JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
STRONGYLOIDIASIS PRESENTING AS RECURRENT COLITIS
ABERRANT RIGHT SUBCLAVIAN ARTERY: A RARE CAUSE OF DYSPHAGIA
R. Boyilla, MD; G. Randall, DO; A. Subedee, MD; W.K. Kellum, MD Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge *Presented as a mystery case Introduction: We describe a case of strongyloidiasis hyperinfection syndrome that exemplifies the pitfalls and risks in diagnosing and managing this potentially fatal illness. Case: A 73-year-old woman who emigrated from Ecuador 30 years ago presented with diffuse, progressively worsening abdominal pain and nausea for one week. She presented with similar symptomsmultiple times in the past 4 years. Prior workup included colonoscopies with biopsy demonstrating focal active colitis and proctitis, including an eosinophilic infiltrate. Prior stool ova & parasite exams were negative. Three months prior to presentation, she had been diagnosed with Drug Reaction with Eosinophilia and Systemic Symptoms syndrome (DRESS), and treated with high-dose steroids with prolonged taper, still ongoing at time of presentation. On presentation, her abdomen was diffusely tender with hypoactive bowel sounds. Lab results revealed hypoalbuminemia and Computerized Tomography scan of the abdomen revealed ascending colitis. She received stress-dose steroids, intravenous fluids, and empiric ciprofloxacin and metronidazole. Initial stool exam was negative for ova & parasites. Esophagogastroduodenoscopy was performed, revealing gastritis and duodenitis, with biopsy revealing intracryptal larval Strongyloides stercoralis . Repeat stool exam revealed rhabditiform Strongyloides larva. Oral ivermectin therapy was commenced. During the interval, she developed fever, lethargy, and became minimally responsive. Ivermectin was continued via nasogastric tube, albendazole was added, along with broad-spectrum antibiotics to cover gram-negative meningitis and sepsis. Shortly thereafter, the patient developed multi-system organ failure and expired. Discussion: Strongyloidiasis affects 10-40 percent of population in tropical/subtropical countries. This parasite can survive in human body for decades through autoinfection. In settings of immunosuppression, such as with steroids as in our patient, hyperinfection with widespread migration of the parasite beyond the GI tract can occur with resultant sepsis derived from bowel bacterial flora. Eosinophilia is frequently absent and stool exam has poor sensitivity. A high index of suspicion is needed to diagnose chronic Strongyloidiasis in immigrants with chronic abdominal symptoms, especially when there is a lack of eosinophilia and falsely negative stool exam.
C. Saraceni, MD; W.C. Kwan, MD; M. Spera, MD; S. Landreneau, MD Department of Internal Medicine, LSU Health Sciences Center - New Orleans *Presented as a mystery case Introduction: Aberrant right subclavian artery (also known as Arteria Lusoria) is the most common congenital anomaly of the aortic arch occurring in 0.5% to 1.8% of the population. The aberrant artery crosses midline behind the esophagus (80%), between the trachea and esophagus (15%), or anterior to the trachea (5%). The retroesophageal course of the right subclavian artery, although usually asymptomatic, may cause compression and a type of dysphagia known as dysphagia lursoria. Case: A 50-year-old woman with a medical history of von Willebrand disease, hypertension, asthma, and peripheral neuropathy presented with several weeks of progressive dysphagia associated with heaviness in her chest and 60 lb. weight loss. Her dysphagia began with solid foods and progressed such that three days prior to presentation, she could no longer tolerate solids or liquids. CTneck angiography revealed a congenitally anomalous aortic arch with a retroesophageal aberrant right subclavian artery. Barium esophagram did not reveal any intrinsic mass, polyp, diverticulum, or stricture. There was mild extrinsic mass effect on the posterior aspect of the upper esophagus however this caused no limitation of contrast passage. An EGDwas unremarkable and esophageal manometry was unremarkable with normal LES with normal relaxation. Discussion: Most patients with aberrant right subclavian arteries remain symptom-free throughout their lifetimes. Various proposed mechanisms for dysphagia include age related increased esophageal rigidity, right subclavian aneurysm formation, and elongation of the aorta. Barium swallow remains an effective tool for initial evaluation usually showing a characteristic diagonal impression in the esophagus at the level of 3rd-4th vertebra. EGD may reveal a pulsating mass around the same level. Esophageal manometry may reveal a high-pressure zone 25-30cm from the nose. CT angiography of the aortic arch, or endoscopic ultrasound are often used for definitive diagnosis. Initial treatment with a prokinetic or anti-reflux drug may be followed by surgery or endoscopic dilation if conservative therapy fails.
J La State Med Soc VOL 170 MARCH/APRIL 2018 55
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