Its Not Always Clostridium difficile: Stronglyoides-Induced Acute Colonic Pseudo-Obstruction

Abstract

Introduction: Stronglyoides stercoralis (S. stercoralis) is an intestinal nematode found in the soil of tropical and subtropical areas. Patients commonly present with abdominal pain, diarrhea, and vomiting. We report a rare case of S. stercoralis presenting as acute colonic pseudo-obstruction (Ogilvie syndrome). Case presentation: A 75-year-old Ethiopian female presented with diarrhea and bloating for one week. She had a history of glioblastoma multiform with recent resection and recurrent severe Clostridium difficile (C. diff) infection. Physical exam revealed an afebrile, hemodynamically stable, ill-appearing, bedbound female. Her abdomen was distended, non-tender with normo-active bowel sounds. Laboratory findings were notable potassium 2.8 mmol/L, creatinine 0.33 mg/dL, albumin 2.1g/dL, lactic acid 0.9 mmol/L, and a normal white blood count of 5.2 103/mcL (eosinophil's 0%). C. diff assay was positive. Abdominal X-ray revealed significant gaseous distention of the colon with no evidence of an obstructing mass. The patient was diagnosed with severe C. diff colitis complicated by Ogilvie syndrome. She was treated with oral vancomycin, intravenous metronidazole, and her electrolytes were optimized. Further imaging was concerning for a sigmoid volvulus, she underwent sigmoidoscopy for decompression which was negative. She was discharged on a vancomycin taper, however returned 3 days later with respiratory distress, worsening watery diarrhea (>1600ml/day) and increased abdominal girth. Repeat C. diff toxin assay was negative, her electrolytes were within normal range, and her abdominal x-ray was consistent again with Ogilvie's syndrome. Stool ova & parasite analysis along with bronchoalveolar lavage revealed the presence of S. stercoralis. She was diagnosed with pulmonary and GI strongyloidiasis and was treated with ivermectin with subsequent improvement in her abdominal distension and diarrhea. Discussion: Ogilvie's syndrome presents with a clinical picture of intestinal obstruction in the absence of a mechanical cause. Known risk factors include a history of C. diff, recent surgery, and electrolyte abnormalities, all present in our patient. It's an unusual manifestation of S. stercoralis, and should be considered in immunocompromised individuals from endemic areas. This case demonstrates the importance of having a high degree of suspicion for identifying all potential causes of Ogilvie syndrome.Figure 1Figure 2Figure 3