Strongyloides Hyperinfection in Renal Transplant - diagnosis by Endoscopic Intestinal Biopsy

Introduction: Intestinal parasites continue to be a significant health problem in renal transplantation patients. Strongyloides infection is unique that it excretes larvae and can continue life cycle by auto infective cycle also.
Presentation of the case: We present a 26 years old man presented with acute cellular rejection after three months of kidney transplantation. Before transplantation stool of both recipient and donor was negative for parasites. He received three doses of intravenous methylprednisolone. After one month he presented with severe epigastric pain and vomiting. On examination he was malnourished, dehydrated and lost two kilograms of weight over one month. His serum albumin was 2.9 mg/dL. Pain did not subside with proton pump inhibitors. Stool examination was negative for parasites. As index of suspicion for parasites was high, upper GI endoscopy was done; it showed multiple ulcers in duodenum. Biopsy of the ulcer showed strongyloides infection He was treated with ivermectin. Abdomen Pain was subsided soon. He gained weight of 1.5 kilograms over next month.
Conclusion: When transplant patients from developing country with recent increase of immunosupression presents with severe abdomen pain, the intestinal parasitic infection should be entertained. If stool examination is negative and serology is unavailable, early evaluation by endoscopic biopsy is helpful to diagnose strongyloides. Prolonged treatment with ivermectin and follow-up stool examinations are important for complete cure of strongyloides infection.