Strongyloides stercoralis hyperinfection syndrome presenting as mechanical ileus after short-course oral steroids for chronic obstructive pulmonary disease (COPD) exacerbation.

We report a case of a fatal Strongyloides stercoralis hyperinfection syndrome (SHS) in a migrant from Kenya, who had been living in Germany for three decades. A short-course oral steroid treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation had been administered four weeks prior to the presentation. The initial clinical and radiological findings suggested a mechanical small bowel obstruction as a cause of ileus. Our case highlights the importance of maintaining a high index of suspicion for strongyloidiasis in patients from endemic areas even years after they left the country of origin. It demonstrates that even a five-day course of prednisolone is able to trigger SHS in patients with underlying strongyloidiasis. History of frequent previous administration of oral prednisolone for COPD exacerbations in our case raises the question why and how the last steroid regimen provoked SHS. SHS can present with multiple gastrointestinal symptoms including ileus and the absence of eosinophilia during the whole course of the disease should not lower the level of suspicion in the appropriate clinical setting.

Toxocara encephalitis presenting with autonomous nervous system involvement.

Human toxocariasis has been reported to cause a broad spectrum of neurological syndromes, including encephalitis, meningitis and meningo-radiculitis. Nevertheless, cerebral infection by Toxocara may go undiagnosed due to its rarity, elusive symptoms and lack of availability of appropriate testing. We report the case of a 54-year-old man who presented with abdominal pain and paralytic ileus approximately 3 weeks after having eaten raw snails (a folk remedy for peptic ulcer). Three weeks later, marked eosinophilia ensued, associated with mental clouding, nystagmus, diplopia, peripheral limbs ataxia, urinary retention, slackened deep tendon reflexes, arthralgias and myalgias. Cerebrospinal fluid (CSF) examination demonstrated an eosinophilic meningitis, and Toxocara canis cerebral infection was diagnosed by positive serology and by the detection of T. canis DNA in the CSF. The patient made a full recovery following treatment with albendazole and corticosteroids. Physicians should be aware of this rare presentation of toxocariasis, whose diagnosis is, today, facilitated by molecular biology techniques. A history of ingestion of raw snails may alert the clinician to consider the possibility of such an uncommon condition.

Case of acute ileus caused by a spirurina larva.

A growing body of clinical cases suggests that a kind of nematode larva, type X larva of the suborder Spirurina that inhabits firefly squids (Watasenia scintillans, or 'Hotaru-ika' in Japanese), can cause acute ileus in humans. However, the larva itself has rarely been found in the wall of the obstructed intestine. We describe here a case of acute ileus, in which a type X spirurina larva was found histologically. A 60-year-old Japanese man suffered from acute abdomen, and an emergency laparotomy revealed a marked stenosis of the ileum. Histological study of the surgically resected ileum showed severe eosinophilic enteritis and a nematode larva. The morphological features of this larva were identical to those of the type X spirurina larva. Interestingly, the larva that was found existed within a small blood vessel, suggesting that the larva migrans of type X spirurina can take place via vasculature. The patient in the present case did not recall ingesting raw squids prior to the onset of his disease. Hence, this indicates that even if the ingestion of raw firefly squids is uncertain, spirurina infection should be included in the differential diagnosis of acute ileus or eosinophilic enteritis.