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Imaging Diagnosis

Radiology plays an important role in the diagnosis and management of patients with intestinal and pulmonary strongyloidiasis. Some patients will be referred with the clinical diagnosis of pneumonia, peptic ulceration, sprue, giardiasis, hookworm disease, amebiasis, and other gastrointestinal diseases. Recognition of the various clinical and radiological disease patterns seen in strongyloidiasis may suggest the correct diagnosis. The radiological changes correlate well with the pathological process and, therefore, provide an index for grading the disease and for planning therapy.

Intestinal Strongyloidiasis

During the early stages of the disease, or in less severe infections, the radiological findings will be somewhat nonspecific, yet may suggest the diagnosis to the astute observer. An upper gastrointestinal and small bowel series may show prominent mucosal folds in the gastric antrum and an irritable, spastic, tender duodenal bulb and C-loop with prominent, thickened, spiked transverse mucosal folds (valvulae conniventes) (Figs. 13.6, 13.7, 13.8). There may be flocculation of barium in the duodenum and proximal jejunum from excess fluid and mucous secretions and rapid peristalsis and irritability. The caliber of the proximal small intestine is difficult to evaluate because of the flocculation, poor mucosal coating, and rapid transit. The radiographic appearance of the duodenum and jejunum is typical of inflammation and irritability, such as may be seen also with giardiasis. Occasionally the ileum may show widening and coarsening of the valvulae conniventes, but spasm and inflammatory changes are unusual beyond the jejunum. Rarely, the colon may show mucosal irregularity and ulceration (Fig. 13.7B). This pattern of the disease is reversible and the intestines will return to a more normal appearance after appropriate treatment (Fig. 13.7).

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Fig. 13.6 Strongyloidiasis in the early stages of the disease, when the clinical presentation may mimic duodenitis and peptic ulceration. Three different patients from Colombia (A and B) and India (C). Upper GI series in all three patients demonstrates irritability and spasm of the pylorus, duodenal bulb and C-loop, and proximal jejunum. Exaggerated movement of barium in the second and third portions of the duodenum was noted fluoroscopically. Mucosal folds are thickened and irregular in some areas but their outline is indistinct. The duodenal C-loop and proximal jejunal loops demonstrate poor filling and outlining of their contours because of the irritability, edema, and excess mucous secretions present. The overall appearance is that of inflammation and irritability in the duodenum and proximal jejunum such as may also be seen in giardiasis. Note the somewhat unusual involvement of the gastric antrum in patients A and C. (D) Strongyloides stercoralis in the human bowel. There is a copious outpouring of mucus into the bowel lumen. In the mucus one can see longitudinal and cross-sections of larvae. Eggs and larvae are present in the crypts.

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Fig. 13.7 Strongyloidiasis of the small bowel and colon in a 38-year-old Puerto Rican man admitted to the hospital with gastrointestinal bleeding and cirrhosis (proven by liver biopsy). He required two units of blood. Strongyloides stercoralis filariform larvae were found in his urine and rhabditiform larvae in his feces and duodenal aspirate. Serum protein was 5.1 (albumin 1.6 gm) on admission and 7.2 gm/100ml (albumin 2.4 gm) 3 weeks later after treatment with thiabendazole. In (A) there is marked irritability and spasm of the pylorus, duodenal bulb and C-loop, and proximal jejunal loops, with spiking and coarsening of the mucosal folds throughout the proximal small bowel. In (B) there is widening and thickening of the valvulae conniventes in the ileum, but no spasm is identified in the distal small bowel. There is irregularity and ulceration of the transverse colon. (C) Follow-up GI series 1 month after treatment shows a much more normal mucosal pattern throughout the small intestine. There is no evidence of irritability or spasm and the only residual abnormality is some thickening and prominence of the mucosal folds, especially in the ileum. (Courtesy of Dr. Emanuel Levine, Brooklyn, New York.) (D) Intestine of patient with strongyloidiasis showing S. stercoralis in the lamina propria surrounded by inflammatory cells. AFIP 63-2327-1.

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Fig. 13.8 Strongyloidiasis of the small bowel in a Puerto Rican man showing both inflammatory and malabsorption changes on films from a small bowel series taken 30 minutes (A), 2 hours (B), and 3 hours (C) after ingestion of barium. Note in (A and B) dilatation of the duodenal C-loop and proximal jejunal loops, with marked edema and thickening of the valvulae conniventes. In (B and C) there is fragmentation and segmentation of the barium and a moulage appearance with poor visualization of the distal jejunal and ileal loops from excess fluid and mucus in the bowel. There is also considerable hypomotility, as evidenced by the delayed transit time and delayed gastric emptying. The overall appearance suggests an inflammatory process in the proximal small bowel as well as a malabsorption pattern in the jejunum and ileum. (Courtesy of Dr. Heriberto Pagan-Saez, San Juan, Puerto Rico).

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