Hypoalbuminemia Secondary to Strongyloideshyper Infection - An Often Missed Entity

Strongyloidesstercoralis is distinguished among helminths by its unique ability to replicate in the human host. Strongyloidiasis (infection by S.stercoralis) can be contracted by walking barefoot on contaminated soil or through autoinfection. A 53-year-old male farmer presented to our outpatient department for evaluation of a progressive increase in abdominal distension and pedal edema. History was positive for alcohol intake but there were no signs of liver failure.Examination showed bilateral grade 2 pedal edema till the knees and free fluid in the abdomen. Investigations revealed normal cell counts, hypoalbuminemia, mildly elevated ALT, AST and typical coagulation profile. Ultrasound abdomen showed mild hepatomegaly with moderate ascites. Urine microscopy was negative for proteinuria. Esophagogastroduodenoscopy which was done as a part of screening for signs of liver failure, revealed duodenitis with multiple small ulcers (1-2 mm) and focal edema, which were biopsied. Histopathological examination showed crypts containing multiple Strongyloides and larva containing eggs. So, the stool was sent for examination, which revealed the rhabtitiform larva of Strongyloides. Hypoalbuminemia in this patient is concluded to be secondary to protein losing enteropathy due to strongyloides hyperinfection superimposed by alcoholism. He was commenced on a course of Ivermectin and Albendazole and protein rich diet. The patient's symptoms resolved on follow-up, and the albumin level gradually improved to 2.8g/dl.