Atypical gastric presentation of strongyloidiasis in an immunecompetent patient.

4−year history of epigastric pain, nausea, vomiting, and watery diarrhea without mucus or blood. She received medication including lanzoprazol, and antidiarrhea and antispasmodic treatments without improvement. Her medical history was unremarkable, with no hospital admis− sions or surgical procedures. Vital signs were normal. Physical examination re− vealed tenderness in the colonic area with normal bowel sounds. No signs of peritoneal irritation were detected. Ab− dominal ultrasound was normal. Labora− tory tests reported eosinophilia (9%). HIV test was negative. Normal lymphocyte subpopulations were present. No para− sites were found in repeated fecal smears. Upper endoscopy demonstrated multiple subepithelial hemorrhages in the gastric antrum (l" Fig. 1 a), and edema, erythe− matous spots, small ulcers, loss of vascu− lar pattern, thickened folds, and mucosal erosions in the duodenum (l" Fig. 1 b). Biopsy samples were taken from the antrum and duodenum. The presence of eggs, larvae, and adult forms of Strongyloides stercoralis was evident (l" Fig. 1 c, d). Treatment with albendazole, 400 mg, was indicated twice a day for 3 days within 3 weeks [1]. A reduction in subepithelial hemorrhages, edema, and ulcers was ob− served 6 weeks later but parasites were still detected. Nitazoxanide was then in− itiated, but it was not well tolerated due to vomiting. Therefore, two doses of iver− mectin, 200 mg/kg/day, were indicated [2], resulting in a remarkable improve− ment of symptoms, including resolution of gastric and duodenum lesions; histolo− gy was negative for parasites 6 weeks after treatment (l" Fig. 2 a, b). The patient has remained asymptomatic after 1 year of follow−up. Gastric involve− ment in strongyloidiasis has been rarely reported but reduced gastric acid secre− tion might favor infection and invasion of the stomach [3], via consequent spu− tum swallowing or retrograde migration from the proximal small intestine [4]. Al− though this patient was immunecompe− tent, with a low risk for S. stercoralis in− fection, the history of long−term medica− tion with proton pump inhibitors, could be considered a predisposing condition allowing the parasite to access the stom− ach. Atypical gastric presentation of strongyloidiasis in an immunecompetent patient