Diffuse Ulcerative Colitis Not Always Inflammatory Bowel Disease (IBD)

Abstract

Disseminated strongyloidiasis often presents with gastrointestinal (GI) symptoms and should be part of the differential diagnosis, especially in immunocompromised patients. It is a common infection in tropical and subtropical regions but has a prevalence up to 25% in individuals in the United States from endemic areas (immigrants, refugees, travelers, military personnel) and those living in southeastern states. Immunocompromised patients are at increased risk. We report a case of a 35-year-old Ethiopian man, diagnosed as HIV positive 3 years ago on HAART, who presented with chronic abdominal pain (intermittent, 10/10 severity) of 3 years' duration, but without diarrhea or blood in stool. Six months previously, multiple colonic biopsies had revealed diffuse acute and chronic inflammation with cryptitis and mucosal eosinophilia without parasitic forms being identified; small bowel biopsy showed no significant diagnostic abnormality. Repeat multiple colon biopsies revealed numerous intraluminal and intramucosal larva consistent with Strongyloides, diffuse acute and chronic inflammation with cryptitis and crypt dropout, mucosal ulceration, granulation tissue and tissue eosinophilia. Strongyloidiasis can involve any segment of the GI tract and has a broad range of endoscopic features. In previous studies, duodenal findings included edema, brown mucosal discoloration, erythematous lesions, subepithelial hemorrhages, and megaduodenum. In the colon, the findings included loss of vascular pattern, edema, aphthous ulcers, erosions, serpiginous ulcerations, and xanthoma-like lesions. Multiple discrete ulcers studded the entire colon in our patient. Diffuse GI involvement is often associated with hyperinfection and septic shock with an 87% mortality. Our patient with CD4 count 187/mL had limited symptoms on HAART and responded promptly to ivermectin. Our case study emphasizes the utility of colonoscopy and multiple colonic biopsies in establishing the diagnosis of strongyloidiasis and the efficacy of HAART in prevention of hyperinfection.