31 October 2008 Case of the Week
#133
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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.
What is your diagnosis?
Diagnosis:
Strongyloides stercoralis
Discussion:
Subsequent stool findings showed
Strongyloides ova.
Strongyloides 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.
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