Strongyloides stercoralis eosinophilic granulomatous enterocolitis

Inflammatory bowel disease vs strongyloidiasis

We report the case of a 38-year-old woman with a 10-year history of ulcerative proctosigmoiditis. Two months after traveling to Morocco, she developed gastrointestinal symptoms accompanied by eosinophilia in blood tests. Four months later, she progressed to systemic illness with pulmonary involvement. A colonoscopy revealed aphthous ileitis with nonspecific histology suggestive of Crohn's Disease (CD). Ultimately, serology confirmed Strongyloides stercoralis infection. Strongyloidiasis is underdiagnosed in Spain, and its differentiation from CD presents a diagnostic challenge.

Strongyloidiasis

Strongyloidiasis is a neglected tropical disease caused primarily by the roundworm Strongyloides stercoralis. Strongyloidiasis is most prevalent in Southeast Asia and the Western Pacific. Although cases have been documented worldwide, global prevalence is largely unknown due to limited surveillance. Infection of the definitive human host occurs via direct skin penetration of the infective filariform larvae. Parasitic females reside in the small intestine and reproduce via parthenogenesis, where eggs hatch inside the host before rhabditiform larvae are excreted in faeces to begin the single generation free-living life cycle. Rhabditiform larvae can also develop directly into infectious filariform larvae in the gut and cause autoinfection. Although many are asymptomatic, infected individuals may report a range of non-specific gastrointestinal, respiratory or skin symptoms. Autoinfection may cause hyperinfection and disseminated strongyloidiasis in immunocompromised individuals, which is often fatal. Diagnosis requires direct examination of larvae in clinical specimens, positive serology or nucleic acid detection. However, there is a lack of standardization of techniques for all diagnostic types. Ivermectin is the treatment of choice. Control and elimination of strongyloidiasis will require a multifaceted, integrated approach, including highly sensitive and standardized diagnostics, active surveillance, health information, education and communication strategies, improved water, sanitation and hygiene, access to efficacious treatment, vaccine development and better integration and acknowledgement in current helminth control programmes.

Non-clostridium difficile induced pseudomembranous colitis

Pseudomembranous colitis is severe inflammation of the inner lining of the colon due to anoxia, ischemia, endothelial damage, and toxin production. The majority of cases of pseudomembranous colitis are due to Clostridium difficile. However, other causative pathogens and agents have been responsible for causing a similar pattern of injury to the bowel with the endoscopic appearance of yellow-white plaques and membranes on the mucosal surface of the colon. Common presenting symptoms and signs include crampy abdominal pain, nausea, watery diarrhea that can progress to bloody diarrhea, fever, leukocytosis, and dehydration. Negative testing for Clostridium difficile or failure to improve on treatment should prompt evaluation for other causes of pseudomembranous colitis. Bacterial infections other than Clostridium difficile, Viruses such as cytomegalovirus, parasitic infections, medications, drugs, chemicals, inflammatory diseases, and ischemia are other differential diagnoses to look out for in pseudomembranous colitis. Complications of pseudomembranous colitis include toxic megacolon, hypotension, colonic perforation with peritonitis, and septic shock with organ failure. Early diagnosis and treatment to prevent progression are important. The central perspective of this paper is to provide a concise review of the various etiologies for pseudomembranous colitis and management per prior literature.

Inflammatory bowel disease later diagnosed as strongyloides colitis in migrants to Canada: a case series

Strongyloides colitis is a gastrointestinal manifestation of the parasitic infection, Strongyloides stercoralis, which may be misdiagnosed and treated as ulcerative colitis (UC) in patients presenting in non-endemic regions. Treatment of Strongyloides colitis as UC can lead to a lethal hyperinfection syndrome. Therefore, prior to commencing immunosuppressive treatment of UC, it is essential to use diagnostic markers to differentiate the two etiologies. In this case series, we discuss two migrant patients who were previously diagnosed with UC and treated accordingly who presented to our clinic for further investigation of suspected parasitic infection.

