Alok Kumar Mantri1, Ajay Kumar1, Sanjeev Sachdeva1, Puja Sakhuja2, Amarender Singh Puri1
Department of 1Gastroenterology and 2Pathology, GB Pant Hospital, New Delhi
Dr Amarender Singh Puri
Strongyloides stercoralis (S. stercoralis) is a helminthic infection with diverse clinical manifestations varying from an asymptomatic infection to a potentially fatal hyper-infection syndrome (HIS) and disseminated Strongyloidiasis (DS).1 The uncommon gastrointestinal manifestations of S. stercoralis infestation are gastrointestinal bleed, duodenal obstruction, small bowel obstruction; perforation, pancreatitis and rarely gastric outlet obstruction.2-3 Unfortunately, even in tropical countries where S. stercoralis infestation is common, there is a delay in the diagnosis due to the low index of suspicion. We report a patient who presented with gastric outlet obstruction (GOO) due to S. stercoralis infestation and responded to anti-helminthic therapy.
A 23-year-old female presented to our hospital with recurrent non-bilious vomiting of 4 weeks. The frequency of vomitus gradually increased from 2-3 times per day to 6-8 times per day over the same period. There was no history of abdominal pain, hematemesis, melena or fever. In the past, she had been diagnosed with idiopathic thrombocytopenic purpura for which she had been treated with oral prednisolone at a daily dosage of 40 mg for four weeks, which was gradually tapered and finally discontinued one month prior to the onset of the vomiting. General physical examination was unremarkable except for mild pallor and pedal edema. Routine investigations were as follows:
Hemoglobin was 8.6 gm/dL, total leukocyte count 7,600 cells/mm3, absolute eosinophil count 450 cells/mm3, platelet count 30,000 cells/mm3, total bilirubin 1.6 mg/dL, AST 82 IU/L, ALT 38IU/L, ALP 186 IU/L, total protein 5.2 gm/dL, Serum albumin 3.1 gm/dL, Blood urea 22 mg/dL and serum creatinine was 0.6 mg/dl. Stool examination did not show ova or cysts; ELISA for HIV I-II was negative. CECT abdomen showed gastric antral wall thickening with normal small intestine (Figure 1D, 1E). Upper gastrointestinal endoscopy (UGIE) showed edema and nodularity in antrum and in the first part of duodenum (D1) along with mild narrowing at the D1-D2 junction (Figure 1A). Multiple biopsies were taken from the antrum and duodenal bulb. The histopathology showed multiple larvae of S. stercoralis invading into the lamina propria of the duodenum and antrum (Figure 1B, 1C). She was started on tablet ivermectin 6 mg once a day for 6 weeks. Her symptoms started to improve 1 week after starting ivermectin and she became asymptomatic 6 weeks later. No recurrence was noted on follow up after 6 months. Repeat UGIE 6 weeks after ivermectin treatment showed normal antrum and duodenal mucosa (Figure 1F).
The commonest causes of benign GOO in India are peptic ulcer disease, corrosive induced injury and gastro-duodenal tuberculosis.4 A recent study from India has suggested that there is a paradigm shift in the etiology of benign GOO with these three conditions accounting for nearly 75% of all patients diagnosed to have GOO due to nonmalignant disease.5 Endoscopic biopsies from the antrum or duodenum are an essential part of the work up in a patient with GOO. Upper gastrointestinal endoscopy findings in Strongyloidiasis are non-specific and include gastric fold enlargement, mucosal edema and erythema, sub-epithelial hemorrhages, ulceration and a deformed duodenal bulb. In the present case, it was the histology which helped in the diagnosis. In previous reports, endoscopic biopsy helped in establishing the correct diagnosis in almost 90% of the cases.Thus, in all suspected cases of S. stercoralis infection endoscopic biopsies from the abnormal appearing mucosa of the stomach or duodenum are a must.
To conclude, Strongyloidiasis is an uncommon cause of benign GOO which should be considered as a differential diagnosis in immunosuppressed patients. Endoscopic biopsy is helpful in making the correct diagnosis. Oral ivermectin is the drug of choice in both immune competent and immunosuppressed patients.
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