Strongyloides stercoralis mesenteric lymphadenopathy: Clue to the etiopathogenesis of intestinal pseudo-obstruction in HIV-infected patients

Mesenteric lymph node involvement in Strongyloides stercoralis hyperinfective states, described as an autopsy finding, remains a relatively poorly recognized and possibly underreported, antemortem phenomenon. Furthermore, the occurrence of S stercoralis mesenteric lymphadenopathy as a tocsin of bowel strongyloidiasis and the clue to the cause of intestinal pseudo-obstruction are undescribed. We report S stercoralis mesenteric lymphadenopathy and intestinal pseudo-obstruction in 5 HIV seropositive male patients, 21 to 42 years, who presented with abdominal pain and variable vomiting, diarrhea, and constipation. All were pale, pyrexial, and emaciated with abdominal distension. The preoperative diagnosis was intestinal obstruction. Poor clinical response on conservative therapy necessitated laparotomy. Dilated small bowel loops, ascites, and mesenteric lymphadenopathy were consistently noted; a diagnosis of pseudo-obstruction due to underlying tuberculosis or lymphoma was made. The mesenteric lymph nodes were biopsied. The pertinent nodal features were a dense infiltrate of eosinophils, eosinophil microabscesses and degranulation, a focal Splendore-Hoeppli phenomenon, and randomly disposed, but elusive, S stercoralis filariform larvae. Clinical deterioration confirmed intestinal complications at repeat laparotomy. Intestinal resections were performed in 4 patients; histopathologic appraisal confirmed intestinal strongyloidiasis. All patients died within 3 to 7 days after surgery. Heightened awareness of S stercoralis mesenteric lymphadenopathy as a sentinel of intestinal strongyloidiasis and etiopathogenetic clue of intestinal pseudo-obstruction may allow timely diagnosis and medical treatment and avoidance of further surgery, potentially reducing the long-term morbidity associated with S stercoralis hyperinfection.