Strongyloidiasis. When to suspect the wily nematode

Strongyloidiasis is a tenacious soil-transmitted nematode infestation endemic in the south-eastern United States. Thirty-three cases were diagnosed in a series of 1,290 stool examinations in 971 patients at Veterans Administration Medical Center, Mountain Home, Tennessee. Most patients had a concurrent major illness, such as chronic lung disease, serious bacterial infection, or cancer. A minority presented with gastrointestinal symptoms alone. Skin rash was uncommon. Eosinophilia, IgE elevation, and skin anergy were common. Atypical presentations included severe proctitis, colitis, and exacerbation of inflammatory bowel disease. In a patient with the hyperinfection syndrome, the diagnosis was made only at autopsy. Since strongyloidiasis seems to present like an opportunistic illness, all physicians, not just those in endemic areas, should consider its presence in the appropriate setting.