A case report: Severe disseminated infection caused by Strongyloides stercoralis in an immunocompromised patient by metagenomic next-generation sequencing

Background

Strongyloides stercoralis (S. stercoralis) is a nematode that is widely distributed in the tropical and subtropical regions of the world and which can cause severe disseminated infection in immunocompromised individuals. However, strongyloidiasis, the disease caused by S. stercoralis, is difficult to diagnose because of its non-specific clinical presentation and the inadequate performance of conventional diagnostic methods.

Case description

We report the case of a 75-year-old male patient with severe disseminated infection caused by S. stercoralis. The patient had a medical history of seasonal bronchitis and, as a consequence, had taken prednisone for many years. Initial clinical tests failed to detect any pathogens, but metagenomic next-generation sequencing (mNGS) resulted in the identification of S. stercoralis in the patient's bronchoalveolar lavage fluid (BALF) and blood. Subsequently, routine testing repeatedly detected nematode larvae in the patient's stool and sputum. Through a combination of mNGS results and clinical symptoms, the patient was finally diagnosed with severe disseminated infection caused by S. stercoralis.

Conclusion

The clinical manifestations of disease caused by infection with S. stercoralis are not specific; therefore, early and accurate diagnosis is very important. mNGS can detect S. stercoralis even when it is present at only a low level. This case report supports the notion that mNGS is a valuable tool in the diagnosis of severe disseminated infections caused by S. stercoralis in immunocompromised patients.

Strongyloidiasis: what every gastroenterologist needs to know

Strongyloidiasis is caused by the intestinal roundworm, Strongyloides stercoralis, which has the potential for fatal outcome. It may present with vague gastrointestinal symptoms and mimic gastrointestinal diseases such as inflammatory bowel disease, and as such, it should be in the purview of the gastroenterologist. While strongyloidiasis is generally asymptomatic or produces mild symptoms in patients with an intact immune system, individuals who are immunocompromised may develop life-threatening disease through hyperinfection syndrome and disseminated disease. The worm has a complex lifecycle and is able to autoinfect its host, thereby allowing indefinite persistence even decades after initial infection. This leads to cases where travelers, and those who lived in endemic countries, may present years after travel. With its features of prolonged infection, relatively high global prevalence, and potential for fatal outcomes, it is imperative for all clinicians to be aware of this disease. Owing to its involvement with the gastrointestinal system, however, we will outline salient points about strongyloidiasis for the gastroenterologist.

Strongyloides stercoralis colitis in a patient positive for human T-cell leukaemia virus with rheumatoid arthritis during an anti-rheumatic therapy: a case report

An elderly woman with rheumatoid arthritis (RA) presented with a chief complaint of abdominal pain and diarrhoea while undergoing treatment with low-dose corticosteroids and abatacept. Endoscopic and histopathological findings revealed manifestations of ulcerative colitis (UC). An intermediate dose of corticosteroids and 5-aminosalicylic acid were administered. Abatacept was discontinued; the anti-TNF biologic, golimumab, was administered for treatment of both RA and UC. However, colitis worsened in response to this therapeutic regimen. Colonoscopy revealed severe mucosal lesions; larvae were detected in samples taken from multiple shallow mucosal ulcers. The patient was diagnosed with Strongyloides stercoralis colitis based on the results of an anti-parasite antibody test and examination of the larval DNA. Furthermore, serology revealed a positive test for antibodies against human T-cell leukaemia virus type 1 (HTLV-1). Immunosuppressive treatment was terminated; ivermectin was administered, which resulted in improvements in colitis symptoms within a few weeks. There are several published reports describing S. stercoralis colitis as a lethal mimic of UC. Corticosteroid and anti-TNF therapies have been reported as among the major risk factors associated with strongyloidiasis in patients with HTLV-1 infection. Therefore, HTLV-1 and Strongyloides infections may be considered in cases of new-onset gastrointestinal symptoms during immunosuppressive therapy, particularly in HTLV-1-endemic regions.

