In a 44-year-old male who recently immigrated from Bosnia-Herzegovina to Austria, computed tomography for an episode of acute pancreatitis revealed pancreatic pseudocysts, mild ascites and peritonitis. Due to proven alcohol abuse and furthermore unremarkable medical history no further investigation was forced, and the patient was discharged from the Department of Surgery after conservative therapy.
About six months later, he was readmitted to the Department of Internal Medicine due to abdominal pain and massive ascites. Surprisingly, paracentesis (8,000 ml) produced morphological chylous ascites (Fig. 1) with triglyceride levels of 1,999 mg/dl. Further investigation revealed regular liver (serum) and pancreatic (serum and ascites) enzymes, and was unremarkable for malignancy or bacterial and fungal infection. Technetium scintigraphy  excluded leaks of the lymphatic system as a consequence of pancreatitis.
Despite discharge after clinical stabilisation, he had to be re-admitted six weeks later, presenting with massive weight gain (19 kg) and deterioration of his general condition. Another paracentesis revealed chylous ascites (16,000 ml) without further hints regarding microbial or cytologic diagnosis. Measurement of hepatic venous pressure gradient (HVPG: 4 mmHg) excluded idiopathic portal hypertension for any reason.
Thereafter, screening for debatable parasite infestation revealed positive IgG for S. stercoralis and negative results for Trichinella, Ascaris, Toxocara, Taenia solium, Echinococcus and Fasciola serology. Tests for human immunodeficiency virus (HIV), mycobacterium tuberculosis, human T-cell lymphotropic virus (HTLV), and stool microscopy for parasites were negative.
Exposure to the pathogen may have taken place while the patient was working and sleeping at construction sites with poor sanitation in Bosnia-Herzegovina, a work environment for migrants from all over the world, as detailed history revealed. History and clinical examination were negative for any skin rashes.
Before treatment initiation with ivermectin (0.23 mg/kg BW per os/qd, i.e. 21 mg), another paracentesis had to be performed as the patient deteriorated again, with dyspnoea. As chylous ascites was still present, a sample was sent to the Institute of Specific Prophylaxis and Tropical Medicine at the Medical University of Vienna, questioning whether S. stercoralis might be detectable in ascites as well, which finally could be proven only by PCR revealing strongyloides DNA, whereas repeated stool tests remained negative.
After treatment, neither ascites nor general condition showed clinical improvement on follow-up visits. Thus, a second cycle of Ivermectin was initiated, but this time on two occasions, 2 weeks apart . After this the patient improved significantly, with a gain in appetite and stabilisation of body weight within the next visits. A last paracentesis revealed chylous fluid, however, without detectable strongyloides DNA. Diuretic treatment was reduced consecutively, and finally completely withdrawn, without recurrence of ascites.