31 October 2008 – Case of the Week #133

 

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We thank Dr. Angela Bohlke, Tulane University Hospital, New Orleans, Louisiana (USA) for contributing this case.  To contribute a Case of the Week, email NatPernick@Hotmail.com with the clinical history, your diagnosis and diagnostic microscopic images in JPG, GIF or TIFF format (send as attachments, we will shrink if necessary). Please include any other images (gross, immunostains, etc.) that may be helpful or interesting. We will write the discussion (unless you want to), list you as the contributor, and send you $35 (US dollars) by check or PayPal for your time after we send out the case. Please only send cases with high quality images and a diagnosis that is somewhat unusual (or a case with unusual features).

 

Case of the Week #133

 

Clinical History

 

A 43 year-old Honduran man presented with diarrhea and abdominal pain for one month. Physical findings and endoscopy were unremarkable. Duodenal biopsies were obtained.


Micro images: #1; #2; #3

 

What is your diagnosis?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis:

 

Strongyloides stercoralis

 

Discussion:

 

Subsequent stool findings showed Strongyloides ova.

 

Stronglyoides is a nematode whose larvae buries into the mucosa of the duodenum and jejunum, where they mature into adults. The females then lay eggs, which develop into larvae that pass into the stool, where they mature and become infective. The infective larvae penetrate intact skin, usually through the feet. The larvae enter the circulatory system, are transported to the lungs, and enter the alveolar spaces. They then are carried to the trachea and pharynx, are swallowed, and enter the intestinal tract, where the process is repeated. If the larvae become infective before leaving the body, they may invade the intestinal mucosa or perianal skin, causing autoinfection (see life cycle).

 

Most patients suffer diarrhea, malabsorption or no symptoms. Immunocompromised individuals can acquire disseminated strongyloidiasis, a possibly fatal condition in which worms move into other organs (WormBook 2007 May 23:1).

 

Diagnosis is by stool exam, looking for larvae, or by biopsy of small intestinal mucosa, looking for the adult female or eggs. There is often granulomatous or eosinophilic inflammation. In female worms, the intestine or ovaries may be prominent (image). In gravid females, an egg (green arrow) may be identified within the uterus .

 

Treatment is with antihelminths, such as thiabendazole (Ann Pharmacother 2007;41:1992). Prevention is by wearing shoes in endemic areas.

 

 

 

 

Nat Pernick, M.D., President
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