Strongyloides stercoralis Hyper infection Syndrome

Strongyloides stercoralis is a helminth, widely distributed in tropical and subtropical countries. Its infestation in humans usually does not produce symptoms. However, in some patients, severe and life-threatening forms of this infection can occur, especially in immunocompromised individuals. Severe parasitic infection is triggered by any imbalance in the host’s immunity favouring the auto-infective cycle. This results in an increase in the intraluminal parasitic burden. In addition, tissue infestation is also very common. Clinical presentation is variable, and it is very difficult to diagnose clinically. Diagnosis requires a high index of suspicion. In some cases, the diagnosis is established only on histopathological examination of the excised tissue by the pathologist. Here, the authors report a case of an elderly male diabetic patient, who presented to the emergency department with the features of acute abdomen. On exploratory laparotomy, he was found to have the features suggestive of gangrene of small bowel. Resection of the gangrenous bowel was done, and end-to-end anastomosis was done as the rest of the bowel appeared to be normal. However, the patient died of multi-organ failure and septicaemia on the second postoperative day. The resected intestine showed tissue infestation of Strongyloides stercoralis on histopathological examination. In this review article, the authors summarize a case of hyper infection syndrome of strongyloidiasis and discuss the various aspects of Strongyloides stercoralis infection with emphasis on life cycle of the parasite and different clinical features of the disease.

Granulomas in the gastrointestinal tract: deciphering the Pandora's box

Granulomas are organised collection of activated histiocytes induced by a persistent antigen stimulus. A wide variety of antigens encountered by the gastrointestinal tract are of this nature and hence the resulting granulomatous inflammation represents a tissue reaction pattern. The potential causes can be broadly classified as infections or non-infectious immune reactions. There is also a group where a cause is never identified. Granulomas may be of varying morphological appearance, most commonly epithelioid, foreign body type, suppurative and necrotizing. This may provide a clue as to the aetiology; however, in most cases, the cause requires further inquiry. Pathologists may need to cut deeper levels to look for foreign material and apply special stains to look for microorganisms. Pathologists also need to be certain that the process is a true granuloma and not a mimic. The site of occurrence in the gastrointestinal tract and the clinical setting is often paramount in establishing the aetiology. For instance, infections are more likely the cause in developing countries or when there is immunosuppression. Similarly, granulomas in the stomach are usually due to Crohn's disease; however, it is only rarely the cause of granulomas isolated to the appendix.

Strongyloides Colitis as a Harmful Mimicker of Inflammatory Bowel Disease

Autoinfection caused by Strongyloides stercoralis frequently becomes a life-long disease unless it is effectively treated. There is overlapping histomorphology between Strongyloides colitis and inflammatory bowel disease; a low index of suspicion can lead to misdiagnosis and fatal consequences. We present a case of Strongyloides colitis mimicking the clinical and pathologic features of inflammatory bowel disease. A 64-year-old female presented to the emergency department with a four-day history of abdominal pain, diarrhea, and hematochezia. Colonoscopy revealed diffuse inflammation suggestive of inflammatory bowel disease, which led to initiation of 5-aminosalicylic acid and intravenous methylprednisolone. Biopsies of the colon revealed increased lymphoplasmacytic infiltrate of the lamina propria with eosinophilic microabscesses and presence of larvae, consistent with Strongyloides stercoralis. Immunosuppressive medication was halted. The patient ultimately died a few days later. This case emphasizes the importance of identifying the overlapping clinical and pathologic features of Strongyloides colitis and inflammatory bowel disease. A high index of suspicion and recognition of particular histological findings, including eosinophilic microabscesses, aid in the correct diagnosis. Definitive diagnosis is crucial as each disease carries distinct therapeutic implications and outcome.

Eosinophilic Enteritis Due to Anisakis: A Call for Pathologists' Attention

Anisakis simplex, a common parasite of the fish we eat, can cause eosinophilic enteriis by direct parasitization. The authors describe six cases of intestinal anisakiasis dignosed by morphologic and immunologic studies in vivo and in vitro, five being retospective cases of unclassified eosinophilic enteritis. All patients presented with symptoms of acute abdomen requiring urgent surgery. They all had segmental lesions in the jejunum and/or ileum. Histologically the authors observed eosinophilic miroabscesses; in two cases Anisakis larvae were found. None of the patients declared having eaten raw fish. The surgical pathologist plays a basic role in detecting this disase, although additional serologic investigation of anti-Anisakis IgE and a skin test should be done whenever possible.

