A female in her late 50’s with a history of T-cell lymphoma presented with intractable nausea and vomiting for one week. Her lymphoma was being treated with cycle four of five of EPOCH (Etoposide, Prednisolone, Oncovin–Vincristine, Cyclophosphamide, and Hydroxydaunorubicin). She was unable to tolerate any oral intake for several days prior to her admission, and reported epigastric fullness. As part of her diagnostic workup she underwent a CT scan of her abdomen with findings characteristic of duodenitis. Upper endoscopy revealed an esophageal ulcer and severe duodenitis, which were biopsied. Subsequently, she was placed on high dose proton pump inhibitor for presumed enteritis. Her condition remained unchanged and the duodenal biopsy pathology returned positive for Strongyloides Stercoralis. Treatment was recommended with Ivermectin or Albendazole, which are only available in oral preparations. After consultation with our infectious disease pharmacist, an Ivermectin retention enema was formulated. After three days of therapy, the patient tolerated a liquid diet and was advanced to oral Ivermectin.
Strongyloidiasis is a common parasitic infection endemic to tropical and subtropical regions with an estimated 30-100 million people infected worldwide. The patient immigrated to the USA 25 years ago and returned to her birthplace in Haiti once ten years prior to her presentation. Initial strongyloides infection occurs when the filariform larvae, often found in soil, come in contact with the skin. The patient described above most likely had exposure during her early childhood years with autoinfection allowing the nematode to persist undetected for decades. Our patient had two risk factors for reactivation of strongyloides, HTLV-1 infection and immune compromise secondary to cytotoxic therapy. HTLV-1 is a common but underappreciated retrovirus that is the causative agent in the development of T-cell lymphoma/leukemia and HTLV-1 associated myelopathy. It is typically acquired during infancy through breastfeeding, but can also be transmitted through blood or sexual contact. Infection with HTLV-1 carries a cumulative lifetime risk of developing T-cell Leukemia/lymphoma at 2-5% and HTLV-1 associated myelopathy at less than 2%. Having HTLV-1 infection even in the absence of malignancy or myelopathy further predisposes individuals to symptomatic strongyloidiasis.
Clinicians frequently encounter immunocompromised patients, many of which were born in areas endemic for parasitic infections. Serology and stool studies are insensitive for strongyloides in the immunocompromised patient and consultation with a specialist is frequently required. Duodenitis is one of the more common presentations of symptomatic strongyloidiasis with the diagnosis typically made on biopsy. It is imperative for the clinician to consider parasitic infections in order to effectively care for immunocompromised patients.
To cite this abstract:Mishkin A, Karim IS. “Worms in My Intestines?” a Rare Cause of Duodenitis. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 691. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/worms-in-my-intestines-a-rare-cause-of-duodenitis/. Accessed July 22, 2019.