Abstract
A 58-year-old incarcerated male with history of asthma and schizophrenia was seen in prison clinic with a four-month history of abdominal pain, nausea, vomiting, few episodes of hematemesis and 13 lb weight loss. Physical exam showed epigastric and RLQ tenderness on palpation. CBC was significant for persistently elevated absolute eosinophil count and percentage, ranging from 1600 to 3700 (normal < 500) and 20-26% (normal 0-5%) for six months prior to presentation. CT scan of the abdomen revealed gastric wall thickening and mesenteric lymph node enlargement. EGD showed mild chronic gastritis with negative H.pylori immunostains on biopsies and a fundic gland polyp. Colonoscopy revealed inflammation in the cecum, two diminutive tubular adenomas in the sigmoid colon, and a hyperplastic polyp in the rectum. Colon biopsies were positive for prominent eosinophilic infiltrates and abscess. Further tests were ordered and one of his home medications, Carbamazepine was held, as it is known to cause eosinophilic colitis. Fecal calprotectin was borderline elevated while stool ova and parasites, Microsporidia Ag and Giardia Ag were negative. Serum tests for Toxocara species, HIV serologies and tryptase levels were negative and SPEP was normal. After several weeks of stopping Carbamazepine, the patient continued to be symptomatic with rising peripheral eosinophilia (eosinophil percentage of 32%). Serologies for Strongyloides were found to be high; indicative of current or past infection. The patient was then treated with Albendazole for 7 days with subsequent improvement in his GI symptoms. Strongyloides stercoralis infections are common in tropical countries but can be seen in underprivileged US populations such as immigrants, refugees, and prisoners. The sensitivity of stool ova and parasite testing is less than 50% for strongyloides. Our patient denied any recent travel to endemic areas, however infection exposure may occur over 30 years prior to presenting symptoms. Even with no signs of parasitic infection on colonic biopsies, in a patient with high clinical suspicion such as our patient (incarcerated with GI symptoms, peripheral eosinophilia, and eosinophilic colitis) serological testing with ELISA IgG to Strongyloides filariform larvae (sensitivity 80%, specificity 97%) must be undertaken. Treatment is easy and relatively affordable with a short course of antihelminthic agents. Repeat blood work in 6 months should show improvement in peripheral eosinophilia.Figure 1Figure 2
Published Version
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