Small-Bowel Paralytic Ileus From Strongyloides stercoralis

Abstract

A 57 year-old Dominican man with a medical history of type II diabetes mellitus, well-managed with oral antidiabetic medication, presented to the hospital with an 8-week history of constipation, abdominal distention, nausea, and vomiting. On initial presentation he was found to have diabetic ketoacidosis. Three days later, the patient was re-admitted with similar symptoms. He reported a 28-pound unintentional weight loss. Computed tomography scan on admission showed diffuse small-bowel dilation and wall thickening suggestive of small-bowel obstruction (Figure A). A nasogastric tube was placed, resulting in 3 L of semisolid output per day. The patient denied prior abdominal surgeries or opioid use, and a colonoscopy 7 years ago was normal. Given diffuse small-bowel dilation, esophagogastroduodenoscopy was performed showing marked erythema and edema in the second portion of the duodenum (Figure B). Biopsy specimens showed evidence of Strongyloides stercoralis (Figure C). S stercoralis has various clinical presentations but constipation is not a common manifestation. Our patient presented with significant weight loss and diabetic ketoacidosis likely owing to malabsorption from small-bowel paralytic ileus. Rectal ivermectin resulted in the return of bowel function within 72 hours. Subsequently, nasogastric tube output significantly decreased, diet was advanced, and ivermectin was transitioned to oral form to complete a 14-day course. Patient informed consent was obtained for the writing of the manuscript and case details.