Strongyloides Stercoralis Infection Presenting With Severe Malabsorption And Arthritis In An Immune Competent Host

Douglas Weinstein; Gerond Lake-Bakaar

摘要

We describe a 69-year-old woman without evidence of immunosuppression who developed a severe malabsorption syndrome associated with Strongyloides stercoralis infection. She went on to develop a severe arthritis of the ankle even after successful eradication of the parasite. Resection of the ankle mass revealed a cartilaginous loose body with degenerative calcification, ossification and cystic degeneration. This case is unusual because of the severity of clinical symptoms, the extent of histological damage to the duodenal mucosa and the development of arthritis after eradication of the parasite. Strongyloidiasis should be considered in the differential diagnosis of severe malabsorption and acute arthritis. Introduction Strongyloides stercoralis is a widespread, soil-transmitted intestinal nematode affecting 100 million people in 70 countries, most commonly in tropical and subtropical areas and in the southeastern US [1,2]. Human infection occurs when filariform larvae penetrate the intact skin and enter the venous microcirculation via the lymphatics. The organism then travels to the lung, penetrates the alveoli and moves up the bronchus, where it is swallowed down the esophagus to the intestine. In the duodenum and upper jejunum, the larvae mature into adult females that produce eggs, which are shed in the stool as rhabditiform larvae. While most rhabditiform larvae are excreted, some return to being filariform larvae and begin an autoinfective cycle by penetrating colonic mucosa or peri-anal skin leading to chronic infection [2]. In half of all cases, chronically infected individuals are asymptomatic. Typical symptoms include epigastric pain, diarrhea, nausea, vomiting, constipation and weight loss. Gastrointestinal and pulmonary symptoms can considerably worsen with the hyperinfection syndrome, where the parasite burden increases due to a rapid autoinfective cycle without widespread dissemination [2] In the immunosuppressed host, severe infection can occur in which the filariform larvae disseminate widely, leading to fatal sepsis, meningitis and ARDS [2,3,4,5]. Many cases of S. stercoralis have been reported following endoscopic diagnosis of intestinal invasion [6,7]. Most of these cases are mild and resolve uneventfully after antihelminthic treatment. Here, we report a case of severe S. stercoralis malabsorption syndrome in a patient without evidence of immunosuppression. Treatment with antihelminthic agents appeared to result in clinical and endoscopic resolution. However, the patient later presented with arthritic symptoms. Although arthritis has been described in association with S. stercoralis, the literature reports resolution of the arthritis with elimination of the parasite [6, 8,9,10,11,12, 14, 23]. Our case is unusual because of the severe symptoms and possible dissemination to joints in an immune competent host. The development of arthritis after initial clinical response to antihelminthic therapy raises questions about the etiology of the arthritis. Case Report This 69-year-old woman, originally from the Dominican Republic, had lived continuously in New York City for over 10 years. She presented to our institution with a one-month history of diarrhea, headache, crampy abdominal pain, fever, chills, dizziness, weakness and nausea. She described the diarrhea as always occurring post-prandially and usually twenty times per day and at night. She had lost twenty pounds over the past month. She denied recent travel but lived in poor, unhygienic conditions. Her dog, which had been ill with diarrhea for weeks, died shortly after she became ill. Her history was significant for arthritic back pain and GERD. She was taking loperamide and ranitidine with little symptomatic benefit. Her physical exam was significant for a diffusely tender upper abdomen. Hematological abnormalities included eosinophils of 7.6% (laboratory normal 0 to 5%). Laboratory abnormalities included borderline hyponatremia and hypokalemia. Endoscopy was s

机译：我们描述了一个没有免疫抑制证据的69岁妇女，该妇女发展了与甾体类固醇菌感染相关的严重吸收不良综合征。即使成功消除了寄生虫，她仍继续发展为严重的踝关节炎。切除踝关节肿块后发现软骨松散，伴有变性钙化，骨化和囊性变性。由于临床症状的严重性，对十二指肠粘膜的组织学损害程度以及根除该寄生虫后关节炎的发展，因此此病例是不寻常的。在严重吸收不良和急性关节炎的鉴别诊断中应考虑圆线虫病。简介硬皮实线虫是一种广泛的，经土壤传播的肠道线虫，在70个国家/地区影响1亿人口，最常见于热带和亚热带地区以及美国东南部[1,2]。当丝状幼虫穿透完整的皮肤并通过淋巴管进入静脉微循环时，就会发生人类感染。然后，该生物传播到肺部，穿透肺泡并向上移动支气管，然后被食道向下吞入肠道。在十二指肠和空肠上，幼虫成熟成卵，成虫成卵，然后在粪便中脱落成大戟状幼虫。虽然大多数横纹肌样幼虫被排泄，但有些恢复为丝状幼虫并通过穿透结肠粘膜或肛门周围皮肤而开始自体感染循环，从而导致慢性感染[2]。在所有情况的一半中，慢性感染的个体无症状。典型症状包括上腹痛，腹泻，恶心，呕吐，便秘和体重减轻。过度感染综合征会导致胃肠道和肺部症状严重恶化，在这种情况下，寄生虫负担由于快速的自体感染周期而没有广泛传播而增加[2]在免疫抑制的宿主中，会发生严重感染，其中丝状幼虫广泛传播，导致致命性败血症，脑膜炎和ARDS [2,3,4,5]。内窥镜检查诊断为肠道入侵后，已报道了许多固醇链球菌病例[6,7]。这些病例大多数是轻度的，抗蠕虫药治疗后病情平稳。在这里，我们报道了一个没有免疫抑制证据的患者中严重的S. stercoralis吸收不良综合征的病例。用抗蠕虫药治疗似乎可导致临床和内窥镜检查。但是，患者随后出现关节炎症状。尽管已经描述了与固醇链球菌相关的关节炎，但是文献报道通过消除寄生虫可以解决关节炎[6,8,9,10,11,12,14,23]。我们的病例不常见，因为症状严重，并且可能传播到免疫能力强的宿主的关节中。对蠕虫病治疗的最初临床反应后，关节炎的发展引起了关于关节炎病因的疑问。病例报告这位来自多米尼加共和国的69岁妇女在纽约市连续生活了10多年。她向我们机构介绍了一个月的腹泻，头痛，腹部绞痛，发烧，发冷，头晕，虚弱和恶心的病史。她形容腹泻通常在餐后发生，通常每天晚上有20次。她过去一个月瘦了二十磅。她拒绝了最近的旅行，但生活在恶劣，不卫生的条件下。她的狗腹泻了好几周，病了后不久就死了。她的病史对关节炎性背痛和GERD有重要意义。她正在服用洛哌丁胺和雷尼替丁，没有任何症状上的益处。她的体格检查对上腹部弥漫性柔软非常重要。血液学异常包括嗜酸性粒细胞为7.6％（实验室正常值为0至5％）。实验室异常包括边缘性低钠血症和低钾血症。内镜检查

Strongyloides Stercoralis Infection Presenting With Severe Malabsorption And Arthritis In An Immune Competent Host

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