Case Presentation: A 46 year-old male from India presented with acute epigastric abdominal pain, dysphagia, decreased appetite, nausea, and generalized weakness. This case starts 6 months prior to admission when he was found to have an elevated creatinine at a routine primary care visit. Subsequently, due to worsening kidney function, a kidney biopsy was performed and he was diagnosed with IgA nephropathy and placed on high dose prednisone. After being on treatment for 2.5 months, he presented with the above gastrointestinal symptoms. Evaluation by upper gastrointestinal endoscopy (EGD) revealed candida esophagitis and a duodenal ulcer secondary to H. Pylori. He was placed on fluconazole and triple therapy for his Helicobacter Pylori infection. One day after discharge he re-presented with a pre-syncopal event and was found to have an acute upper gastrointestinal bleed from a bleeding duodenal ulcer that required epinephrine injection and clipping. During this 11 day hospitalization, he was weaned off his prednisone, completed his candida esophagitis and H. Pylori antibiotic treatment and developed Clostridium difficile diarrhea, for which he was placed on oral vancomycin. He unfortunately could only tolerate 3 days at home when he returned with intractable nausea and vomiting and was noted to be severely malnourished. Initial work-up focused on ruling out glucocorticoid insufficiency and consideration of gastrointestinal beriberi but his symptoms continued despite intravenous thiamine repletion. Repeat EGD revealed diffuse gastric and duodenal erythema and swelling, concerning for acute gastritis. Stomach biopsies revealed an acute parasitic infection of his gastric and duodenal mucosa with increased eosinophils and subsequently had a serum IgG for Strongyloides stercoralis that was positive. Given the severity of his infection he was treated with a 14 day course of Ivermectin. He responded rapidly within 48 hours and was fully tolerating a regular diet on discharge.
Discussion: Strongyloides infection was not on the initial differential diagnosis list for several reasons including the rarity of this infection in the United States, the absence of significant eosinophilia during his hospitalization, and because biopsies taken from his initial EGD did not show signs of a parasitic infection. However in retrospect, his overall re-presentation was consistent with an acute Strongyloides infection with likely hyperinfection given his history of steroid induced immunosuppression. This parasitic infection is most commonly acquired in tropical and subtropical areas of the world, such as India and can persist for years, frequently asymptomatically, due to the phenomenon of autoinfection.
Conclusions: Strongyloides stercoralis infection is a disease that can be difficult to diagnose unless one has a high clinical suspicion. Although not commonly seen in the United States, it is a disease with high potential for mortality and should be considered in the appropriate patient populations.