Pre-school of 3 years 10 months coming and resident of Sarayacu, province of Pastaza, Ecuador.
Established on the banks of the Boboaza River, inhabitants have the cultural habit of barefoot.
The child was born at home and the childbirth was by her grandmother.
The patient had a history of diarrhea that required hospitalization and chronic anemia two years ago.
He was admitted to our Pediatrics Service for a three-day clinical course characterized by moderate diffuse abdominal colic pain.
Concomitantly, she presented several episodes of semi-liquid stools with small amounts of fresh blood.
The clinical picture was accompanied by a marked weight loss in the last month and evident compromise of the general state.
Physical examination revealed a child with signs of severe malnutrition, anthropometry (weight and height Z -2), poor general condition, T 37 °C, HR 110 per min, RR 23 per min, and pulse oximetry 93%.
The skin presented turgidity, decreased dry oral mucous membranes, generalized dryness and decreased subcutaneous cellular tissue.
Cardiopulmonary examination was normal.
Abdominal examination revealed diffuse pain in the abdomen, predominantly mesogastrium, increased hydroaerial sounds, without visceromegaly.
Normal extremities without edema.
An anal examination revealed active bleeding with red blood cells.
Laboratory tests showed normocytic anemia (hemoglobin 8 g/dl), 13,500 leukocytes/mm3 with 71% segmented and 18.4% irregular.
Liver and kidney function was normal.
Abdominal ultrasonography was performed with no relevant findings and direct microscopic observation of depositions with absence of remnants and polymorphonuclear cells, and abundance of parasites (50-60 per field).
HIV serology was negative.
With the diagnosis of lower gastrointestinal bleeding, the patient underwent an exploratory laparotomy finding multiple masses suggestive of malignancy.
The patient was admitted with several episodes of hematochezia. A multiple colon was performed, finding a large amount of fluid in the dark brown color in the lumen, adhered to the mucosa.
In addition, a polypoid formation of 18 mm in diameter, elevated, pulsatile, with an ulcer in the cecum, covered with fibrin on its surface, was observed.
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The patient also presented several episodes of melena posterior to the mental illness.
She was treated with continuous infusion of red blood cells.
The patient underwent upper endoscopy which showed mild erythematous gastropathy without bleeding traces, with multiple cysts in the duodenum.
On continuing with melena, the child underwent a second laparotomy in which free fluid of approximately 50 cc was found in the abdominal cavity, in addition to a mass of 5 cm in diameter partially obstructive Treitz angle extending to 90 cm.
In addition, multiple lymph nodes up to 3 cm in diameter were found at the root of the mesentery, mesocolon and transverse colon.
Intestinal resection was performed with enteroenterostomy plus right hemicolectomy, procedure without complications.
Histopathological analysis of the resected piece of the small intestine mass (ileum) and colon was reported with foci of lymphoid follicular hyperplasia, polymorphonuclear inflammatory infiltrate of the mucosa, submucosa and muscular plane.
The ileum wall showed areas of mucosal ulceration, with an important chronic granulomatous inflammatory process of all layers, with multiple giant cells, in addition to a polymorphonuclear infiltrate colon as well as moderate eosinophilic, in the colon.
Ziehl Neelsen stain was negative.
With hematoxylin-eosin staining, filariform larval structures were identified in the mucosa.
Within the granulomatous infiltrate larvae and eggs of a nematode were also identified structurally compatible with S. stercoralis (unavailable image).
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The patient was initially managed in intensive care with antimicrobial therapy with ceftriaxone and metronidazole, intravenous solution and parenteral nutrition, progressing favorably.
Due to the findings in the histopathological study, he received treatment with ivermectin 200 μg/kg per day for five days.
The clinical response was satisfactory, normalizing the characteristics of the stools.
After a 12-day stay, the patient was discharged in good condition, asymptomatic and with normal laboratory parameters.