IBD or strongyloidiasis?

INTRODUCTION

Strongyloides has been shown to infrequently mimic inflammatory bowel disease (IBD) or to disseminate when a patient with IBD and unrecognized strongyloides is treated with immunosupression.

CASE REPORT

A man from Ecuador, living in Spain for years, with a history of type 2 diabetes mellitus and psoriasis treated with topical corticosteroids, was admitted to the hospital with an 8-month history of diarrhoea. Blood tests showed hyperglycemia, hyponatremia, elevated CRP and faecal calprotectin. Colonoscopy suggested IBD. The patient improved with steroids, pending biopsy results, and he was discharged. Biopies were compatible with IBD, but careful examination revealed strongyloides. He was given a prescription of albendazole. He had to be readmitted due to SIADH, which resolved with fluid restriction. Upon discharge albendazole was prescribed again. The patient skipped most of the out-patient-clinic visits. He returned a year later on 10 mg/week methotrexate, asymptomatic, with 20% eosinophilia, and admitting he had never taken the strongyloides treatment for economical reasons. He then received a week of oral albendazol at the hospital. Biopsies and blood cell count were afterwards normal (eosinophils 3.1%) and serology for strongyloides antibodies was negative.

DISCUSSION

This case is of interest for four rarely concurring reasons. It´s a worm infection that mimics IBD; the infection was diagnosed by colon biopsy; the infection caused a SIADH; and, most interestingly, even though the patient is on immunosupression, he remains asymptomatic.

Strongyloides stercoralis hyperinfection syndrome: a case series and a review of the literature

BACKGROUND

Strongyloides stercoralis may lead to overwhelming infestation [Strongyloides hyperinfection syndrome (SHS)]. We aimed at describing a case series of patients admitted in intensive care unit (ICU) with SHS and report a literature review of such cases.

PATIENTS AND METHODS

Retrospective multicenter study of 11 patients admitted to the ICU of tertiary hospitals with SHS between 2000 and 2013. Literature review with Pubmed retrieved 122 cases. Logistic regression analysis was performed to identify predictive factors of ICU mortality and shock occurrence.

RESULTS

133 patients [median age 53 (39, 64), 72.2 % males] were included. Underlying immunosuppression was present in 127 patients, mostly long-term corticosteroid treatment in 111 (83.5 %) patients. Fever (80.8 %), respiratory (88.6 %), and gastrointestinal (71.2 %) symptoms were common clinical manifestations. Shock occurred in 75 (57.3 %) patients and mechanical ventilation was required in 89 (67.9 %) patients. Hypereosinophilia and a concomitant bacterial infection were observed in 34 (34.3 %) and 51 (38.4 %) patients, respectively. The in-ICU mortality rate was 60.3 %. Predictive factors of ICU mortality were shock occurrence [Odds ratio (OR) 18.1, 95 % confidence interval (95 % CI) 3.03-107.6, p < 0.01] and mechanical ventilation (OR 28.1, 95 % CI 3.6-217, p < 0.01). Hypereosinophilia (OR 0.21, 95 % CI 0.06-0.7, p = 0.01) and a concomitant bacterial infection (OR 4.68, 95 % CI 1.3-16.8, p = 0.02) were independent predictors of shock occurrence.

CONCLUSION

SHS remains associated with a poor outcome, especially when associated with shock and mechanical ventilation. Deterioration to shock is often related to concomitant bacterial infection. The poor outcome of established SHS pleads for a large application of antiparasitic primary prophylaxis in at-risk patients.

