Patient: Male, 61Final Diagnosis: Strongyloides stercolaris-associated diarrheaSymptoms: Diarrhea • epigastric pain • nausea • weight lossMedication: IvermectinClinical Procedure: Colonic biopsiesSpecialty: Infectious DiseasesObjective:Rare diseaseBackground:Strongyloides stercoralis infection is endemic in subtropical and tropical regions but is reported rather sporadically in temperate countries. In the USA, the highest rates of infection are from the southeastern states, predominantly among immigrants. There is paucity of case reports on S. stercoralis infection among HIV-infected patients who were born and raised in the USA.Case Report:A 61-year-old male with known HIV infection (CD4 count: 235 cells/uL, undetectable HIV RNA, on antiretroviral therapy) presented with a 3-month history of diarrhea. He was initially diagnosed to have diarrhea secondary to norovirus and later with Escherichia coli. He was treated with levofloxacin but the diarrhea persisted. Stool PCR, Clostridium difficile enzyme-linked immunoassay, cryptosporidium and giardia antigen, cyclospora and isospora smear, and fecal microscopy were all negative. Peripheral blood eosinophil count was 1,000 eosinophils/mcL. Colonic biopsies revealed fragments of S. stercoralis larvae within the crypts. The patient was treated with ivermectin with improvement of symptoms. Social history revealed that he was born and raised in the northeastern USA. He was a daily methamphetamine user and engaged in anal sex with men. He denied travel to endemic areas, except for a visit to Japan more than 30 years ago.Conclusions:Our case highlights that S. stercoralis may be an underdiagnosed/under-reported cause of chronic diarrhea among HIV-infected patients. What makes this case peculiar is that the patient was born and raised in the continental USA, absence of recent travel to endemic areas, and relatively high CD4 counts. Parasitic infections, such as S. stercoralis, should be considered among HIV-infected patients with persistent diarrhea and eosinophilia regardless of ethnicity or recent travel history.

Progressive multifocal encephalopathy (PML) is a rare demyelinating disease that typically presents in immunodeficient patients. We report a case of a previously healthy 62-Year-Old woman who suffered from an unsteady gait, throbbing headaches, and progressive left-sided weakness and numbness. Stroke was initially suspected based on imaging and symptoms. A series of follow-up magnetic resonance images of the brain showed a right parietal lesion growing in size as the patient became unable to walk and experienced increasing lethargy and confusion. A biopsy of the lesion was positive for the John Cunningham virus (JCV). A diagnosis of PML was made and she was started on mefloquine. No improvement was seen on this treatment and her condition worsened. Although PML remains uncommon in immunocompetent individuals, it cannot be ruled out based on their immune status. Although the exact cause remains uncertain, underlying or transient states of immunosuppression may be responsible for reactivation of the JCV in these patients.

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of LyE may reveal rings, furrows, strictures, edema, or esophagitis, similar in appearance to patients with EoE. Some patients, like ours, may have a normal-appearing esophageal mucosa on endoscopy. The diagnosis of LyE relies on mucosal biopsy and histology. Hallmark findings include spongiosis or intercellular edema, and peripapillary lymphocytosis without significant presence of neutrophils or eosinophils. Current treatment options include PPI, swallowed topical corticosteroids, and endoscopic dilation.[2344] Figure 1. (A, Pre dilatation esophagus) (B, Post dilatation mucosal disruption of mid & distal esophagus) (C, squamous mucosa with increased intraepithelial and patchy peripapillary lymphocytes).

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