Case Presentation:

A 67 year–old previously healthy woman with HIV (CD4 count 1233/mm³) was admitted for 1 month of progressive odynophagia and dysphagia that began with solids and progressed to liquids. She reported food “getting stuck.” These symptoms were accompanied by recurrent emesis, anorexia, and an unintentional weight loss of 14 kg. Outpatient treatment for thrush did not improve her symptoms. Her medications included tenofovir/emtricitabine, raltegravir, famotidine, compazine, and nystatin. She used IV drugs 10 years prior and was a sex worker. She was admitted due to the delay in her workup. On examination, the temperature was 36.8°C, blood pressure 91/52 mmHg, pulse 72 bpm, respiratory rate 20 breaths per minute, and oxygen saturation 98% while breathing ambient air. She appeared malnourished, her oropharynx was without thrush, there was epigastric tenderness, the left leg was edematous, and there was a serpiginous erythematous peri–anal macular rash. The remainder of the examination was normal. Her laboratory analysis was significant for Na (125 mEq/L), Cl (78 mEq/L), HCO3 (40 mEq/L), albumin (2.2 g/dl), and serum total protein (4.1 g/dl). CT of the chest and abdomen after contrast bolus revealed a thickened distal esophagus, focal duodenal collapse in the region of the SMA, multiple pulmonary emboli, and upper lobe ground glass opacities. The patient underwent EGD which revealed shallow duodenal erosions with overlying exudates and fluid reflux from the distal duodenum. Biopsies taken from the esophagus, stomach, and duodenum showed numerous nematode larvae identified as Strongyloides stercoralis. Elevated Strongyloides IgG antibodies (4.47 IV) confirmed the diagnosis. Further questioning found that the patient had walked barefoot in Texas, Mexico and Guatemala.

Discussion:

Strongyloides is a nematode endemic in the tropics and sporadic in more temperate climates such as the US and Europe. Worm larvae from the soil infect the skin and travel hematogenously to the alveolar spaces from where they can be coughed up and ingested. Although subclinical infection may persist for decades through an autoinfection cycle, disease symptoms are varied and include nausea, diarrhea, cough and a pathognomonic pruritic serpiginous rash (larva currens). Most patients with Strongyloides recover after two doses of ivermectin. Symptoms reflecting a small bowel obstruction (SBO) as seen in this case, however, are rare. Worm hyperinfection can be triggered by malnourishment or steroids and can lead to intestinal inflammation and stenosis. In this case, the patient’s weight loss may have caused mesenteric fat thinning, which resulted in duodenal compression in the region of the SMA (SMA syndrome). Together hyperinfection and SMA syndrome caused a proximal SBO in this patient.

Conclusions:

The purpose of this vignette is to increase awareness of Strongyloides as a cause of SBO.