Radiological appearance of small bowel in severe strongyloidiasis

Abstract

A 20-year-old male patient reported to us with abdominal discomfort, diarrhea, and marked weight loss for the last six months. Mild epigastric tenderness showed on physical examination. Laboratory results included intermittent Guaiac-positive stools, mild anemia, and eosinophilia. Stool examination was strongly positive for Strongyloides stercoralis larvae. Upper gastrointestinal and small bowel series radiograph ( Figure A and B) revealed pseudo-stenosis of the third part of duodenum (white arrow head) with proximal duodenal dilatation (curved white arrow), reflux of barium into the main bile duct (thin white arrow), and ribbon bowel or pipe stem appearance in jejunum (thick white arrow). These imaging findings are very suggestive of strongyloidiasis. Jejunal biopsy was done, revealing partial villous atrophy. The patient was treated with ivermectin, but there was poor patient compliance and the patient was lost to follow-up. He continued taking ivermectin intermittently for abdominal discomfort without any supervision. The patient presented to us after two years with similar complaints. Stool test was again positive for strongyloides larvae, but there was no eosinophilia. No upper gastrointestinal study was done at that time. The patient was counseled for complete treatment for eradication of the disease, and was treated with two courses of ivermectin with close monitoring by stool examination, after which the radiographic appearance returned to normal ( Figure C). Treatment with ivermectin completely eradicated the disease, and the patient's clinical condition improved significantly. To the best of our knowledge typical radiological findings of strongyloidiasis are rarely being reported and are diagnostic of strongyloidiasis.Um paciente do sexo masculino de 20 anos de idade relatou desconforto abdominal, diarréia e perda de peso nos últimos seis meses. Ao exame físico havia dor epigástrica leve. Resultados laboratoriais incluíram exame das fezes (guaco positivo), anemia leve e eosinofilia. Larvas de Strongyloides stercoralis foram encontradas nas fezes. Radiografias do intestino superior e do intestino delgado (Figuras A e B) revelaram pseudo-estenose da terceira parte do duodeno (cabeça de seta branca) com dilatação duodenal proximal (curvas seta branca), refluxo de bário no ducto biliar principal (seta branca fina) e fita intestinal ou aparência de cabo de cachimbo no jejuno (seta branca grossa). Estes achados de imagem são muito sugestivos de estrongiloidíase. Biópsia jejunal revelou atrofia vilosa parcial. O paciente foi tratado com ivermectina, mas houve baixa adesão e ele não retornou a consulta. Fez uso intermitente de ivermectina por desconforto abdominal, sem qualquer supervisão. Dois anos depois ele voltou ao hospital com queixa similar. Novo exame de fezes revelou larvas de Strongyloides, porém não houve eosinofilia. Estudo radiológico do trato gastrintestinal superior não foi feito naquela época. Paciente foi orientado para o tratamento completo para a erradicação da doença. O paciente foi tratado...

Intestinal strongyloidiasis: radiological findings that support the diagnosis

“…In S. stercoralis infection, the imaging findings of the alterations to the large intestine are nonspecific and similar to those seen in inflammatory/infectious intestinal diseases of other causes, especially the edema of the duodenal wall and of the proximal small intestine, as well as mucous congestion, coarse folds, and dilation of the bowel loops (7-9) . At that stage, the radiological images are similar to those seen in hypoalbuminemia, ascites and peritonitis.…”