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Year : 2011  |  Volume : 54  |  Issue : 3  |  Page : 644-645
Concurrent infection of candidiasis and strongyloidiasis in an endoscopic biopsy in an immunocompetent host


1 Department of Pathology, Meenakshi Medical College Hospital and Research Institute, Enathur, Kanchipuram, India
2 Department of Gastroenterology, Meenakshi Medical College Hospital and Research Institute, Enathur, Kanchipuram, India

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Date of Web Publication20-Sep-2011
 

How to cite this article:
Prakash G, Gupta RK, Prakhya S, Balakrishnan R. Concurrent infection of candidiasis and strongyloidiasis in an endoscopic biopsy in an immunocompetent host. Indian J Pathol Microbiol 2011;54:644-5

How to cite this URL:
Prakash G, Gupta RK, Prakhya S, Balakrishnan R. Concurrent infection of candidiasis and strongyloidiasis in an endoscopic biopsy in an immunocompetent host. Indian J Pathol Microbiol [serial online] 2011 [cited 2020 May 24];54:644-5. Available from: http://www.ijpmonline.org/text.asp?2011/54/3/644/85131


A 70-year-old female coming from a rural background was admitted to our hospital with a two month history of epigastric pain, dyspepsia, abdominal bloating, progressive dysphagia, anorexia and insidious weight loss. She had a known history of bronchitis. On examination, she was conscious and oriented, exhibited moderate pallor and had epigastric tenderness. Except for hemoglobin of 4 g/dl, all her investigations including chest radiograph were within normal range. The patient had no peripheral eosinophilia. Her serology was non-reactive for both HIV and hepatitis B. Routine stool examination was also non-contributory. Based on her symptoms, the patient was subjected to an esophagogastroduodenoscopy (EGD) which revealed multiple patchy white plaques over the esophageal mucosa in the distal 10 cm [Figure 1]a and b along with edema, erythema, punctuate tiny hemorrhages and multiple sessile, bleb-like lesions or pseudopolyps in the first part of duodenum [Figure 1]c and d. Endoscopic biopsies were taken from representative areas in both the esophagus and duodenum and sent for histopathological examination. The patient was diagnosed with esophageal candidiasis on the basis of endoscopic findings and started on antifungal therapy along with red cell transfusion for her low hemoglobin level. Histopathologic examination of the esophageal biopsy showed mildly dysplastic and ulcerated epithelium with overlying hyphal and yeast forms of Candida, which was confirmed by a PAS stain [Figure 2]a-c. The dysplasia was probably secondary to the Candidiasis infection. The duodenal biopsy showed florid Strongyloides stercoralis infestation with eggs and both larval and adult forms of the parasite mostly within the crypts of the duodenal mucosa and even on the surface epithelium [Figure 3]a-d. Other prominent features included mild to moderate duodenitis with prominent eosinophilic infiltrate around many of the adult parasites, crypt distortion and focal villous blunting [Figure 3]a and d. A final diagnosis of esophageal candidiasis with strongyloidiasis of the duodenum was given. On the basis of this report, albendazole was added to the patient's treatment regimen. The patient's condition improved considerably with this dual treatment. Unfortunately, the patient took discharge against medical advice on the eighth day and did not return for follow-up.
Figure 1: (a and b) Endoscopic view showing multiple patchy white plaques over the esophageal mucosa. (c and d) Endoscopic view showing edema, erythema and multiple bleb-like lesions ("pseudopolyps") in the first part of duodenum; arrow in (d) showing site of biopsy

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Figure 2: (a) Low power view showing hyphal and yeast forms of Candida overlying esophageal epithelium (Hemotoxylin and eosin (H and E), ×100). (b) High power view of mildly dysplastic and ulcerated esophageal epithelium adjacent to the Candida colony (H and E, ×400). (c) High power showing the Candida colony (PAS, ×400)

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Figure 3: (a) Scanner view of duodenal mucosa with many crypts showing Strongyloides larvae along with normal (arrow) and blunted (arrowhead) duodenal villi (H and E, ×40). (b) Low power view of duodenal mucosa clearly showing several crypts fi lled with larval and adult forms of Strongyloides (H and E, ×100). (c) Low power view showing Strongyloides eggs within crypts and free larval forms overlying the surface epithelium (H and E, ×100). (d) High power view showing a single Strongyloides larva within a crypt surrounded by prominent eosinophilic infiltrate in the lamina propria; also seen a Strongyloides egg in an adjacent crypt (H and E, ×400)

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   Discussion Top


Both Candida and Strongyloides infection, though several times commoner in immunocompromised hosts can rarely infect immunocompetent hosts.

Commonly found as commensals in upper gastrointestinal tract (GIT), Candida are dimorphic fungi that can cause a range of infections both in healthy and immunocompromised hosts respectively. It usually grows on warm moist surfaces inside the body and is one of the most common etiologies of infectious esophagitis particularly in immunosuppressed patients like those suffering from malignancy, HIV, transplant recipients, diabetics and those on long-term corticosteroid therapy or proton pump inhibitors (PPIs). [1] The usual symptoms of esophageal candidiasis are dysphagia, oral thrush and abdominal discomfort. EGD demonstrates characteristic whitish plaques in the esophagus, which on biopsy show hyphal and yeast forms of Candida (both HandE and PAS) overlying desquamated hyperplastic or dysplastic esophageal squamous epithelium as in our case. Complications include ulceration, hemorrhage and esophageal obstruction secondary to stricture formation.

Strongyloides stercoralis is an intestinal parasite, endemic in both tropical and temperate regions with a complex lifecycle. [2],[3] It usually resides in the duodenum, colon or rarely in the stomach. Infection is acquired when the larva penetrates the skin to enter the circulation, reaches the lungs from where they are coughed up and swallowed into the intestines to develop into mature adult worms. It is usually asymptomatic in healthy hosts but can rarely cause life-threatening hyperinfection. [4] Common symptoms are dyspepsia, abdominal pain, bloating, diarrhea, vomiting, and small bowel obstruction as well as cough, wheezing, and even pneumonia. [3] Predisposing factors are low socioeconomic status, rural occupations, malnutrition, alcoholism, old age, immunocompromised conditions like therapy with corticosteroids, cyclosporine, and anti-cancer drugs, hematologic malignancies and infection with HIV and HTLV-1 viruses and rarely in persons taking PPIs chronically. [3],[4],[5] Although initial diagnosis is usually suspected by suggestive history and peripheral eosinophilia and established by a routine stool examination, neither are sensitive tests and therefore EGD with mucosal biopsy is vital for diagnosing Strongyloides infection. [2],[3],[4] Endoscopic features include erythema, edema, subepithelial hemorrhages, mucosal blebs or pseudopolyps, white villi, stenosis and megaduodenum. [2],[3] Characteristic biopsy features are duodenitis, villous blunting and even atrophy, ulceration, crypt distortion, infiltration of the lamina propria with plasma cells and eosinophils and Strongyloides eggs, larvae and adult worms both within the crypts and the surface epithelium. [2],[3],[5]

Besides old age, malnutrition and a rural occupation, the patient had no other major known risk factor(s), which could account for his infections. Thus, this is the first case in the world, to the best of our knowledge, with such a rare dual infection in an immunocompetent host, which has been diagnosed by endoscopic biopsy. Our case highlights the importance of endoscopic biopsy of the upper GIT as an indispensible tool in the workup of undiagnosed chronic abdominal pain.

 
   References Top

1.Sood A, Sharma M, Jain NP, Chawla LS, Kumar R. Esophageal candidiasis following omeprazole therapy: A report of two cases. Indian J Gastroenterol 1995;14:71-2.  Back to cited text no. 1
[PUBMED]    
2.Thompson BF, Fry LC, Wells CD, Olmos M, Lee DH, Lazenby AJ, et al. The spectrum of GI strongyloidiasis: An endoscopic-pathologic study. GastrointestEndosc 2004;59:906-10.  Back to cited text no. 2
    
3.Kishimoto K, Hokama A, Hirata T, Ihama Y, Nakamoto M, Kinjo N, et al. Endoscopic and histopathological study on the duodenum of Strongyloidesstercoralishyperinfection. World J Gastroenterol 2008;14:1768-73.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Satyanarayana S, Nema S, Kalghatgi AT, Mehta SR, Rai R, Duggal R, et al. Disseminated Strongyloidesstercoralis in AIDS: A report from India. Indian J PatholMicrobiol 2005;48:472-4.  Back to cited text no. 4
    
5.Rivasi F, Pampiglione S, Boldorini R, Cardinale L. Histopathology of gastric and duodenal Strongyloidesstercoralis locations in fifteen immunocompromised subjects. Arch Pathol Lab Med 2006;130:1792-8.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Rajib K Gupta
Department of Pathology, Meenakshi Medical College and Research Institute, Enathur, Kancheepuram - 631 552
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.85131

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