In spite of recent advances with experiments on animal models, strongyloidiasis, an infection caused by the nematode parasite Strongyloides stercoralis, has still been an elusive disease. Though endemic in some developing countries, strongyloidiasis still poses a threat to the developed world. Due to the peculiar but characteristic features of autoinfection, hyperinfection syndrome involving only pulmonary and gastrointestinal systems, and disseminated infection with involvement of other organs, strongyloidiasis needs special attention by the physician, especially one serving patients in areas endemic for strongyloidiasis. Strongyloidiasis can occur without any symptoms, or as a potentially fatal hyperinfection or disseminated infection. Th2 cell-mediated immunity, humoral immunity and mucosal immunity have been shown to have protective effects against this parasitic infection especially in animal models. Any factors that suppress these mechanisms (such as intercurrent immune suppression or glucocorticoid therapy) could potentially trigger hyperinfection or disseminated infection which could be fatal. Even with the recent advances in laboratory tests, strongyloidiasis is still difficult to diagnose. But once diagnosed, the disease can be treated effectively with antihelminthic drugs like Ivermectin. This review article summarizes a case of strongyloidiasis and various aspects of strongyloidiasis, with emphasis on epidemiology, life cycle of Strongyloides stercoralis, clinical manifestations of the disease, corticosteroids and strongyloidiasis, diagnostic aspects of the disease, various host defense pathways against strongyloidiasis, and available treatment options.

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Warfarin is the most widely used oral anticoagulant and is indicated for many clinical conditions. Levofloxacin, a fluoroquinolone, is one of the most commonly prescribed antibiotics in clinical practice and is effective against Gram-positive, Gram-negative, and atypical bacteria. While small prospective studies have not revealed any significant drug-drug interaction between warfarin and levofloxacin, several case reports have indicated that levofloxacin may significantly potentiate the anticoagulation effect of warfarin. We report 3 cases of serious bleeding complications that appear to be the result of the interaction between warfarin and levofloxacin. Physicians should be aware of this potential interaction and use caution when prescribing levofloxacin to patients taking warfarin.

Strongyloidiasis can present with a wide variety of symptoms and can lead to a potentially fatal hyperinfection. Although any factors that suppress the host defense mechanisms can potentially trigger hyperinfection, prolonged steroid use has been quite well described. A patient with disseminated small cell lung cancer suffered a Strongyloides stercoralis hyperinfection syndrome complicating ectopic adrenocorticotropic hormone (Cushing syndrome). Evaluation revealed lymphopenia, elevated levels of adrenocorticotropic hormone in the setting of elevated cortisol levels, a normal pituitary, and metastatic malignancy. S. stercoralis larval forms were seen in the stool and sputum. At autopsy, S. stercoralis larval forms were seen in the lung along with evidence of metastatic small cell lung carcinoma.

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Biloma" is a collection of bile outside of the biliary tree that could occur postoperatively in patients who undergo laparoscopic cholecystectomy or in patients with blunt trauma to the liver. Spontaneous or impulsive bilomas with no identifiable cause occur rarely. We report a case of a 60-year-old woman with no history of hepatobiliary surgery or trauma, who was admitted for right upper quadrant pain. An abdominal examination revealed tenderness in the right upper quadrant (RUQ). Her alkaline phosphatase level was 2,343 IU/L. Computed tomography of the abdomen and pelvis with contrast showed perihepatic, periduodenal, and right paracolic gutter ascites. The image-guided aspiration of the peritoneal cavity yielded greenish fluid that was determined to be bile. The cytological studies were negative for malignancy and microorganisms. The ultrasound images of the RUQ were negative for cholecystitis and gallstones, and the results of the hepatobiliary nuclear scan study (HIDA) were unremarkable. Magnetic resonance cholangiopancreatography (MRCP) revealed an intact intrahepatic and extrahepatic biliary tree and confirmed the presence of multiple lakes of bile ascites.During the entire hospital stay, the patient remained stable without any unifying diagnosis and she was discharged with a pigtail catheter. A follow-up abdominal CT scan revealed a complete resolution of the bilomas. We consider this as a spontaneous extra-and intrahepatic biloma of unknown etiology and should be in our differentials when a patient presents with right upper quadrant abdominal pain.