Diagnosis Of Strongyloidiasis In The Antrum, Duodenum, And Colon By Endoscopy Of A Patient With Hiv

INTRODUCTION: Diagnosis of strongyloides is often delayed because symptoms are nonspecific. Strongyloides is a potentially fatal parasitic infection particularly in immunosuppressed patients. There are few reports of strongyloides in non-endemic areas. We present a case of a 45-year-old man with human immunodeficiency virus (HIV) who presented with generalized weakness and abdominal pain diagnosed with gastrointestinal strongyloidiasis. CASE DESCRIPTION/METHODS: A 45-year-old man with HIV presents with generalized weakness and abdominal pain. He presented to our hospital after multiple prior visits with no improvement. His abdominal pain was non-radiating, associated with nausea, emesis, and no bowel movement for 1 week. His vitals were: 36.9C, 108/76 mmHg, 91 BPM. He had an unremarkable physical exam with a soft, nontender, nondistended abdomen. Laboratory tests revealed a hemoglobin of 8.6 g/dL (ref 13.5–16.5) and MCV 71 fL (ref 82–97), WBC 5.8 K/cumm (ref 4.5–10 K/cumm) with 68.4% neutrophils, 15.5% lymphocytes, and 5.1% eosinophils. His CD4 count was 133/cumm (ref 494–1694/cumm) while on antiretroviral therapy with bictegravir, emtricitabine, and tenofovir. Abdominal computed tomography demonstrated segmental jejunal wall thickening and large stool burden though no colonic dilatation or wall thickening (Figure 1). Stool cultures had no growth. Esophogogastroduodenoscopy with push enteroscopy revealed significant edema in the duodenum with exudates (Figure 2). Colonoscopy revealed friable, erythematous, edematous mucosa without ulceration. Histopathological examination revealed strongyloides in the antrum, duodenum (Figure 3), and colon. Concurrent infections with candidiasis and cytomegalovirus in the esophagus were also seen. He was prescribed ivermectin, fluconazole, valganciclovir and discharged home. DISCUSSION: Diagnosis of strongyloides is typically made by histopathological biopsy specimens, emphasizing the important role of endoscopy as a diagnostic tool. Stool samples fail to detect larvae in up to 70% of cases. Early detection of strongyloides may prevent a fatal course of infection especially in immunocompromised patients. Strongyloides infection may occur regardless of absolute WBC or CD4 counts. Eosinophilia is typical in parasitic infections but may not always be present. No change in eosinophils could be the result of immune dysregulation secondary to HIV. This case highlights the importance of endoscopic evaluation for infection causing gastrointestinal symptoms in an immunocompromised patient.Figure 1.: Axial image of abdominal computed tomography showing wall thickening of small bowel and large stool burden in the ascending and transverse colon.Figure 2.: Significant edema in the duodenum with exudates seen on esophogogastroduodenoscopy.Figure 3.: Hematoxylin and eosin stain demonstrating strongyloides throughout the duodenum.