Image 57: This 45 year old male, immigrated to Canada from Haiti in 1992. He described persisting epigastric pains since 1989. His normal bowel habit was one hard movement per 2 days. Gastroscopies in 1999 and 2005 and 2 oesophagoscopies revealed no abnormalities. He had little response to proton pump inhibitors, antacids or H2 blockers. His only past illness was a cholecystectomy in 2005. In 2007 an endoscopy revealed mild antral inflammation, an erythematous duodenal mucosa with a number of apthous ulcers and the biopsy findings shown here. His hematology and liver enzymes were normal. What was the diagnosis?

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Image 57:  The objects are the eggs (both morula and larval stage) of Strongyloides stercoralis in the duodenal crypts. mucosa and lamina propria. Several eggs measured 70 µm long and the larva 13.5 µm wide. A fresh stool was 4+ positive for both rhabditiform and filariform larvae. He was HTLV1 positive and had never been on steroids. He denied any itchy rashes in the past. His strongyloides serology (recombinant NIE antigen, National Centre for Parasitology, MCTD) was positive. It is reasonable that anyone from the tropics with dyspepsia unresponsive to therapy should have a strongyloides serology. Stool exams for strongyloides (concentration, Harada-Mori, Baermann extraction, charcoal culture and agar plate techniques) will miss 30-80 % of cases and small intestine biopsies, like this one, are infrequently positive.

Agar plate	Duodenoscopy 2007 (apthous ulcers)