Monday, September 4, 2017

Case of the Week 459

This week's case is a stool specimen from an elderly man from Kentucky. He reports no travel history outside of the United States. The patient presented with an approximate 50 pound unintentional weight loss over the past several months as well as diarrhea and abdominal cramping.

The following were seen on the stool concentrate (Images courtesy of our Clinical Microbiology Fellow, Dr. Alexandra Bryson):
(10x objective)

(40x objective)

Diagnosis? What forms are seen here?


Anonymous said...

Strongyloidiasis. It's endemic here in rural Kentucky.

Anonymous said...

Strongyloides stercoralis rhabditiform larvae. The higher magnification shows the short buccal cavity as well as the genital primordia. The eggs are already embryonated and this explains the autoinfection leading to the fast weight loss. We usually do not get to see the ova in less severe infections where the diarrhea flow is not as fast.

Florida Fan

adebiyi said...
This comment has been removed by the author.
Nate said...

So I was thinking Strongy with the region and then you can see folks as they get older get symptomatic who may have had it for years. I always have a hard time saying short or long buccal cavity when I'm looking at just one species and not a mixed infection comparing so that one is 50/50 to me, and the first 40x picture doesn't look particularly short and the second could just be the angle that makes it look short. I may just be missing it to, but I'm having a hard time saying there is truly a genital primordium. It's hard when you can't focus up and down.. Also, typically you don't see eggs in stool, so I would think hook worm is something to strongly consider here. Definitely endemic in regions of the South though you don't see it much with people wearing shoes now a days.

I would say that regardless of the worm pictured, rhabditiform larvae are present.

Anonymous said...

I think I can see the short buccal canal of Strongyloides. If so, would the presence of eggs in the stool be associated with a particularly intense infection and the reported diarrhea?

I'm pretty new at this, thank you for posting these cases and the library of flash cards. Both are extremely helpful and fun to look at as I become familiar with common and exceptional parasites!

Mark Fox

PS I posted last week about phoresy, but I think the questing behavior you described is the more likely explanation. The tick wanted to cling to the highest point, and that poor weevil just happened to be it! Here's a photo of another questing tick from a Louisiana salt marsh:

angélica maria said...

Hiperinfeccion por Strongyloides sp.A una de las larvas se le aprecia el primodio genital. Lo cual lo diferencia de una infección por uncinarias.

Sugar Magnolia said...

Strongyloides stercoralis. I concur that the short buccal cavity is a classic feature. This must be quite the heavy infestation, as the eggs are a rare sighting in a stool specimen. The larvae themselves are rhabditiform. Thank you for sharing these impressive slides with us! It would be very uncommon to see this in practice.

To Florida Fan - I do hope you are out of harm's way from Irma. My heart is with you and your fellow Floridians; we are still on the long road to recovery in coastal South Texas due to Hurricane Harvey. Please stay safe.

Anonymous said...

Sweet Magnolia,
Thank you for your heart warming thoughts, we made it safely to Atlanta. Let's put our fate into God's caring hands and our resilient resolve to build it better, not only for ourselves but also the generations to come.
Floria Fan

Bobbi Pritt said...

I'm so glad to hear that!! Thank you for letting us know.

Bobbi Pritt said...

Thank you for the note Mark. I'm glad you're finding my blog and website to be useful. I really enjoy comments so I appreciate that you took the time to post. Have a great week! Bobbi

Khalid Elfeel said...

Strongyloides stercoralis ( soil transmitted )
L1 ( Rhabditiform) larva passes out with the feces onto soil, where it develop through free living L2 stage larva to the infective L3 filariform larva within 1- 2 day.
L1 larva has a short buccal capsule, genital primordium and pointed tail.