An unusual cause of malabsorption in an immunocompetent host
Sachdev Atul, Duseja Ajay, Nada Ritambhara*, Mohan Harsh*, Bhalla Ashish
Medicine & *Pathology,
Gastrointestinal tract infestation with Strongyloides stercoralis is common in the tropical and subtropical areas of the world. In an immunocompetent person, disease is generally asymptomatic. However, it has the potential to cause serious life threatening disease in an immunocompromised patient. We report a 55 years old immunocompetent person who presented with malabsorption secondary to strongyloides stercoralis infestation. Unusual infestations like strongyloides should also be considered while investigating malabsorption.
Key words: Malabsorption, Strongyloidiasis, immunocompetent
Strongyloides stercoralis is a nematode that infests the human intestine especially in tropical and subtropical regions, most of these infections being asymptomatic. However, it can cause substantial intestinal disease and can disseminate widely to extra intestinal sites such as lungs, kidney or brain (the hyper infection syndrome), especially in the immunocompromised host1. In immunocompetent hosts, these parasites cause a low grade, chronic infection, which has been seen even up to 40 years after exposure2. Presentation as malabsorption in an immunocompetent host is an uncommon event. We report a case of a 55-year-old immunocompetent male who presented with features of malabsorption because of strongyloides stercoralis infestation.
55-year-old male labourer from
Fig-1: Strongyloides stercoralis larvae (arrow) infiltrating the crypt epithelium (H&E x 40)
He was treated with albendazole 10mg/kg/day for three days but the stool examination done after seven days showed the persistence of larvae. He was treated again with Thiobendazole 25 mg/kg/day for three days. Repeat stool examination done after one week was negative for the larvae. On follow-up his diarrhoea had subsided and he had started gaining weight.
Strongyloidiasis primarily presents with dermatological and gastroenterological (GI) disease. Skin manifestations are usually in the form of urticarial eruptions or ‘larva currens.’ None of these were present in our patient. GI manifestations are usually in the form of indigestion, cramping lower abdominal pain, pruritis ani and intermittent or persistent dirrhoea.3 Various uncommon GI manifestations have also been described,3 malabsorption being one of them.4 Our patient had malabsorption as was evident on characteristic history, physical examination, abnormal D-Xylose test and findings on barium meal follow through examination. Strongyloides stercoralis infestation was demonstrated by the presence of larvae in the stool and endoscopic biopsies.
In most of the earlier reports of Strongyloidiasis, patients presenting as chronic diarrhoea or malabsorption had either an associated immunosuppressive illness or were on immunosuppressive treatment.5 In patients, who did not have any associated immunosuppressive disease or medication, HIV was not excluded, it being a pre HIV era.5 Our patient did not have any associated illness suggestive of immunosuppression and was not on any immunosuppressive treatment. He did not have history suggestive of congenital immune deficiency, and had normal cell counts, normal serum globulins, a positive mantoux test and a negative HIV serology.
Malabsorption in an immunocompetent patient because of strongyloides stercoralis is an unusual manifestation and that makes this case interesting.
Terashima A, Alvarez H. Strongyloides stercoralis hyper infection associated
with human T cell lymphotrophic virus type I infection in
2. Gill GV, Bell DR. Strongyloides stercoralis infection in former far East prisoners of war. Br Med J 1979; 2:572-4.
3. Grove DI. Strongyloidiasis: A conundrum for gastroenterologist. Gut 1994; 35:437-40.
4. O’Brien W. Intestinal malabsorption in an acute infection with Strongyloides stercoralis. Trans R Soc Trop Med Hyg 1989; 150:92-3.
Milder JE, Walzer
PD, Kilgore G, Rutherford I and Klein M. Clinical features of Strongyloides
stercoralis infection in an endemic area of the
Address for Correspondence: