Case+4+Discussion

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Multiple dilated loops of bowel with specific abnormally large gaseous distention of ascending colon, with large amounts of stool in sigmoid colon causing distention of colon. No air fluid levels observed. No free air. No overt 'coffee bean sign' (which would be consistent with volvulus). Xray appearing consistent with severe ileus.
 * Xray read:**

"Yes," you say, "I’d like to obtain stool microscopy."
 * Discussion:**

Stool microscopy returns with finding of heavy amounts of Strongyloides, indicating roundworm infection.

Diagnosis?
 * Severe ileus secondary to Strongyloides roundworm infection.**

Intestinal nematode infection is among the most common of all infections worldwide, most prevalent among rural communities in warm and humid climates where sanitation facilities are inadequate. The true burden of disease is poorly understood due to the generally nonspecific, insidious, and therefore often under-reported signs and symptoms of infection. Attempts to quantify the effects have shown the loss of 1-2 million DALYs (disability adjusted life-years) worldwide per nematode infection alone. Sub-saharan Africa specifically has had estimates of 5% of total DALYs lost due to communicable disease. The reality is that children growing up in endemic communities in Africa can be expected to be infected soon after weaning with constant reinfection (of even multiple organisms) for the remainder of their lives. And because of this infection during crucial young years, studies have posited an effect on growth and learning due to iron deficiency anemia (specifically hookworm) and other nutrient deficiencies. Specifically, a cluster of trials in Kenya have demonstrated that therapy results not necessarily in immediate cognitive gains, but definite improvement in school attendance suggesting the need for remedial catch-up education.

Our patient was found have strongyloides infection. This organism lives in the soil and completes a life cycle there before penetrating skin and enter a parasitic life cycle moving through lung alveoli to the bronchi to the esophagus, and finding a final home in the human intestine. Symptoms are very nonspecific and range from asymptomatic to severe disease with disseminated infection. However, as in all nematode infection, worm burden leads to malabsorption, abdominal pain and bloating, distention, episodic constipation, weight loss. Severe complications include, among others, bowel obstruction and, as in our case, severe paralytic ileus.

Of note, based on the xray alone, there was initial concern for volvulus. However given the chronicity of the symptoms in the absence of symptoms of a true obstruction, with xray demonstrating picture consistent with ileus, volvulus became less likely. However the coffee-bean sign for pediatric volvulus should be familiar.

Treatment for strongyloidiasis is advocated ivermectin 200mcg/kg/day for at least 2-3 days. We do stock that here and it was administered to the child. However given the degree of colonic distention seen, concern for bowel perforation was palpable, and therefore decompression was attempted with serial enemas. Soap enemas here consist of literally inserting a rod of soap into the rectum. PO administration of a laxative was thought to be dangerous in context of the distention. This was unsuccessful, and on consultation with a pediatric surgeon, patient was transferred to central hospital for possible surgical decompression.

The inner family doctor inside of you is screaming "How do we prevent this?" Wearing shoes has never been shown by studies to decrease nematode infection in these environments -- as much as we continue to receive Tom’s shoes and are forced to distribute them here. Education regarding waste management combined with education has been successful. In addition MOH through the WHO in most sub-Saharan African countries are now engaging in yearly de-worming Albendazole treatment to school aged children (as well as pregnant mothers). The role out has been spotty, and it is interesting that our patient has intermittently missed school due to his nematode infection. May he have missed a dose?