Umesh Chandra Parashari; Sachin Khanduri; Dileep Kumar
Department of Radio Diagnosis, Era's Lucknow Medical College, Lucknow, India
A 20-year-old male patient reported to us with abdominal discomfort, diarrhea, and marked weight loss for the last six months. Mild epigastric tenderness showed on physical examination. Laboratory results included intermittent Guaiac-positive stools, mild anemia, and eosinophilia. Stool examination was strongly positive for Strongyloides stercoralis larvae. Upper gastrointestinal and small bowel series radiograph (Figure A and B) revealed pseudo-stenosis of the third part of duodenum (white arrow head) with proximal duodenal dilatation (curved white arrow), reflux of barium into the main bile duct (thin white arrow), and ribbon bowel or pipe stem appearance in jejunum (thick white arrow). These imaging findings are very suggestive of strongyloidiasis. Jejunal biopsy was done, revealing partial villous atrophy. The patient was treated with ivermectin, but there was poor patient compliance and the patient was lost to follow-up. He continued taking ivermectin intermittently for abdominal discomfort without any supervision. The patient presented to us after two years with similar complaints. Stool test was again positive for strongyloides larvae, but there was no eosinophilia. No upper gastrointestinal study was done at that time. The patient was counseled for complete treatment for eradication of the disease, and was treated with two courses of ivermectin with close monitoring by stool examination, after which the radiographic appearance returned to normal (Figure C). Treatment with ivermectin completely eradicated the disease, and the patient’s clinical condition improved significantly. To the best of our knowledge typical radiological findings of strongyloidiasis are rarely being reported and are diagnostic of strongyloidiasis.
Um paciente do sexo masculino de 20 anos de idade relatou desconforto abdominal, diarréia e perda de peso nos últimos seis meses. Ao exame físico havia dor epigástrica leve. Resultados laboratoriais incluíram exame das fezes (guaco positivo), anemia leve e eosinofilia. Larvas de Strongyloides stercoralis foram encontradas nas fezes. Radiografias do intestino superior e do intestino delgado (Figuras A e B) revelaram pseudo-estenose da terceira parte do duodeno (cabeça de seta branca) com dilatação duodenal proximal (curvas seta branca), refluxo de bário no ducto biliar principal (seta branca fina) e fita intestinal ou aparência de cabo de cachimbo no jejuno (seta branca grossa). Estes achados de imagem são muito sugestivos de estrongiloidíase. Biópsia jejunal revelou atrofia vilosa parcial. O paciente foi tratado com ivermectina, mas houve baixa adesão e ele não retornou a consulta. Fez uso intermitente de ivermectina por desconforto abdominal, sem qualquer supervisão. Dois anos depois ele voltou ao hospital com queixa similar. Novo exame de fezes revelou larvas de Strongyloides, porém não houve eosinofilia. Estudo radiológico do trato gastrintestinal superior não foi feito naquela época. Paciente foi orientado para o tratamento completo para a erradicação da doença. O paciente foi tratado com dois cursos de ivermectina com acompanhamento de perto pelo exame de fezes após o qual a aparência radiográfica voltou ao normal (Figura C). O tratamento com ivermectina erradicou a doença e a condição clínica do paciente melhorou significativamente. Achados típicos radiológicos da estrongiloidíase são raramente relatados e sugerem o diagnóstico da estrongiloidíase.
REFERENCES
1. Reeder M, Palmer P. Srongyloidasis. In: Reeder M, Palmer P, editors. The radiology of tropical diseases. Baltimore: Williams and Wilkins; 1981. p. 451-472. [ Links ]
2. Medina LS, Heiken JP, Gold RP. Pipestem appearance of small bowel in strongyloidiasis is not pathognomonic of fibrosis and irreversibility. Am J Roentgenol 1992; 159:543-544. [ Links ]
3. Penalba C, Cerf M, Bigot JM, Edouard A, Rieux D. Radiological aspects of the duodenum and small intestine in severe strongyloidiasis. Apropos of 4 cases. J Radiol 1983; 64:241-248. [ Links ]
Address to:
Dr. Umesh Chandra Parashari
Dept of Radio Diagnosis/Era’s Lucknow Medical College
Hardoi Road, Sarfarazganj
226003 Lucknow, India
Phone: 91 522 240-8122; 91 522 240-8123; Fax 91 522 240-7824
e-mail: drumesh.rd@gmail.com
Received in 22/09/2011
Accepted in 08/12/2011
