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A. G. Bhaskar$ N Postgraduate Medical Journal (March 1977) 53, 139-142. Postgrad Med J: first published as 10.1136/pgmj.53.617.139 on 1 March 1977. Downloaded from Pseudo-obstruction and a sprue-like syndrome from strongyloidiasis C. BARTHOLOMEW* A. K. BUTLERt M.D., F.R.C.P.Ed. M.B., F.R.C.S. A. G. BHASKAR$ N. JANKEY M.Sc. M.B., M.R.C.Path. Departments of *Medicine, tSurgery and tPathology, General Hospital, Port-of-Spain, Trinidad, West Indies Summary were also large mesenteric nodes throughout the Symptomatic disease from Strongyloides stercoralis mesentery. A diagnosis of lymphoma was con- has been recognized for the first time in Trinidad. Five sidered and a biopsy of the jejunum and of a node cases are reported, all showing clinical features was taken. suggestive of a sprue-like syndrome. Subtotal jejunal Under the dissecting microscope the jejunal villi villous atrophy was seen in one case and partial appeared convoluted. The patient died on the third villous atrophy in two. Three patients had laparotomies postoperative day. The histology of the jejunum because of intestinal obstruction. showed villous with numerous adult suspected partial partial atrophy Protected by copyright. A sprue-like syndrome in certain Caribbean im- female S. stercoralis in the crypts and a moderate migrants should arouse a suspicion of S. stercoralis. infiltrate of round cells and a few eosinophils in the lamina propria. The mesenteric node showed reactive Introduction hyperplasia only. Parasitic infection as a cause of diarrhoea, and malabsorption is well recognized in heavy infections Case 2 of hookworm (Sheehy et al., 1962) and Giardia A 46-year-old male was admitted to the Port-of lamblia (O'Donovan, McGrath and Boland, 1942). Spain General Hospital with a history of episodic Tissue invasion of the small bowel has been de- diarrhoea for several months, peri-umbilical pain, monstrated in hookworm and giardial infections anorexia for 6 months with excessive flatulence and (Brandborg et al., 1967) but S. stercoralis has much borborygmi. There was ankle oedema and weight- more tissue invasive potential. loss of 15 kg in 6 months. A barium meal showed Infection with Strongyloides stercoralis is protean delayed gastric emptying. The small bowel coils were in its clinical manifestations but a sprue-like pattern dilated and the transit time was increased. A surgical http://pmj.bmj.com/ is not uncommon. opinion recommended laporatomy but at operation no mechanical obstruction was found. The small Case reports bowel was grossly dilated and thickened. The Case 1 mesenteric nodes were obviously enlarged and a A 19-year-old male was admitted to the Port-of- nodal biopsy was reported as showing non-specific Spain General Hospital with a history of diarrhoea adenitis. Two weeks postoperatively his haemoglo- and vomiting for 2 months with epigastric pain and bin was 9-6 g/100 ml; white cell count 9600/mm3 with distension of the abdomen. He had lost 10 kg in 5 6% eosinophils. The serum albumin was 1-6 g/100 on September 26, 2021 by guest. months. ml; faecal fat 9 g/day. An attempt at a small biopsy His haemoglobin was 10-8 g/100 ml. White cell at this stage was unsuccessful. The patient's diar- count 9000/mm3 with 3% eosinophils. The serum rhoea worsened and he was put on prednisone 60 albumin was 3-1 g/100 ml. A barium meal and mg a day but died 1 week later. At post-mortem there follow-through showed distension of the coils of the was some autolysis of the bowel and numerous S. small intestine. stercoralis were present in the mucosa of the small A surgical opinion was sought and a diagnosis of bowel. partial intestinal obstruction was made. At operation there was no evidence of mechanical obstruction but Case 3 there was obvious dilatation of the jejunum. There A 56-year-old male complained of vomiting, Correspondence: Dr C. Bartholomew, General Hospital, anorexia, epigastric pain, foul-smelling pale loose Port-of-Spain, Trinidad, West Indies. stools and abdominal distension for 3 months. 140 C. Bartholomew et al. Postgrad Med J: first published as 10.1136/pgmj.53.617.139 on 1 March 1977. Downloaded from rili' .lif.i.i..··;s*;i: ::: r ..j.i.;f '" rfgear· ·-·---- - *U:.;p.--·--:-.R:::.· `i ,·· :..f" :'· :*r::.··.· * FIG. 1. Low power histology of jejunal mucosa of flat type in case 4 showing helminths in the crypts (x 58). .....; .4~¢ ~'¢.. Protected by copyright. ;,; ,~,* '"..., '".""~r~',..... i ,,!_~ i... ~~ii!_~....:~? i~.