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Case Report
 
Gastroscopic findings of Strongyloidiasis causing unresolved upper gastrointestinal bleeding
Keywords :
Wattana Sukeepaisarnjarden, Kittishak Sawanyawisuth
Department of Medicine, Faculty of Medicine,
and Research Center in Back, Neck, Other Joint Pain and
Human Performance (BNOJPH),
Khon Kaen University,
Khon Kaen 40002, Thailand


Corresponding Author
: Dr Kittisak Sawanyawisuth
Email: kittisak@kku.ac.th


DOI: http://dx.doi.org/10.7869/tg.229

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48uep6bbph|2000F98CTab_Articles|Fulltext
Strongyloides stercolaris is a common soil-transmitted parasite in Thailand and tropical countries. It infects 1.8% of school children in southern Thailand.[1] Disseminated infection or hyperinfection are common in immunocompromised patients such as those on corticosteroid treatment, HIV infection and organ-transplant recipients.[2-5] Upper gastrointestinal bleeding (UGIB) caused by S. stercolaris is an uncommon but severe complication.[2-4] Gastroscopic findings in strongyloidiasis causing UGIB are limited. We report here a case of unresolved UGIB due to S. stercolaris infection with features observed on gastroscopy.

Case report

A 39-year-old woman presented with hematemesis for two weeks. She had been on corticosteroids for Bell’s palsy since two months. No history of alcoholism, NSAIDs or liver disease was reported. Physical examination was normal except Cushingoid appearance and mild anemia. Gastroscopy was performed twice but showed only diffuse gastritis and duodenitis. Due to unresolved hematemesis gastroscopy was repeated a third time when it revealed diffuse suppurative ulcers in the stomach and nearly the entire duodenum (Figures 1 & 2). Numerous S-shaped, motile worms were detected in the gastric contents (Figure 3).







Discussion

Diagnosis of UGIB due to S. stercolaris infection is difficult and easily missed given its rarity. In this case, the diagnosis was made after two weeks of hematemesis and three gastroscopy attempts. The identification of a larva of S. stercolaris is a crucial diagnostic clue and can be isolated from the gastric contents microscopically. Detection of its eggs in stool examination is also helpful.

There are no pathognomonic gastroscopic findings. A report from Malaysia showed edematous mucosa at the prepyloric area.[5] A bleeding gastric ulcer with eggs and larvae identified in the mucosal layer was also reported. In our patient the gastroscopic findings were non-specific but showed ulcers throughout the upper gastrointestinal area from stomach to the duodenum. Suppurative ulcers may occur due to superimposed bacterial infection. Eosinophilic infiltration may be another clue for gastric strongyloidiasis. Even though there is no specific clinical manifestation for gastric strongyloidiasis, some suggestive features are important. Most previous reports of UBIG caused by S. stercolaris are always severe.[2,3] In addition, the patients also always have co-morbid conditions such as corticosteroid use, malignancy, organ transplant or HIV infection. Physicians in tropical areas should be aware of S. stercolaris associated UGIB given its difficult diagnosis, non-specific gastroscopic findings and severity of UGIB.

References
  1. Anantaphruti MT, Nuamtanong S, Muennoo C, Sanguankiat S, Pubampen S. Strongyloides stercoralis infection and chronological changes of other soil-transmitted helminthiases in an endemic area of southern Thailand. Southeast Asian J Trop Med Public Health. 2000;31:378–82.
  2. Bollela VR, Feliciano C, Teixeira AC, Junqueira AC, Rossi MA. Fulminant gastrointestinal hemorrhage due to Strongyloides stercoralis hyperinfection in an AIDS patient. Rev Soc Bras Med Trop. 2013;46:111–3.
  3. Bhatt BD, Cappell MS, Smilow PC, Das KM. Recurrent massive upper gastrointestinal hemorrhage due to Strongyloides stercoralis infection. Am J Gastroenterol. 1990;85:1034–6.
  4. Dees A, Batenburg PL, Umar HM, Menon RS, Verweij J. Strongyloides stercoralis associated with a bleeding gastric ulcer. Gut. 1990;31:1414–5.
  5. Shekhar KC, Krishnan R, Pathmanathan R, Fook CS. Gastric strongyloidiasis in a Malaysian patient. Southeast Asian J Trop Med Public Health. 1997;28:158–60.