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Eosinophilic esophagitis : a classic presentation

Gastrointestinal infection with Strongyloides stercoralis is seen commonly throughout the world. Unlike with other parasitic infections such as Ascaris lumbricoides and Fasciola hepatica, hepatobiliary complications have rarely been described with S. stercoralis. We report a case of papillary stenosis and biliary obstruction caused by S. stercoralis. A 46 y/o male from the Virgin Islands presented with crampy abdominal pain and nausea. Exam showed a cachectic man with epigastric tenderness. Laboratory data revealed eosinophilia (21%), albumin 1.3 g/dl, alkaline phosphatase of 88 iu/l, and total bilirubin of 0.6mg/dl. Abdominal ultrasound and CT scan identified a dilated biliary duct (CBD 11mm) and pancreatic duct. An ERCP was performed demonstrating a swollen, edematous ampulla with dilated pancreatic and biliary ducts (treated by sphincterotomy). Biopsies of the ampulla revealed the presence of numerous S. stercoralis ova. Further evaluation revealed hyperinfection with the presence of pulmonary infiltrates while bronchoalveolar lavage was positive for adult parasites. He was HIV negative, however, immunosuppression from underlying infection with HTLV-1 was identified. The patient recovered following treatment with thiabendazole for 2 weeks. This case highlights the need to consider Strongyloides infection as a cause for papillary stenosis.