·a ·;" :'i ,+:·. iq :i http://pmj.bmj.com/ i~~~~~~~l~:~ ,',lFIS~:~E:.7':.alE". FIG. 2. Higher magnification of jejunal mucosa (case 4) showing helminths curled in crypts (x 290). His haemoglobin was 10-3 g/100 ml; white cell count Numerous adult female S. stercoralis were seen 12,200/mm3 with 2% eosinophils. He was admitted to curled up in the crypts of Lieberkuhn and ova were a surgical unit and a diagnosis of partial small bowel present in the stroma. on September 26, 2021 by guest. obstruction was made. A barium meal and follow- He was treated with thiabendazole 50 mg/kg through showed a distended stomach and dilatation body-weight for 2 days and his symptoms promptly of the small bowel. At 24 hr most of the barium was subsided. In 2 months he gained 7 kg and has since still in the stomach and small bowel. regained all his weight. He remains well. A laparotomy was performed. There were grossly dilated and thickened loops ofjejunum but there was Case 4 no evidence of mechanical obstruction. The mesen- A 50-year-old man was admitted to hospital teric lymph nodes were enlarged. A biopsy of the complaining of having semi-solid bowel motions jejunal mucosa and one of the nodes was taken at four or five times a day for the past 9 months, operation. The histology of the jejunum showed excessive flatulence, borborygmi, epigastric fullness partial villous atrophy with plasma cells and after meals, oedema and weight-loss of 4 kg over 3 eosinophilic infiltration in the lamina propria. months. Strongyloidiasis and symptomatic disease 141 Postgrad Med J: first published as 10.1136/pgmj.53.617.139 on 1 March 1977. Downloaded from His haemoglobin was 11-2 g/100 ml; white cell Three of the patients were subjected to surgery count 6200/mm3 with 9%/ eosinophils; serum with a mistaken diagnosis of partial small bowel albumin 3-0 g/100 ml; faecal fat 10 g/day. Stool obstruction, and at laparotomy there were dilated examination for parasites was negative. A barium loops ofjejunum without any evidence ofmechanical meal and follow-through study showed marked obstruction. The mesenteric nodes were also seen to dilatation of the jejunum and a slow transit time. A be enlarged. Even in this respect the similarity to the small bowel biopsy showed a flat mucosa under the clinical picture of sprue holds true in that abdominal dissecting microscope and subtotal villous atrophy colic and episodes of pseudo-obstruction may occur on histological examination. Lying curled up upon in non-tropical sprue (Badenoch, 1960). In a study themselves in the crypts were numerous adult S. on non-tropical sprue, Fone et al. (1960) reported stercoralis and ova. The lamina propria showedround that of twelve patients with partial villous atrophy cells and occasional eosinophils (Figs 1 and 2). and diarrhoea, five had colicky abdominal pains for He was treated with thiabendazole 50 mg/kg which laparotomy was performed in two. In both body-weight for 2 days and soon recovered. A these patients the small bowel was oedematous and jejunal biopsy taken 3 weeks later failed to show any the mesenteric lymph nodes were enlarged Strongyloides and there was a normal villous pattern. Abdominal colic and dilated small intestines have also resulted in erroneous laparotomy for tropical Case 5 sprue (Baker and Mathan, 1931). A 41-year-old female was admitted to hospital Abdominal lymphadenopathy, as seen in complaining of weight-loss of 3 kg, intermittent strongyloidiasis, is also seen in non-tropical sprue diarrhoea up to twelve times a day, peri-umbilical and as a lymphomatous complication of this disease pain and intermittent vomiting over the past 4 (Best and Cooke, 1961; Tonkin, 1963), and may lead months. to erroneous speculations on gross inspection at Her haemoglobin was 11-5 g/100 ml; white cell laparotomy as occurred in Case 1. Moreover, a Protected by copyright. count 12,500/mm3 with 5%/ eosinophils; serum reticulo-sarcoma, or Hodgkin's disease involvement albumin 3-6 g/100 ml; faecal fat 5-0 g/day. Strongyl- of the bowel and abdominal nodes, can also cause oides larvae were seen on stool examination. A diarrhoea and steatorrhoea (Sleisenger, Almy and small bowel biopsy showed a normal villous pattern Barr, 1953) and may likewise lead to misdiagnosis with a plasma cell and eosinophilic infiltrate in the initially before histological reports are received. lamina propria. Adult Strongyloides were seen in the In strongyloidiasis, the histology of the jejunum crypts. A barium study was not done. may show a normal villous pattern, partial villous She was treated with thiabendazole 50 mg/kg body- atrophy and, as seen in Case 4, strongyloidiasis must weight and her symptoms subsided soon afterwards. now be added to the ever increasing list of diseases Her weight had increased by 7 kg in 2 months. resulting in a flat biopsy or subtotal villous atrophy. The nematodes are found curled upon themselves Discussion in the crypts of Lieberkiihn and some invade the Non-tropical sprue is rare in the West Indies and stroma and are seen lying in the interglandular http://pmj.bmj.com/ tropical sprue has been reported only from the connective tissue and sub-mucosa.
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