Strongyloides stercoralis hyperinfection associated with impaired intestinal motility disorder

Infection by Strongyloides stercoralis is a highly prevalent helminthiasis, which is mostly distributed in the tropical and subtropical regions of the world. Although a substantial number of cases are asymptomatic or paucisymtomatic, severe and life-threatening forms of this infection still occur and not infrequently is lately diagnosed. Gram-negative bacteria septicemia, which frequently accompanies the severe helminthiasis, contributes to the high mortality rate. Severe infection is invariably triggered by any imbalance in the host's immunity, favoring the auto-infective cycle, which increases the intraluminal parasite burden enormously. Clinical presentation of severe cases is varied, and diagnosis requires a high suspicion index. Acute abdomen has been reported in association with S. stercoralis infection, but intestinal necrosis is rarely found during the surgical approach. The authors report the case of a man who sought the emergency unit with recent onset abdominal pain. Clinical and imaging features were consistent with obstructive acute abdomen. Scattered adhesions and a necrotic ileal segment with a tiny perforation represented the surgical findings. The patient outcome was unfavorable and respiratory distress required an open lung biopsy. Both surgical specimens showed S. stercoralis infection. Unfortunately the patient underwent multiple organ failure and septicemia, and subsequently died. The authors call attention to the finding of intestinal necrosis and impaired intestinal motility disorder as possibilities for the diagnosis and risk factor, respectively, for a severe infection of S. stercoralis.

Strongyloidiasis with emphasis on human infections and its different clinical forms

Strongyloidiasis (caused by Strongyloides stercoralis, and to a lesser extent by Strongyloides fuelleborni) is one of the most neglected tropical diseases with endemic areas and affecting more than 100 million people worldwide. Chronic infections in endemic areas can be maintained for decades through the autoinfective cycle with the L3 filariform larvae. In these endemic areas, misdiagnosis, inadequate treatment and the facilitation of the hyperinfection syndrome by immunosuppression are frequent and contribute to a high mortality rate. Despite the serious health impact of strongyloidiasis, it is a neglected disease and very little is known about this parasite and the disease when compared to other helminth infections. Control of the disease is difficult because of the many gaps in our knowledge of strongyloidiasis. We examine the recent literature on different aspects of strongyloidiasis with emphasis in those aspects that need further research.

Severe strongyloidiasis: a systematic review of case reports

BACKGROUND

Strongyloidiasis is commonly a clinically unapparent, chronic infection, but immuno suppressed subjects can develop fatal disease. We carried out a review of literature on hyperinfection syndrome (HS) and disseminated strongyloidiasis (DS), in order to describe the most challenging aspects of severe strongyloidiasis.

METHODS

We conducted a structured search using PubMed to collect case reports and short case series on HS/DS published from 1991 to 2011. We restricted search to papers in English, Spanish, Italian and French. Case reports were classified as HS/DS according to given definitions.

RESULTS

Records screened were 821, and 311 were excluded through titles and abstract evaluation. Of 510 full-text articles assessed for eligibility, 213 were included in qualitative analysis. As some of them were short case series, eventually the number of cases analyzed was 244.Steroids represented the main trigger predisposing to HS and DS (67% cases): they were mostly administered to treat underlying conditions (e.g. lymphomas, rheumatic diseases). However, sometimes steroids were empirically prescribed to treat signs and symptoms caused by unsuspected/unrecognized strongyloidiasis. Diagnosis was obtained by microscopy examination in 100% cases, while serology was done in a few cases (6.5%). Only in 3/29 cases of solid organ/bone marrow transplantation there is mention of pre-transplant serological screening. Therapeutic regimens were different in terms of drugs selection and combination, administration route and duration. Similar fatality rate was observed between patients with DS (68.5%) and HS (60%).

CONCLUSIONS

Proper screening (which must include serology) is mandatory in high - risk patients, for instance candidates to immunosuppressive medications, currently or previously living in endemic countries. In some cases, presumptive treatment might be justified. Ivermectin is the gold standard for treatment, although the optimal dosage is not clearly defined in case of HS/DS.

