positivity does not exceed 46% [10],[15] . Endoscopic evaluation has been recognized to be an important tool for diagnosing strongyloidiasis, as worms and their maturing larvae colonize in the duodenum [5] . Thus, this procedure is the most sensitive diagnostic technique for strongyloidiasis, with a false-negative frequency less than 10% [10] . Duodenal biopsies were able to establish a diagnosis when the stool analysis was negative in 24% of patients, thus avoiding exposure to a fatal outcome [5] . Moreover, in our patient, various stages of S. stercoralis were found colonizing in the crypts and glands of the duodenal biopsy, in the presence of negative single stool examination. The clinical presentation of hyperinfection syndrome is consistent with classic strongyloidiasis, which includes nausea, vomiting, diarrhea, weight loss, abdominal pain, gastrointestinal hemorrhage, cough, fever, and dyspnea [6],[7],[8],[10],[11],[12],[13],[16],[17],[18],[19],[20] . Because the clinical presentation of hyperinfection syndrome is similar to classic strongyloidiasis, the condition may be easily ignored by both the patient and physician [4] . As hyperinfection syndrome and disseminated disease can rapidly become fatal, early diagnosis and treatment is very important.

To conclude the diagnosis of strongyloidiasis may be made by means of stool examination. However, with the low diagnostic rate of this tool, a high degree of suspicion is required when examining duodenal biopsies, particularly those obtained from immunocompromised patients, to avoid autoinfection/hyperinfection syndrome and disseminated disease, which can be life-threatening.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Concha R, Harrington W Jr, Rogers AI. Intestinal strongyloidiasis: recognition, management, and determinants of outcome. J Clin Gastroenterol 2005; 39:203-211.  Back to cited text no. 1
    
2.
Murthy VS, Geethamala K, Kumar BD, Rao MS. Strongyloidiasis of duodenum clinically masquerading as gastric malignancy. Ann Trop Med Public Health 2013; 6:248-250.  Back to cited text no. 2
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Shafaghi A, Askari K, Hajizadeh H, Mansour-Ghanaei F. Gastric strongyloidiasis as multiple small gastric nodules. Am J Case Rep 2012; 13:7-10.  Back to cited text no. 3
    
4.
Kakati B, Dang S, Heif M, Caradine K, McKnight W, Aduli F. Strongyloides duodenitis: case report and review of literature. J Natl Med Assoc 2011; 103:60-63.  Back to cited text no. 4
    
5.
Kishimoto K, Hokama A, Hirata T, Ihama Y, Nakamoto M, Kinjo N, et al. Endoscopic and histopathological study on the duodenum of Strongyloides stercoralis hyperinfection. World J Gastroenterol 2008; 14:1768-1773.  Back to cited text no. 5
    
6.
Liu LX, Weller PF. Strongyloidiasis and other intestinal nematode infections. Infect Dis Clin North Am 1993; 7:655-682.  Back to cited text no. 6
    
7.
Roxby AC, Gottlieb GS, Limaye AP. Strongyloidiasis in transplant patients. Clin Infect Dis 2009; 49:1411-1423.  Back to cited text no. 7
    
8.
Thompson BF, Fry LC, Wells CD, Olmos M, Lee DH, Lazenby AJ, et al. The spectrum of GI strongyloidiasis: an endoscopic-pathologic study. Gastrointest Endosc 2004; 59:906-910.  Back to cited text no. 8
    
9.
Agrawal V, Agrawal T, Ghoshal UC. Intestinal strongyloidiasis: a diagnosis frequently missed in the tropic. Trans R Soc Trop Med Hyg 2009; 103:242-246.  Back to cited text no. 9
    
10.
Ganesh S, Cruz RJ Jr. Strongyloidiasis: a multifaceted disease. Gastroenterol Hepatol (N Y) 2011; 7:194-196.  Back to cited text no. 10
    
11.
Marcos LA, Terashima A, Dupont HL, Gotuzzo E. Strongyloides hyperinfection syndrome: an emerging global infectious disease. Trans R Soc Trop Med Hyg 2008; 102:314-318.  Back to cited text no. 11
    
12.
Asdamongkol N, Pornsuriyasak P, Sungkanuparph S. Risk factors for strongyloidiasis hyperinfection and clinical outcomes. Southeast Asian J Trop Med Public Health 2006; 37:875-884.  Back to cited text no. 12
    
13.
Pirisi M, Salvador E, Bisoffi Z, Gobbo M, Smirne C, Gigli C, et al. Unsuspected strongyloidiasis in hospitalised elderly patients with and without eosinophilia. Clin Microbiol Infect 2006; 12:787-792.  Back to cited text no. 13
    
14.
Ardic N. An overview of Strongyloides stercoralis and its infections. Mikrobiyol Bul 2009; 43:169-177.  Back to cited text no. 14
    
15.
Martín-Dávila P, Fortún J, López-Vélez R, Norman F, Montes de Oca M, Zamarrón P, et al. Transmission of tropical and geographically restricted infections during solid-organ transplantation. Clin Microbiol Rev 2008; 21:60-96.  Back to cited text no. 15
    
16.
Fardet L, Généreau T, Poirot JL, Guidet B, Kettaneh A, Cabane J. Severe strongyloidiasis in corticosteroid-treated patients: case series and literature review. J Infect 2007; 54:18-27.  Back to cited text no. 16
    
17.
Porto AF, Neva FA, Bittencourt H, Lisboa W, Thompson R, Alcântara L, et al. HTLV-1 decreases Th2 type of immune response inpatients with strongyloidiasis. Parasite Immunol 2001; 23:503-507.  Back to cited text no. 17
    
18.
Schaeffer MW, Buell JF, Gupta M, Conway GD, Akhter SA, Wagoner LE. Strongyloides hyperinfection syndrome after heart transplantation: case report and review of the literature. J Heart Lung Transplant 2004; 23:905-911.  Back to cited text no. 18
    
19.
Berry AJ, Long EG, Smith JH, Gourley WK, Fine DP. Chronic relapsing colitis due to Strongyloides stercoralis. Am J Trop Med Hyg 1983; 32:1289-1293.  Back to cited text no. 19
    
20.
Genta RM. Global prevalence of strongyloidiasis: critical review with epidemiologic insights into the prevention of disseminated disease. Rev Infect Dis 1989; 11:755-767.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2]


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