Strongyloidiasis differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2], Furqan M M. M.B.B.S[3]

Overview

Strongyloidiasis can mimic other worm infections like Ascaris lumbricoides, Trichuris trichiura, hookworm infections (Necator americanus and Ancylostoma duodenale), Enterobius vermicularis (pinworm) and gastrointestinal pathologies such as peptic ulcer disease, intussusception in children, and bile duct stone.

Differentiating Strongyloidiasis from other diseases

The table below summarizes the findings that differentiate strongyloidiasis from other nematode infections:

Differentiating strongyloidiasis from other Nematode infections
Infection	Nematode	Transmission	Direct Person-Person Transmission	Duration of Infection	Pulmonary Manifestation	Location of Adult worm(s)	Treatment
Strongyloidiasis	Strongyloides stercoralis	Filariform larvae penetrate skin or bowel mucosa	Yes	Lifetime of the host	Löffler's syndrome Chronic cough Pneumonia or sepsis in hyperinfection	Embedded in the mucosa of the duodenum and jejunum	Ivermectin Albendazole Thiabendazole
Trichuriasis	Trichuris trichiura (whipworm)	Ingestion of infective ova	No	1-3 years	No pulmonary migration, therefore, no pulmonary manifestation	Anchored in the superficial mucosa of cecum and colon	Albendazole Mebendazole
Ascariasis	Ascaris lumbricoides	Ingestion of infective ova	No	1-2 years	Löffler's syndrome (usually about 9-12 days after exposure to ova) Cough Substernal discomfort Crackles Wheezing Transient opacities	Free air in the lumen of the small bowel (primarily jejunum)	Albendazole Mebendazole Pyrantel pamoate Ivermectin Levamisole Piperazine
Hookworm infection	Necator americanus and Ancylostoma duodenale	Skin penetration by filariform larvae	No	3-5 years (Necator) 1 year (Ancylostoma)	Löffler's syndrome Transient opacities	Attached to the mucosa of mid-upper portion of the small bowel	Albendazole Mebendazole Levamisole Pyrantel pamoate
Enterobiasis	Enterobius vermicularis (pinworm)	Ingestion of infective ova	Yes	1-month	Extraintestinal migration is very rare	Free air in the lumen of cecum, appendix, adjacent colon	Albendazole Mebendazole Pyrantel pamoate Ivermectin Levamisole Piperazine

• Strongyloidiasis, when it involves the gastrointestinal tract, presents with abdominal pain and must be differentiated from other GI disorders like peptic ulcer disease, intussusception, and bile duct stone.
• The table below summarizes the findings that differentiate strongyloidiasis from peptic ulcer disease, intussusception, and bile duct stone:

Disease	Common findings	Differentiating features	Laboratory findings
Peptic ulcer disease	Abdominal pain Bloating and abdominal fullness Nausea, and lots of vomiting Loss of appetite and weight loss Hematemesis	Epigastric with severity relating to mealtimes Waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus)	Rapid urease testing positive H. pylori on histology Negative stool exam and serology
Intussusception	Abdominal pain that is colicky and intermittent	Currant jelly stools Most cases occur in children ages 6 months - 2 years	Ultrasound findings include the target and pseudokidney signs
Bile duct stone	Acute abdominal pain Nausea and vomiting	Pain is usually located in the upper right abdominal area radiates to shoulders Jaundice	Bilirubin Abnormal liver function tests Elevation of pancreatic enzymes

The table below summarizes the findings that differentiate intestinal strongyloidiasis from other conditions that may cause abdominal pain and diarrhea

	History	Symptoms				Diagnosis
		Abdominal pain	Diarrhea		Peritoneal Signs	Stool examination	Laboratory Findings	Gold standard
			Dysentry	Watery
Intestinal strongyloidiasis	Travel to the endemic areas	+	-	+	-	Eggs	Eosinophilia	Stool exam
Intestinal infections	Antibiotic use	+	+	-	+	-	Leukocytosis	Blood culture
Inflammatory bowel disease	Exacerbations	+	+	-	+	Occult blood	Leukocytosis	Biopsy
Irritable bowel syndrome	Altered bowel habits	-		+	-	-	-	Clinical diagnosis
Peritonitis and abdominal sepsis	Surgery Diverticular disease Inflammatory bowel disease, Obstruction	+	-	-	+	-	Leukocytosis	CBC,Blood culture
Cholera	Poor sanitation Contaminated water supply	-	-	+	-	-	Leukocytosis	Clinical diagnosis
Diverticulitis	Constipation	+	+	-	+	Occult blood	Leukocytosis	CT

The table below summarizes the findings that differentiate pulmonary strongyloidiasis from other conditions that may cause cough, wheezing, dyspnea and hemoptysis

Disease	History	Symptoms							Diagnosis
		Cough		Dyspnea	Hoarsness	Hemoptysis	Wheezing	Hypoxia	Laboratory Findings	Imaging
		Productive	Dry
Pulmonary strongyloidiasis	Travel to the endemic areas	-	+	+	+/-	+	+/-	-	Eosinophilia	Segmental or lobar opacities Pleural effusion Cavitations and abscesses
Chronic obstructive pulmonary disease	Smoking	+	-	+	+	-	+	+	-	Hyperinflation
Acute respiratory distress syndrome	Surgery Infection or sepsis Acute medical illness Trauma	-	+	+	-	-	+	+		Diffuse infiltrates
Asthma	Family history Previous exacerbations	-	+	+	-	-	+	+	Mild eosinophilia
Pneumonia	Ill contact	+		+	-	+	-	+	Leukocytosis	Consolidation