Whipple's disease with normal duodenal histology diagnosed by ileal biopsy using balloon endoscopy.

A 34 year-old previously healthy Japanese woman presented with a 4 year history of migratory arthralgia, chronic diarrhea, mild fever, and 10 kg weight loss. She was initially misdiagnosed with seronegative arthritis, followed by eosinophilic gastroenteritis. Oral prednisolone was found to be ineffective. Upper endoscopy revealed normal duodenal mucosa. Duodenal biopsy specimen indicated no abnormalities. However, balloon endoscopy revealed white shaggy villi in the ileum, and a biopsy specimen from which revealed diffuse infiltration of foamy macrophages in the lamina propria. These macrophages contained diastase-periodic acid-Schiff positive granules, consistent with Whipple's disease. Polymerase chain reaction analysis of DNA extracted from the ileum was compatible with Whipple's disease. In most previously reported cases of Whipple's disease, the duodenum was affected and duodenal biopsy specimens led to a diagnosis of Whipple's disease. Whipple's disease with normal duodenal histology is extremely rare and balloon endoscopy might be a useful diagnostic tool in such a case. The patient was treated with intravenous ceftriaxone and oral trimethoprim-sulfamethoxazole, and her symptoms improved one month after treatment. Balloon endoscopy performed 32 months later revealed complete improvement in lesions of the ileum.

Evaluation of the excluded stomach by double-balloon endoscopy after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Morbid obesity has become a serious health problem. We have been performing laparoscopic Roux-en-Y gastric bypass (LRYGBP) for morbid obesity since February 2002. Although LRYGBP ameliorates complications of morbid obesity, postoperative investigation of the excluded stomach is difficult. In patients with a family history of gastric cancer, resection of the bypassed stomach is sometimes added, but this requires longer operating time. There are two problems associated with LRYGBP: the high rate of gastric cancer in Japan, and how to investigate the excluded stomach. METHODS: To resolve these problems, we introduced double-balloon intestinal endoscopy. We report double-balloon endoscopy (DBE) in 4 patients. RESULTS: No problems with advancing the endoscope were encountered during observation. We used an overtube to insert the scope further in order to avoid forming redundant loops in the small intestine, and two balloons to grip the intestinal wall. Although performing DBE involves a learning curve, there were no major obstacles to passage of the scope into the esophagus, small gastric pouch, lifted jejunum, the jejunojejunal anastomosis, Y-loop, duodenum and excluded stomach. CONCLUSION: Use of the double-balloon technique makes it possible to observe the GI tract after laparoscopic LRYGBP irrespective of the length between the gastrojejunostomy and the jejunojejunostomy.

An inverse relationship between autoimmune liver diseases and Strongyloides stercoralis infection.

A case-control study was undertaken to describe the prevalence of Strongyloides stercoralis infection among patients with autoimmune liver diseases, such as primary biliary cirrhosis (PBC), autoimmune hepatitis (AIH), and primary sclerosing cholangitis (PSC). This study covered 4,117 patients who were admitted to hospitals in Okinawa, Japan, between 1988 and 2006. During this period, 538 patients had the following chronic liver diseases: PBC, AIH, PSC, chronic viral hepatitis group, and alcoholic liver disease. The other 3,579 patients who were hospitalized and underwent parasitologic tests served as controls. The frequency of S. stercoralis infection in the autoimmune liver diseases group (1.0%) was lower than that found in the control group (7.0%; P = 0.0063). None of the female patients with PBC born before 1955 had S. stercoralis infection, which was also statistically significant (P = 0.045). We hypothesized that immunomodulation by S. stercoralis infection may lower the incidence of autoimmune liver disease.

Impairment of host immune response against strongyloides stercoralis by human T cell lymphotropic virus type 1 infection.

A large-scale study was undertaken to clarify the prevalence rate of strongyloidiasis in Okinawa, Japan and to evaluate the relationship between strongyloidiasis and infection with human T cell lymphotropic virus type 1 (HTLV-1). The prevalence rate of Strongyloides stercoralis and HTLV-1 infection were 6.3% and 14.0%, respectively. Among 2,185 patients more than 50 years of age, the rate of S. stercoralis infection was significantly higher in patients with HTLV-1 infection compared with patients without HTLV-1 infection. In 252 patients treated with ivermectin, serum IgE levels and peripheral eosinophil counts were significantly lower in HTLV-1 co-infected patients compared with patients without HTLV-1 infection. In addition, the anthelmintic effect was significantly lower in patients with HTLV-1 infection compared with patients without HTLV-1 infection. Our prospective study demonstrated a prevalence rate for strongyloidiasis and HTLV-1 infections, and clearly demonstrated that co-infection with HTLV-1 impaired the immune response against S. stercoralis.

Comparison of anthelmintic effects of two doses of ivermectin on intestinal strongyloidiasis in patients negative or positive for anti-HTLV-1 antibody.

Coinfection with HTLV-1 (T lymphotropic virus type I) has been observed in approximately 38% of cases of Strongyloides stercoralis infection in Japan. In the present study, we investigated whether the dose of ivermectin corresponding to approximately twice the conventional therapeutic dose could improve the anthelmintic rate without adverse effects in patients with intestinal strongyloidiasis, particularly in those positive for anti-HTLV-1 antibody. A single dose of 6 mg ivermectin (mean, 110 microg/kg) was administered and the same single dose was repeated 2 weeks later in 312 patients with intestinal strongyloidiasis during the period from 1990 to 1999. The long-term anthelmintic rate during the period of 12 months from 4 months after treatment was 77% (117/152) in all patients, and 92.7% (89/96) and 50% (28/56) in those negative and positive for anti-HTLV-1 antibody, respectively. Between 2000 and 2003, ivermectin was administered at 200 microg/kg in 97 patients, and repeated 2 weeks later. The long-term anthelmintic rate was 96.8% (60/62) in all patients, and 100% (42/42) and 90% (18/20) in those negative and positive for anti-HTLV-1 antibody, respectively. These results showed that the long-term anthelmintic rates in all patients in the 200 microg/kg dose group, and especially in those positive for anti-HTLV-1 antibody, were significantly higher than the respective rates of the 110 microg/kg dose group. Based on these results and the observed safety of the double dose of ivermectin, the recommended dose of ivermectin for treatment of intestinal strongyloidiasis should be 200 microg/kg in patients positive for anti-HTLV-1 antibody.

Efficacy of ivermectin for chronic strongyloidiasis: two single doses given 2 weeks apart.

We assessed the efficacy and adverse effects of ivermectin for the treatment of chronic strongyloidiasis. Fifty patients were treated with a single dose of ivermectin at approximately 200 microg/kg, and the dose was repeated 2 weeks later. The eradication rate was 96% (48 of 50 patients) at 2 weeks after the first dose and 98% at 2 weeks after the second dose (49 of 50 patients). In the latter cases, no recurrence was noted at the end of the 4-month post-treatment follow-up period. The gastrointestinal symptoms observed most frequently before the treatment were borborygmus, constipation, and diarrhea. These symptoms improved in the majority of patients after the treatment. Side effects, including nausea and vomiting, occurred in 1 patient (2%), but these were mild and transient. Although abnormal values in laboratory tests were observed in 4 patients (8%), they were mild, and no particular clinical care was required. Thus, ivermectin showed an excellent antihelminthic effect, with little toxicity. Our results indicate that a regimen of two single doses of 200 microg/kg ivermectin, given 2 weeks apart, is clinically suitable for the treatment of chronic strongyloidiasis.