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Strongyloides stercoralis: an unexpected cause of acute abdomen

A 78-year-old Vietnamese man with a past history of diabetes and hypertension presented to our hospital with generalized abdominal pain and distension. He had a raised C-reactive protein of 280 mg/L, normal white cell count of 8.72 × 10/L and acute renal impairment (urea 19 mmol/L, creatinine 137 umol/L; eGFR 44 mL/min/ 1.73 m). A computed tomography abdomen showed dilated and thick-walled small bowel loops but without a transition point (Fig. 1), suggestive of infective enteritis. The patient was treated with intravenous (IV) antibiotics, rehydrated with IV fluids and closely observed. However, his condition deteriorated after 48 h with new onset delirium, increasing abdominal pain and distension, fever, tachycardia, tachypnoea and an abdominal X-ray showing persistent dilated small bowel loops. Management proceeded to an exploratory laparotomy where the small bowel was thick-walled and dilated, but with no transition point to suggest a bowel obstruction. No other intra-abdominal pathology was found besides multiple patches of nodular inflammatory lesions on the small bowel mesentery (Fig. 2). A biopsy of one of the lesions revealed Strongyloides stercoralis larvae (Fig. 3). Post-operatively the patient developed acute respiratory distress syndrome; sputum microscopy showed multiple Strongyloides larvae indicative of a hyperinfective syndrome. He continued to deteriorate despite maximal treatment in the intensive care unit with IV ivermectin and meropenem. After discussing the patient’s poor prognosis with his family, treatment was withdrawn and he passed away shortly afterwards. Strongyloides stercoralis was first described from a faecal sample of a soldier in Vietnam. There are over thirty million people infected worldwide and the incidence of strongyloidiasis is increasing, facilitated by international travel, immigration and the increasing prevalence of immunocompromised patients. Australians with the highest risk of infection are those who have lived in or travelled to endemic areas, especially South East Asian immigrants, and aboriginal communities in Northern Australia.