Association of the sex-related difference of Strongyloides stercoralis-specific IgG4 antibody titer with the efficacy of treatment of strongyloidiasis. count revealed leukocytosis, total white cells, EVP-6124 (Encenicline) 12.1 109/liter (eosinophils, 0.3%), with normal hemoglobin (14.3 g/dl) and platelet (220 109/liter) levels. Electrolyte assay was significant for hyponatremia (sodium, 119 mmol/dl) and was otherwise unremarkable (potassium, 4.7 mmol/dl; blood urea, 4.9 mmol/liter; creatinine, 32 mol/dl; glucose, 7.2 mmol/liter). Liver function test was normal, apart from albumin of 26 g/liter and globulin of 20 g/liter. Serum and urine osmolality were consistent with the syndrome of inappropriate antidiuretic hormone production. His initial symptoms had responded partially to laxatives. Two days later, he became hypotensive and a repeat complete blood count showed a fall in the hemoglobin level to 9.1 g/dl. Emergency gastroscopy revealed an area of erythematous and granular mucosa in the second part of the duodenum resembling lymphangiectasia with no evidence of bleeding. This was biopsied. His conditions stabilized after fluid resuscitation. However, he became acutely Rabbit polyclonal to ANKRD40 dyspneic and hypoxemic the following day. A repeat chest radiograph showed increased pulmonary infiltrates bilaterally. He was ventilated and managed in the intensive care unit. Bronchoalveolar lavage was performed. The duodenal biopsy revealed multiple filariform larvae of within the glandular crypts, with marked surrounding inflammatory infiltrates. Microscopic examination of the smears obtained by bronchoalveolar lavage also showed a large number of larvae. The detection of larvae in both the duodenum and by bronchoalveolar lavage confirmed strongyloides hyperinfection in this patient. Strongyloides-specific IgG antibody (by an enzyme-linked immunosorbent assay method against the soluble antigen derived from processed larvae L3) was elevated at 4.74 (normal, 1.00) (IVD Research, Carlsbad, CA). Tests for other strongyloides-specific immunoglobulin subclasses were not performed. Human immunodeficiency virus and human T-lymphotropic virus type 1 tests were negative. Oral ivermectin (200 g/kg) was prescribed for 10 days with good clinical and radiological recovery. He was discharged 12 days later, and his subsequent antimyeloma chemotherapy was continued without further complications. (ii) Patient 2. A 51-year-old Thai male presented to the neurology service with acute left hemiparesis, motor power of Medical Research Council grade 3/5 in both upper and lower limbs. CT head was significant for a right internal capsule infarct. He was initiated on aspirin and received early inpatient rehabilitation. Baseline complete blood count revealed total white cells at 7.32 109/liter (eosinophils, 12.3%), hemoglobin at 14.1 g/dl, and platelets at 335 109/liter. Urea and creatinine were elevated, at 16.1 mmol/liter and 138 mol/dl, respectively. Apart from a serum albumin of 23 g/liter and a globulin of 32 g/liter, the remaining liver function was normal. Lipid profile was abnormal (total cholesterol, 10.21 mmol/dl; triglyceride, 1.89 mmol/dl; high-density lipoprotein, 1.25 mmol/dl; low-density lipoprotein, 8.11 mmol/dl). Thrombophilia (antithrombin, EVP-6124 (Encenicline) protein C, protein S, EVP-6124 (Encenicline) and lupus anticoagulant) and autoimmune (antinuclear antibodies, anti-double-stranded DNA antibodies, complements 3 and 4) screening was unremarkable. Repeat biochemistry revealed improvement but not normalization of the serum urea and creatinine results. He was discharged 4 days later. Two days later, he was readmitted with colicky abdominal pain and watery diarrhea of 1 1 day’s duration. The clinical examination was significant for bipedal edema and basal crepitations. The abdominal and digital rectal examinations were unremarkable. Repeated laboratory investigations disclosed rising urea and creatinine levels, 19.5 mmol/liter and 236 mol/dl, respectively. Protein was observed on a urine dipstick. Twenty-four-hour urine total protein excretion was 6.44 g/day, consistent with the nephrotic syndrome. He was febrile 2 days later and was empirically treated with intravenous ceftriaxone. Blood cultures subsequently yielded larvae L3) was elevated at 3.24 (normal, 1.00) (IVD Research, Carlsbad, CA). Tests for other strongyloides-specific immunoglobulin subclasses were not performed. The proportions of IgG, IgA, IgM, and IgE were within normal limits. Human immunodeficiency virus and human T-lymphotropic virus type 1 tests were negative. He was progressively dyspneic the following day. Chest radiographs revealed increased basal infiltrates, and the arterial blood gas recording was consistent with type 1 respiratory failure. Intravenous diuretics and oral ivermectin (200 g/kg for 5 days) were prescribed, with improvement of clinical and radiological features 3 days later. Bronchoscopy was not performed. His abdominal symptoms resolved, and his lower limb edema improved with diuretic treatment. He was discharged 10 days from admission. He admitted to the use of traditional Chinese medication after his initial admission for ischemic stroke. He was reviewed in the outpatient clinic, where serum urea and creatinine were documented to have normalized. Repeat stool examination did not demonstrate the presence of strongyloides. He declined renal biopsy and had opted to return to his own country for further management. Discussion. Strongyloides hyperinfection is unique among the parasitic infections because of its ability.