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Image of the month: Target the bugs: Strongyloides stercoralis hyperinfection

Akira Hokama and Kazuto Kishimoto
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DOI: https://doi.org/10.7861/clinmed.2020-1000
Clin Med March 2021
Akira Hokama
AUniversity of the Ryukyus, Nishihara, Japan;
Roles: associate professor
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  • For correspondence: hokama-a@med.u-ryukyu.ac.jp
Kazuto Kishimoto
BUniversity of the Ryukyus, Nishihara, Japan
Roles: consultant gastroenterologist
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ABSTRACT

A 74-year-old woman carrying the human T-lymphotropic virus type-1 (HTLV-1) presented with abdominal pain and vomiting. Computed tomography and microscopic analysis of the gastroduodenal drainage fluid made a diagnosis of paralytic ileus due to Strongyloides stercoralis hyperinfection with underlying HTLV-1 infection. Strongyloidiasis should be included in the differential diagnosis for paralytic ileus in patients who have lived in or migrated from the endemic regions.

KEYWORDS:
  • Strongyloides stercoralis
  • hyperinfection
  • human T-lymphotropic virus type 1
  • ileus
  • computed tomography

Case presentation

A 74-year-old woman presented with abdominal pain, diarrhoea and vomiting for 2 weeks. She had a history of bronchial asthma and her medication included budesonide inhalation solution. Physical examination revealed stable vital signs and leg oedema. Her abdomen was soft, distended and nontender with decreased bowel sounds. Laboratory examination showed white blood cells of 8.1 × 109/L, C-reactive protein of 2.2 mg/L (normal range <1.4), and albumin of 29 g/L (normal range 41–51). Antibodies to human T-lymphotropic virus type-1 (HTLV-1) were positive. Abdominal contrast-enhanced computed tomography showed mural thickening with ‘target sign’ enhancement of the small intestine (Fig 1). On admission, nasogastric tube drainage was performed, and the microscopic analysis of the gastroduodenal drainage fluid revealed Strongyloides stercoralis larvae (Fig 2). A diagnosis of paralytic ileus due to S stercoralis hyperinfection with underlying HTLV-1 infection was made. Treatment of oral ivermectin at 200 μg/kg for 7 days was initiated, resulting in successful eradication and prompt clinical improvement.

Fig 1.
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Fig 1.

Enhanced computed tomography showing mural thickening with ‘target sign’ enhancement of the small intestine and ascites.

Fig 2.
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Fig 2.

Microscopic imaging of the gastroduodenal drainage fluid revealing Strongyloides stercoralis larvae.

Discussion

S stercoralis can persist in the intestine for decades and approximately 400 million people are infected worldwide.1 Immunosuppressive conditions (including ageing, immunosuppressive medication and co-infection with HTLV-1) can cause life-threatening hyperinfection syndrome, characterised by paralytic ileus and Gram-negative bacteraemia.2,3 Co-infection of S stercoralis and HTLV-1 affects each other through altering immunity.3 Strongyloidiasis should be included in the differential diagnosis for paralytic ileus in patients who have lived in or migrated from endemic regions, such as Asia, Africa and South America.

  • © Royal College of Physicians 2021. All rights reserved.

References

  1. ↵
    1. Fleitas PE
    , Travacio M, Martí-Soler H, et al. The Strongyloides stercoralis-hookworms association as a path to the estimation of the global burden of strongyloidiasis: A systematic review. PLoS Negl Trop Dis 2020;14:e0008184.
    OpenUrl
  2. ↵
    1. Kishimoto K
    , Hokama A, Hirata T, et al. Endoscopic and histopathological study on the duodenum of Strongyloides stercoralis hyperinfection. World J Gastroenterol 2008;14:1768–73.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Hirata T
    , Uchima N, Kishimoto K, et al. Impairment of host immune response against Strongyloides stercoralis by human T cell lymphotropic virus type 1 infection. Am J Trop Med Hyg 2006;74:246–9.
    OpenUrlAbstract/FREE Full Text
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Image of the month: Target the bugs: Strongyloides stercoralis hyperinfection
Akira Hokama, Kazuto Kishimoto
Clinical Medicine Mar 2021, 21 (2) e239-e240; DOI: 10.7861/clinmed.2020-1000

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Image of the month: Target the bugs: Strongyloides stercoralis hyperinfection
Akira Hokama, Kazuto Kishimoto
Clinical Medicine Mar 2021, 21 (2) e239-e240; DOI: 10.7861/clinmed.2020-1000
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