S2244 Unusual Presentation of Strongyloides with Microscopic Colitis

Abstract

Introduction: Strongyloides is an endemic helminth in the tropical regions of the world. It has varied presentation from asymptomatic infection to having hyper-infection syndrome and disseminated disease. We present a case of Strongyloides with microscopic colitis- whether they coexist or lead to one another. Case Description/Methods: A 57 year old male presented with multiple episodes of bilious, non-projectile vomiting and bilateral pedal edema for 15 days. He has past history for L5-S1 radiculopathy for which he was given steroids for 3 months and they were tapered off in that period. Antiemetics were started, but there was no relief. His routine blood investigations were normal except for low serum albumin. Contrast enhanced CT Abdomen was normal. Upper GI endoscopy was normal, biopsies from second part of duodenum was taken. Colonoscopy was done;the mucosa was normal and segmental biopsies were taken. Stool examination and duodenal mucosa showed presence of the larva of Strongyloides. Histopathoplogy of colonic mucosa showed features of microscopic colitis; lamina propria in the ileum and caecum showed inflammatory infiltrate and lymphoid aggregates with eosinophils. Transverse colon stroma showed mixed inflammatory infiltrate with many eosinophils and occasional lymphoid aggregates. Oral ivermectin was started and given for 5 days. Along with anti-helminthic, oral budesonide was also given for microscopic colitis. His symptoms improved and was doing well on follow up. Discussion: S.stercorails has the unique ability to complete its life cycle within the host through an asexual autoinfective cycle, allowing infection to persist in the host indefinitely. Immunocompromised state can precipitate hyperinfection syndrome. Hallmark of hyperinfection syndrome is the increase in the larvae in the stool or the sputum leading to gastrointestinal and pulmonary symptoms. GI symptoms include abdominal pain, nausea, diarrhoea and rarely intestinal obstruction and GI hemorrhage. Our patient didn’t develop any of these symptoms while on steroids. On the other hand, microscopic colitis presents with chronic diarrhoea. These symptoms were also not present. Our patient had symptoms due to increased larval load leading to repeated episodes of vomiting. There is scant literature if Strongyloides leads to microscopic colitis. Bacterial infection leading to microscopic colitis is known but parasitic cause is not known yet.Figure 1.: A: Normal stomach with food residue. B: Normal appearing mucosa of the ascending colon. C: Homogeneous eosinophilic deposits of amyloid in submucosal blood vessels of the small bowel (conventional haematoxylin and eosin-stained section 20x) D: Reddish-orange appearance of amyloid protein deposit in submucosal blood vessels of small bowel (congo red-stained section 20x).