(P99) The Importance of a Thorough History: A Case of Subtle Parasitic Disease

Chief Complaint : Dizziness, chest tightness, shortness of breath, and weight loss

History of Present Illness : A 57-year-old male with a past medical history of hypertension, GERD, hiatal hernia, and H. pylori infection presents to the emergency department with an acute pre-syncopal episode. The patient reports sudden onset of lightheadedness, diaphoresis, and tachycardia while brushing his teeth this morning. Symptoms resolved spontaneously after several minutes, and the patient is presently asymptomatic.

The patient also endorses episodic chest tightness and shortness of breath for the past six months. Episodes are provoked by exertion, but have also occurred at rest. During this time, he reports unintentional weight loss of approximately 60 pounds. He denies fevers, cough, abdominal pain, nausea, vomiting, diarrhea, constipation, or rashes.

The patient states that his episodic chest pain and shortness of breath began during an extended stay in Ghana one year ago. He had emigrated here from Ghana approximately thirty years ago. He does not take any medications. He denies recent diet changes.

Pertinent Physical Exam: The patient is cachetic, but is in no acute distress. Skin is warm and dry, and without rashes or lesions. His abdomen is soft and non-tender to palpation. Lungs are clear to auscultation and he is able to speak full sentences. Pulse oximetry is 98% on room air. Blood pressure and heart rate are within normal limits. He is afebrile.

Pertinent Laboratory Data: WBC 3.2k, Eosinophils 2.7%.
Hgb and LFTs are within reference range. HIV negative.
Computed tomography of the abdomen and pelvis with IV contrast reveals several small bowel loops which demonstrate non-specific continuous concentric wall thickening, as well as mild-to-moderate gastric overdistension and mild non-specific dilatation of the main pancreatic duct.

Case Discussion: The patient presents with an acute pre-syncopal episode in the setting of chronic intermittent chest tightness, shortness of breath, and weight loss. He endorses extensive outpatient work-up of his chronic symptoms by multiple specialists over the past six months which included an unremarkable EGD, colonoscopy, and chest CT.

Although his work-up in the emergency department yielded only non-specific findings, he is admitted to the hospital for further work-up in the setting of intermittent chest tightness and progressive unintentional weight loss. During his admission, he has positive serologic Strongyloides IgG antibody testing. He remains leukopenic and his eosinophils trend up to 7.6%. He also develops mild transaminitis with his AST and ALT trending up to 123 and 180, respectively. Additional imaging was obtained, and was notable for scattered small benign-appearing sub-centimeter liver cysts on abdomen MRI.

The patient is discharged with a plan for close outpatient gastroenterology follow-up and treatment with ivermectin. On follow-up a month later, the patient has completed treatment. He continues to endorse intermittent chest tightness but states his weight has been neutral since discharge.

This patient’s weight loss, eosinophilia, and positive antibody testing are consistent with a chronic Strongyloides infection. His weight stabilized after treatment, suggesting the infection was contributing to his weight loss. Additionally, strongyloidiasis has been shown to trigger an asthma-like response in some individuals, which may at least partially explain his episodic chest tightness.

This case highlights the importance of a thorough history and high clinical suspicion for individuals traveling to high risk areas. Non-specific symptoms should prompt further questioning on recent travel to high risk areas or other possible disease exposures. In this case, a thorough history facilitated diagnosis and treatment of an endemic infection which presented with subtle symptoms and lab findings resulting in evasion of detection on extensive outpatient evaluation.

References and Acknowledgements (Optional): none