<b><i>Strongyloides stercoralis</i></b> with Gastroduodenal Involvement and Complicated with SIADH: An Unusual Diagnosis to Consider in Immunosuppressed Patients with Hyperemesis and Eosinophilia

Abstract

&lt;i&gt;Strongyloides stercoralis&lt;/i&gt; is an intestinal nematode that colonizes and reproduces in the upper small intestinal mucosa. Infection in immunocompetent hosts is self-limited but in immunocompromised patients it can be complicated and cause hyperinfection. We present a 60-year-old female who was admitted due to an exacerbation of acquired thrombotic thrombocytopenic purpura requiring high doses of corticosteroids. The patient began to experience persistent pyrosis, nausea, vomiting, and oral intolerance. She was di­agnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Upper endoscopy was performed and showed esophageal, gastric, and duodenal mucosa with edema and erythema. Moreover, there were superficial erosions and thickened folds in duodenum. Gastric and duodenal biopsies were taken. Abdominal computed tomography and magnetic enteroresonance displayed duodenal dilation and inflammatory changes. The histological study of biopsies showed colonization by &lt;i&gt;S. stercolaris&lt;/i&gt; in the antrum and duodenum. &lt;i&gt;S. stercolaris&lt;/i&gt; is a human parasite that is endemic in tropical, subtropical, and temperate regions. Its lifecycle is complex because it completes its entire cycle within the human host; it penetrates the skin, migrates to the lungs, and reach the gastrointestinal tract. The most affected site is the duodenum and upper jejunum. The lifecycle includes autoinfection through the intestinal mucosa or perianal skin, especially in immunocompromised hosts. Immunossuppression can lead to hyperinfection syndrome and disseminated disease. However, involvement of the stomach has relatively rarely been reported. SIADH has been related to systemic hyperinfection, although the mechanism is not clear. The relatively nonspecific clinical and imaging features and the low sensitivity of routine parasite tests make the diagnosis challenging and delayed.

Gastric Parasitic Infection: Thinking outside the Box

“…First, the case presented by Silva et al [5] seems to have an autochthonous origin, something that is now infrequent in the Iberian Peninsula. In contrast, the patient described by Alcázar et al [6] This is an Open Access article licensed under the Creative Commons Attribution-NonCommercial-4.0 International License (CC BY-NC) (http://www.karger.com/Services/OpenAccessLicense), applicable to the online version of the article only. Usage and distribution for commercial purposes requires written permission.…”

“…Ivermectin is the preferred treatment, with albendazole as a secondary option. Both patients underwent treatment with ivermectin, but in the woman treated by Alcázar et al [6] albendazole was combined with ivermectin, since she was immunocompromised and an hyperinfection syndrome was assumed. Both authors describe a complete resolution of the clinical manifestations.…”

“…First, the case presented by Silva et al [5] seems to have an autochthonous origin, something that is now infrequent in the Iberian Peninsula. In contrast, the patient described by Alcázar et al [6]was a Dominican Republic native, and a recent study demonstrated a prevalence of 12% in Latin American migrants [7]. Second, in Silva et al [5], the patient, who was immunocompetent, had a suspicious gastric ulcer with upper gastrointestinal bleeding.…”

“…Published in GE Portuguese Journal of Gastroenterology , Silva et al [5] and Alcázar et al [6] describe 2 cases of strongyloidiasis with different clinical manifestations and settings, but they have in common gastric involvement of the parasitic infection. First, the case presented by Silva et al [5] seems to have an autochthonous origin, something that is now infrequent in the Iberian Peninsula.…”

“…However, subsequent evaluations determined that this nodule was squamous cell carcinoma and gastric histology was unremarkable for neoplastic cells but identified fragments of partially destroyed parasites [5]. Alcázar et al [6] described a 60-year-old female with thrombotic thrombocytopenic purpura, who required high doses of corticosteroids and rituximab and was thus immunocompromised. She had hyperemesis and oral intolerance.…”