When Paradise Gives You Parasites

INTRODUCTION: Infectious, allergic, neoplastic and inflammatory disorders are known causes for peripheral blood eosinophilia. Strongyloidiasis, a parasitic infection endemic to tropical and subtropical regions, is a well-known cause of eosinophilia. Transmission is more common by way of direct skin contact with contaminated soil. Asymptomatic states can be present for decades. Disseminated and severe infections occur most commonly after the use of steroid therapy. Gastrointestinal manifestation can range from abdominal pain, watery diarrhea, constipation, anorexia, weight loss among others, some of which can be fatal. We present a case of Strongyloidiasis as a cause of eosinophilia in an immunocompetent male to emphasize the importance of evaluation of parasitic infections in endemic areas. CASE DESCRIPTION/METHODS: A 74-year-old male with past medical history of neck squamous cell carcinoma s/p radiotherapy in remission since 2017, referred to Gastro clinics for screening colonoscopy. Patient denied weight loss, diarrhea, melena, hematochezia, fever, chills, nausea, vomiting, or any other symptoms. Routine labs without leukocytosis, anemia or thrombocytopenia, renal and liver function test within normal limits. However, marked chronic peripheral eosinophilia ranging from 20-25% was noted. Patient underwent colonoscopy which was relevant for essentially normal macroscopic colonic mucosa. However, scattered white spots at cecum and ascending colon were noted, cold forcep’s biopsy were taken in order to rule out Schistosoma or Strongyloides in the setting of peripheral eosinophilia. Pathology report was relevant for mucosa with marked increase in eosinophils and positive for the presence of Strongyloides parasite. Patient was prescribed Ivermectin 200 µg/kg orally, follow-up labs showed resolve eosinophilia and Strongyloides infection. DISCUSSION: Despite the case presenting a patient with disseminated Strongyloidiasis, clinical manifestations were not concerning for severe infection. The condition was found incidentally by colonoscopy due to characteristic findings on colonic mucosa that in the setting of peripheral eosinophilia increased the clinical suspicion for the presence of the condition. This case reinforces the fact that clinicians should always be aware of abnormal patterns of lab results and use further evaluation in case needed, in order to establish the etiology for the findings, since it will result in a better care for our patients with the appropriate management.Figure 1.: Strongyloides parasite in colonic mucosa.