1823 Esophagitis in Immunocompromised Patient From Strongyloides Reactivation

Abstract

INTRODUCTION: Strongyloides Stercoralis infection affects as many as 30 million people in 70 countries worldwide. It also can undergo cycles of autoinfection leading to chronic disease. This infection is usually asymptomatic and may remain undetected for decades. However, in patients who are immunocompromised, such as patient’s undergoing chemotherapy, receiving long-term corticosteroids, transplant patient, or patient with HIV; severe infection can occur and result in mortality rates as high as 87%. Strongyloidiasis is difficult to diagnose as the parasite load is low and the larval output is irregular. CASE DESCRIPTION/METHODS: 79-year-old Chinese migrant man with metastatic lung adenocarcinoma who was recently started on Erlotinib, presented with nausea, vomiting, diarrhea, generalized weakness, and epigastric pain. He had White Blood Cell count of 7.6 with 6.6% Eosinophils. X-ray and Computed Tomography imaging did not show any changes from prior studies. Esophagogastroduodenoscopy was performed afterwards which showed esophagitis, gastritis, duodenal ulcer and duodenitis. Subsequently, biopsies of the duodenal and esophageal mucosa revealed parasitic larvae consistent with Strongyloides Stercoralis (Figure 1). The patient was started on Ivermectin and had resolution of his symptoms on follow up. Erlotinib was resumed after discharge. DISCUSSION: Although differential diagnosis for esophagitis in immunocompromised patients is broad, our patient was interestingly diagnosed with Strongyloides induced esophagitis via biopsy. The larvae of Strongyloides have potential ability to invade and survive for extended periods in human tissue. They have obligatory tissue phase in which the larvae follows from the portal of entry and eventually to trachea and lung. Depressed cell-mediated immunity secondary to malignant tumor, combined with protein-calorie malnutrition, led to lack of granulomatous immune response to larvae in our patient. Several immunodiagnostic assays have been found ineffective in detecting disseminated infection. Although it is important to detect latent S. Stercoralis infections before administering chemotherapy or before the onset of immunosuppression in patients at risk, a specific and sensitive diagnostic test is lacking. When acute esophagitis does present, it may be severe and disabling, and could result in hospitalization, placement of a feeding tube in the stomach or parenteral nutrition, and steady supportive care. Biopsy, cytology, and culture are recommended for suspected cases.