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Strongyloides Colitis presented with acute abdomen

Strongyloides Colitis presented with acute abdomen

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iMedPub Journals
ARCHIVES OF CLINICAL MICROBIOLOGY
© Under License of Creative Commons Attribution 3.0 License This article is available from:http://www.acmicrob.com
2010Vol.1No. 3:2doi: 10:3823/209
Keywords:
Strongyloides stercoralis
, peritonitis, colitis
Introduction
Strongyloidiasis is caused by a
Strongyloides stercoralis
infection. It isendemic in tropical and subtropical regions and also occurs sporadi-cally in temperate areas [1]. Manifestations of this infection can rangefrom asymptomatic eosinophilia in the immunocompetent host to dis-seminated disease with septic shock in the immunocompromised host,which carry high mortality rate [2].Human
 
infection occurs when infective (lariform) larvae penetrate
 
in-tact skin. Once infected, most people have
 
an asymptomatic, chronicinfection of the gastrointestinal tract, with less developed waxing andwaning of gastrointestinal symptoms. The unique ability of 
Strongyloides stercoralis
to
 
complete its life cyclewithin the human host enables the worms to increase their burden dra-matically through a cycle of autoinfection, which can end up with dis-ease persistence. A high intestinal worm burden can be manifested assevere malabsorption [3-4] and possibly as hyperinfection syndrome,which usually occurs in immunocompromised hosts but has also beenreported in few case series among patients with no known risk factorsfor immunocompromised state
 
[5-6]. The majority of symptomatically infected patients experience wax-ing and waning gastrointestinal symptoms that persist for years dueto the presence of the adult worms in the small bowel, which induceduodenitis [2]. This report covers a rare case of strongyloides enterocolitis that pre-sented initially with malabsorption, then progressed to colonic perfo-ration and secondary peritonitis in a young patient with no known risk factors for hyperinfection apart from malnutrition.
The Case
A thirty-four-year old, Bangladeshi, male patient, who had been work-ing in Bahrain for eight months as security guard, was presented toemergency department with a history of malaise after fatigue of vedays duration. He had history of experiencing chronic abdominal painwith occasional vomiting for more than three years.On examination, the patient was afebrile and hemodynamically sta-ble, but pale and cachectic. He weighed 39 kg and had bilateral ankleedema. Abdominal examination revealed a distended abdomen withascitis; all other systemic examinations were within the normal range.Initial laboratory investigations showed severe anemia with hemoglo-bin of 3.1 gm/dl (microcytic hypochromic picture) and a normal WBCcount with no esinophilia. Serum iron was very low (1µmol/l). A liverfunction test showed hypoalbuminemia, with albumin level of 6 g/dl. Serum urea, creatinine levels were normal and liver enzymes
werenot elevated
, as were the initial chest radiographs. Other investigations,including folate, B12 and hemoglobin electrophoresis, were all normal,and there was no proteinurea.One day after hospitalization, he started to develop high-grade feverand worsening of his abdominal pain. Abdominal examination showedtenderness all over, with a maximum at the epigastric region and re-bound tenderness. His white cell count increased to 24,000/cu.mm,with 26% bands and 0% esinophil. A septic workup was collected and
Strongyloides Colitis presented with acute abdomen
1. Consultant, Infectious Disease Physician Salmaniya Medical Center, Bahrain skhawaja@health.gov.bhP.O. Box 12, Ministry of Health, Bahrain (Corresponding Author)2. Senior Resident, Department of Internal Medicine3. Senior Resident, Department of Internal Medicine
Abstract:
Strongyloides colitis is a rare presentation of strongyloidiasis. The infection is easily curable but carries a high mortality rate if misdiagnosed oruntreated. Here, we report a case of severe Strongyloides colitis in a young Bangladeshi man, who presented with acute abdomen and peritonitis.A low index of suspicion was the main source of diagnostic delay. We believe that the high morbidity and mortality rates after misdiagnosis of this curable infection warrant eorts to increase the awareness of the disease with high index of suspicion, particularly among patients comingfrom endemic areas.
Dr.Safaa AlKhawaja
1
, Dr. Zahra Jafar
2
, Dr. Khalil AlAradi
3
 
iMedPub Journals
ARCHIVES OF CLINICAL MICROBIOLOGY
2010Vol.1No. 3:2doi: 10:3823/209
© Under License of Creative Commons Attribution 3.0 License This article is available from:http://www.acmicrob.com
the patient was started on antibiotics (Piperacillin-Tazobactam andMetronidazole).Repeated chest radiographs revealed gas under his diaphragm, whichraised the suspicion of a perforated viscous. Subsequently, a CT-scanof his chest and abdomen revealed signicant intra-peritoneal air anduid collection with edema and transmural air in colonic wall (Figure1 & Figure 2) with normal lung parenchyma.FIGURE 1: Abdominal CT scan showing signicant free intra-peritonealair and uid colleconFIGURE 2: Abdominal CT scan showing signicant intra-peritoneal airand transmural air and edema of the colonic llFIGURE 3: Photomicrograph of longitudinal section of 
Strongyloidesstercoralis
larva (arrow) in the colonic mucosa surrounded by eosino-phils (400x magnicatn)Histopathologic examination of the resected colonic segment re-vealed a dilated colon with multiple circular deep ulcers. Microscopyshowed heavy inltration of eosinophils, lymphocytes, plasma cells,and neutrophils in the mucosa, with heavy inltration of 
Strongyloidesstercoralis
larva (Figure 3). The patient was given a transfusion of four units of blood and was pre-pared for surgery. A laparotomy revealed a single sealed perforationof 1 cm diameter at the hepatic exure of the colon. The area aroundthe colon was severely inamed, but there was minimal peritonealcontamination. The involved segment of the colon was resected witha proximal colostomy and distal mucous stula. Wide bore drains wereleft in the pelvis and the right paracolic gutter.Postoperatively, the patient was managed in the ICU. The patient im-proved, and the intra-abdominal drains were removed before his trans-fer to the general ward after six days of ICU admission.A preoperative stool analysis was sent and it showed
Strongyloidesstercoralis
lariform larva. Three sets of blood cultures were all sterile. The patient was diagnosed with severe strongyloides colitis, and ac-cordingly he was treated with Albendazole 400 mg twice daily for atotal of 14 days. Serology for
Strongyloides
was positive with high titer. The patient was discharged after 17 days of hospitalization with a planfor closure of colostomy after three months. Later, after the patient hada closure of colostomy, another stool analysis was completed. This timeit was negative for occult blood and
Strongyloides
.
Discussion
Our patient stated that he had had chronic abdominal pain for fewyears prior to this acute presentation, which indicates chronic stron-gyloidiasis.His presentation with fatigue, lower-limb edema and ascitis was likelydue to severe malabsorption which manifested as hypoalbuminemiaand iron-deciency anemia and might be also related to gastrointes-tinal bleeding secondary to worm infestation and ulceration. The pre-sentation of strongyloidiasis with malabsorption has been reported infew case series in the past [3], but not to the severity of malabsorptionpresented in our patient who had severe anemia (hemoglobin 3.1 gm/dl) and severe hypoalbuminemia of 6 g/dl.Our patient then developed severe strongyloides colitis that endedwith colonic perforation and secondary peritonitis, which is very rarepresentation of strongyloidiasis, particularly in the absence of knownrisk factors for an immunocompromised state apart from malnutrition,and with the absence of lung involvement by the
Strongyloides
whichis commonly seen in hyperinfection syndrome [7-8].Diagnosis of strongyloidiasis can be done by stool microscopy and/orserology. The sensitivity of single-stool microscopy is usually around

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