A 52-year-old man was admitted for chronic diarrhea since more than
a year, and progressive low-leg edema over the past three months. His history
revealed that he made several short-term trips to southern China for business.
He was passing loose stool seven to eight times every day. Laboratory tests
revealed a total leukocyte count of 10.5 × 109/L
with 59.7 % neutrophils, 1.5 % eosinophils, and
30 % lymphocytes. His serum albumin level was 11.5 g/L and
serum IgE level was 739 IU/mL (normal range
< 78 IU/mL). The serum human immunodeficiency virus (HIV)
antibody status was negative. Small-intestine follow-through study showed
long-segment narrowing of the lumen of the terminal ileum ([Fig. 1 a]), whereas abdominal computed
tomography demonstrated diffuse wall thickening of the terminal ileum ([Fig. 1 b]). Double-balloon enteroscopy was
carried out via the anal route to further explore the long-segment narrowing in
the ileum. There was loss of the normal villous structure of the terminal ileum
on washing with water ([Fig. 2 a]), and
widespread swelling and erosions with petechiae were noted in the mucosa after
air inflation ([Fig. 2 b];
[Video 1]). Histopathological examination of
biopsy specimens of this area revealed marked leukocytic infiltration, with
eosinophils in the lamina propria ([Fig. 3 a]). Parasitic ova and larvae,
morphologically resembling the filariform larvae of Strongyloides stercoralis, were found within the
intestinal crypts ([Fig. 3 b]). The patient
subsequently received treatment with ivermectin (12 mg/day) for 3 days.
The diarrhea gradually resolved and the serum albumin level rose to
31.2 g/L 4 months after drug treatment.
Fig. 1 Small-intestine series
and abdominal computed tomography demonstrating diffuse wall thickening of the
terminal ileum.
Fig. 2 a Double-balloon
enteroscopy showing disappearance of villi in the terminal ileum under water.
b Air inflation revealed widespread swollen and erosive
mucosa with petechiae.
Fig. 3 a Eosinophils
infiltrating the lamina propria. b Parasitic ova and
larvae resembling the filariform larvae of S.
stercoralis within the intestinal crypts.
Video
1 Washing of the terminal
ileum with water revealing loss of the normal villous structure.
Endoscopy_UCTN_Code_CCL_1AC_2AG