New insights into gastrointestinal and hepatic granulomatous disorders

Numerous diseases that involve the gastrointestinal tract reveal the presence of granulomas on histological analysis. Granulomatous diseases can be either primary or secondary to environmental factors. Granulomas are dynamic structures composed of organized collections of activated macrophages, including epithelioid and multinucleated giant cells, surrounded by lymphocytes. The formation of granulomas is usually in response to antigenic stimulation and is orchestrated through cytokines, immune cells and host genetics. In this Review, the pathogenesis and etiologies of granulomas of the gastrointestinal tract and liver are discussed, as are the available diagnostic tools to help differentiate their various underlying etiologies. In addition, the role of granulomas in harboring latent tuberculosis is reviewed. The effects of tumor necrosis factor antagonists and interferon-α on the development of granulomas are also discussed.

Eosinophilic-Crohn overlap colitis and review of the literature

Eosinophilic colitis is an idiopathic inflammation of the alimentary canal and is characterized by infiltration of the intestinal wall by eosinophils, massive submucosal edema, and peripheral eosinophilia. However, the presence of eosinophils in a colon biopsy requires thorough searching for secondary causes and eosinophilic colitis remains a diagnosis of exclusion. A 67-year-old male patient underwent a diagnostic ileocolonoscopy because of recurrent episodes of diarrhea for the last six months. Colonoscopy revealed a normal terminal ileum while in the entire colon an erythematous mucosa with very slight edema on a continuous pattern that was more pronounced in the left colon. The laboratory workup demonstrated eosinophils slightly elevated, biochemical tests were unremarkable and further clinical and laboratory workup was unremarkable. Histology showed overlapping findings of eosinophilic colitis and Crohn's colitis. Patient started on mesalazine 2.4 with very good results. A review of the literature shows that the spectrum of eosinophil involvement in inflammatory bowel disease as well as in eosinophilic colitis is largely varying, including also some exceptional cases that parallel the case described herein.

Flare-up of ulcerative colitis after systemic corticosteroids: A strong case for Strongyloides

Super-imposed infection with intestinal organisms can mimic a flare-up of underlying disease in patients with inflammatory bowel disease (IBD). We report a case of patient with long standing ulcerative colitis (UC), who presented with abdominal pain, diarrhea and low-grade fever after receiving systemic corticosteroids for an unrelated disorder. Despite a negative stool examination, a peripheral eosinophilia reappeared upon tapering down of a corticosteroid dose. Subsequently, duodenal biopsies showed evidence for Strongyloides, presumably acquired 20 years ago when the patient was residing in Brazil. The patient fully recovered following anti-helmintic therapy. This case underscores the importance of considering Strongyloides in the work-up of flaring-up IBD patients, even if a history of residing or traveling to endemic areas is in the distant past.

Intestinal strongyloidiasis and hyperinfection syndrome

In spite of recent advances with experiments on animal models, strongyloidiasis, an infection caused by the nematode parasite Strongyloides stercoralis, has still been an elusive disease. Though endemic in some developing countries, strongyloidiasis still poses a threat to the developed world. Due to the peculiar but characteristic features of autoinfection, hyperinfection syndrome involving only pulmonary and gastrointestinal systems, and disseminated infection with involvement of other organs, strongyloidiasis needs special attention by the physician, especially one serving patients in areas endemic for strongyloidiasis. Strongyloidiasis can occur without any symptoms, or as a potentially fatal hyperinfection or disseminated infection. Th2 cell-mediated immunity, humoral immunity and mucosal immunity have been shown to have protective effects against this parasitic infection especially in animal models. Any factors that suppress these mechanisms (such as intercurrent immune suppression or glucocorticoid therapy) could potentially trigger hyperinfection or disseminated infection which could be fatal. Even with the recent advances in laboratory tests, strongyloidiasis is still difficult to diagnose. But once diagnosed, the disease can be treated effectively with antihelminthic drugs like Ivermectin. This review article summarizes a case of strongyloidiasis and various aspects of strongyloidiasis, with emphasis on epidemiology, life cycle of Strongyloides stercoralis, clinical manifestations of the disease, corticosteroids and strongyloidiasis, diagnostic aspects of the disease, various host defense pathways against strongyloidiasis, and available treatment options.

