Routine H&E staining of the gastric mucosa (figure 2) showed four Strongyloides stercoralis eggs (*) and one larva (arrowheads). In-house ELISA detecting IgG1/IgG4 against S. stercoralis showed a titre > 1:2560 (cut-off 1:40; Leiden University Medical Center). A faecal specimen revealed larvae using the Baermann and Ridley tests. In retrospect, the diagnosis of strongyloidiasis should have been considered earlier due to his origin, increased eosinophil count and long-term use of immunosuppressants.
Strongyloidiasis is caused by S. stercoralis and is endemic in tropical and subtropical regions. This persistent parasitic infection can lead to intermittent symptoms affecting the gastrointestinal tract, lungs or skin.1 The severity varies from an asymptomatic infection in immunocompetent patients (eosinophilia) to a life-threatening disease, called hyperinfection syndrome, in immunocompromised patients.2
Hyperinfection syndrome is characterised by malabsorption, protein-losing enteropathy and/or colitis or even sepsis. The parasite burden is greatly increased, with high mortality rates if left untreated. Therefore, it is vital to detect and eradicate S. stercoralis prior to initiation of immunosuppressive therapy in high-risk patients.3
However, this is not routine practice and our patient was not screened for this infection prior to the start of immunosuppressants.
In the absence of other causes, we reasoned that the gastric dilatation was the cause of his complaints of malaise, anorexia and hiccups. Gastric ulcers, duodenal obstruction or duodenal dilatation have previously been described in individuals with strongyloidiasis.4 The exact pathophysiological mechanisms remain unknown. The patient was treated with ivermectin 0.2 mg/kg, a broad-spectrum antiparasitic drug, for three days, after which his symptoms resolved completely and remain absent to date.