A rare intestinal manifestation in a patient with common variable immunodeficiency and strongyloidiasis

We report an immunodeficient patient with a rare gastrointestinal manifestation. A 26-year-old male with common variable immunodeficiency (CVID) and bronchiolitis obliterans, who was on intravenous gamma-globulin and prednisone, presented diffuse abdominal pain, nausea, vomiting and constipation of 3 days' duration. He reported 5 years of recurrent respiratory infections and diarrhea with negative stool tests, including tests for Strongyloides stercoralis. A physical exam revealed a poor general condition, anemia, dehydration and a distended painful abdomen with guarding, without abdominal sounds. The radiological study showed marked dilation of the small bowel that was edematous. Resection of the affected loop was performed and the histopathologic study showed transmural infection with S. stercoralis and hemorrhagic necrosis of the muscular layer, without mucosal destruction. The patient developed malabsorption syndrome and septic shock; he was treated with antibiotics and thiabendazole and was finally discharged in a good general condition. CVID is a rare disease and its association with systemic strongyloidiasis is very uncommon, but it has been reported in patients on corticosteroids. Hemorrhagic necrosis of the muscular layer without mucosal destruction was not found in the literature studied.

Histologic study of colonic mucosa in patients with chronic diarrhea and normal colonoscopic findings

BACKGROUND

There are controversies about the importance of biopsies of normal colon mucosa in the investigation of patients with chronic diarrhea.

STUDY

Colonic and terminal ileum biopsies of 167 patients were reviewed. In 5 patients, used as controls, colonoscopy was done due to family history of colon cancer.

RESULTS

The 5 patients without symptoms had no histologic abnormalities. The histologic findings in 162 patients with chronic diarrhea were as follows: 110 patients (67.9%) with normal histology, microscopic colitis not otherwise specified, and isolated small granulomas; 17 (10.5%) patients had findings of borderline diagnostic significance, including possible collagenous colitis, some features of lymphocytic colitis and melanosis coli; and 35 (21.6%) patients, with diagnostic significant histologic findings as collagenous colitis, lymphocytic colitis, minimal change microscopic colitis, eosinophilic colitis, pericrypt eosinophilic enterocolitis, intestinal spirochetosis, schistosomiasis, and Crohn's disease. Of the 52 patients with either borderline or significant diagnostic abnormalities, in 8 (15.4%) the diagnosis was done only with a proximal study (ascending, transverse, or descending colons).

CONCLUSIONS

Histologic lesions of possible diagnostic value could exist in 32.1% of chronic diarrhea patients with normal colonoscopy, which can justify, in certain cases, mucosa biopsies, which might contribute for a more precise etiologic diagnosis; also, the distribution of these histologic changes has pointed out the importance of having all colon segments biopsied.

[Strongyloides stercoralis infection simulating polyarteritis nodosa]

INTRODUCTION

Parasitic infection can present with many different clinical manifestations.

EXEGESIS

A 77 year-old Russian woman, who's been living in France since 50 years was admitted for polyarthritis, myalgia, fever, abdominal pain, and eosinophilia simulating polyarterisis nodosa. Before admission, she was treated by steroids for polymyalgia rheumatica. The diagnosis of Strongyloides stercoralis was performed by parasitologic analysis of feces and colic biopsies. The outcome was favourable under treatment by ivermectine and steroid withdrawal.

CONCLUSION

S. stercoralis can be associated with reactive arthritis. Case reports of S. stercoralis infection mimicking systemic vasculitis are exceptionnal.

Intestinal strongyloidiasis: recognition, management, and determinants of outcome

Significant advances have occurred in our understanding of the biology, immunology, and immunopathology of the usually asymptomatic human infection by the intestinal parasite, Strongyloides stercoralis. Factors that increase the risk for the occurrence of symptomatic intestinal hyperinfection and/or often-fatal disseminated strongyloidiasis have been better defined. The pathophysiology underlying these risk factors, whether disease-related or iatrogenically induced, is a compromised immune system leading to dysfunction of TH-2 helper cells. These specialized lymphocytes are central to maintaining the delicate balance that exists between the infected human host and the stabilized parasite. Recognition of risk factors that impair the function of TH-2 lymphocytes is essential to heightening the index of clinical suspicion enhancing earlier, accurate diagnosis, and the introduction of appropriate therapy. This review summarizes what is understood about infection by S. stercoralis; its focus will be on the epidemiology, diagnosis, clinical presentation patterns in the immunocompetent and immunocompromised human hosts, and recommended treatment regimens.

The spectrum of GI strongyloidiasis: an endoscopic-pathologic study

BACKGROUND

The aim of this study was a detailed endoscopic-pathologic assessment of patients with various forms of GI strongyloidiasis.

METHODS

Six patients with a diagnosis of GI strongyloidiasis who underwent endoscopic evaluation during a 3-year period (January 1998-January 2001) were included. Published information was reviewed in detail, focusing on the endoscopic features and the diagnostic approach to this parasitosis.

OBSERVATIONS

Strongyloidiasis has a broad range of endoscopic features. In the duodenum, the findings included edema, brown discoloration of the mucosa, erythematous spots, subepithelial hemorrhages, and megaduodenum. In the colon, the findings included loss of vascular pattern, edema, aphthous ulcers, erosions, serpiginous ulcerations, and xanthoma-like lesions, and, in the stomach, thickened folds and mucosal erosions. A histopathologic diagnosis of strongyloidiasis was made in all cases.

CONCLUSIONS

Strongyloidiasis can involve any segment of the GI tract. EGD with procurement of biopsy specimens from the duodenum was the most accurate method of diagnosis in this case series.

Eosinophilic gastroenteritis: presentation of two patients with unusual affect of terminal ileum and caecum with manifestations of acute abdomen and literature review

Eosinophilic gastroenteritis is a rare disease; the long-term personal history with digestive symptoms and the course of the disease with relapses and remissions is the key for the disease to be suspected. Endoscopy, CT scan and sonographic studies may provide important indirect signs of the disease and in combination with histological examination the diagnosis can be achieved. The administration of corticosteroids is an important factor for the treatment or the remission of the disease. In this study two cases with unusual location of the disease, on the terminal ileum and caecum, are presented and a literature review is attempted. The disease process, clinical and laboratory findings as well as the surgical approach used are described. Eosinophilic gastroenteritis is a very rare disease with its surgical complications. The disease is a non-surgical disease, thus presurgical diagnosis is important because the entity discussed can be under control by conservative treatment. A high disease suspicious index must be kept in the physicians' mind.

An Update on the Geohelminths: Ascaris lumbricoides, Hookworms, Trichuris trichiura, and Strongyloides stercoralis

Geohelminths remain prevalent throughout the developing world where levels of sanitation, personal hygiene, and maternal education are low. The five species of nematodes responsible for the bulk of disease are Ascaris lumbricoides, the hookworms Ancylostoma duodenale and Necator americanus, Trichuris trichiura, and Strongyloides stercoralis. Geohelminths are acquired through ingestion of fecally contaminated food or water or through contact with infected soil. In developing countries, infection with more than one nematode species and high worm burdens are common. The morbidity is substantial, particularly among children, and deaths occur. Geohelminthic infections are encountered in industrialized countries among immigrants and long-term travelers who have lived in endemic regions where sanitation is poor, and occasionally following autochthonous transmission.

Strongyloidiasis colitis: a case report and review of the literature

A case is described of a nonimmunocompromised man who presented with diarrhea, weight loss, and microcytic anemia. Colonoscopy revealed a pancolitis characterized by aphthoid ulceration on endoscopy and intense tissue eosinophilic infiltrates on biopsy. Both colonic biopsies and stool aspirates revealed the larvae of Strongyloides stercoralis, thus confirming this parasite as the causative agent for the colitis.

[Association of thymoma and severe intestinal strongyloidiasis]

A 59-years-old man with thymoma and severe intestinal strongyloidiasis is reported. The authors pointed out a possible influence of immunological response related with thymoma in the development of hyperinfection by Strongyloides stercoralis.