gastrointestinal ( gi ) tract is the most frequently involved extranodal site in non - hodgkin 's lymphoma ( nhl ) .
individuals with defects in cellular immunity are prone to develop various types of opportunistic infections .
strongyloides stercoralis is found mainly in tropical and subtropical areas , and has been reported to infect 100 million people worldwide .
the diagnosis of parasites often requires a high index of suspicion and the use of specialized techniques .
a 49-year - old man , with no significant co morbidities and no history of smoking or alcohol use , presented with upper abdominal pain and flatulence since 3 months .
thus , the patient was diagnosed with diffuse large b cell nhl ( nhl  dlbcl ) of the stomach stage i - ea . he received three cycles of cyclophosphamide , vincristine , epirubicin , and prednisolone ( ceop ) chemotherapy . following three cycles , upper gi endoscopy revealed an ulcerative lesion involving incisura and distal part of lesser curvature and part of antrum , indicative of progressive disease .
he then received four cycles of salvage mine ( mitoxantrone , ifosfamide , and etoposide ) following which he achieved complete remission .
patient declined further chemotherapy ; therefore , he received consolidation radiation therapy with 45 gy/25 # over 5 weeks to stomach and perigastric nodes .
bone marrow aspiration and biopsy was normal . as there was no concrete evidence of recurrent disease ,
patient again presented 3 months later with 15-day history of persistent dull aching epigastric pain .
abdominopelvic computed tomography ( ct ) scan showed pyloric wall thickness of 1.1 cm , wall thickening around lesser curvature up to 6 mm , tiny sized perigastric nodes , and enlarged left para - aortic nodes in retroperitoneum as well as mesentery .
upper gi scopy showed mucosal thickening in the distal body and antrum of stomach , extending till pyloric rim , with the differential diagnoses being post - treatment changes or residual disease [ figure 1 ] .
stomach biopsy showed gastric mucosa with acute and chronic inflammation accompanying s. stercoralis larvae [ figure 2 ] .
mucosal thickening in distal body and antrum of stomach , extending till pyloric rim strongyloides stercoralis larvae in the foveolar epithelium and lamina propria of gastric mucosa the patient was treated with ivermectin 10 mg ( 200 g / kg ) daily on two consecutive days .
follow - up upper gi scopy showed erosions in the distal body and antrum of stomach .
biopsy showed no organisms , parasites , or helicobacter pylori , with no evidence of lymphoma .
our patient presented about 3 months after completing therapy , with recurrent episodes of epigastric pain , gi bleeding .
ct scan , positron emission tomography ( pet ) scan , and upper gi endoscopy revealed gastric wall thickening and lymphadenopathy .
although it would be tempting to treat this constellation of symptoms and signs as recurrent disease , it would have been inappropriate in our patient .
s. stercoralis is an intestinal roundworm that infects humans transcutaneously . after entering the bloodstream through the skin , the filariform larvae migrate to the lungs ,
ascend up the tracheobronchial tree ( pulmonary migration ) , and descend down the gi tract to reach the small bowel .
most cases of chronic s. stercoralis infection are asymptomatic . if present , the symptoms include gi symptoms like midepigastric pain , vomiting , either constipation or diarrhea , borborygmus , and perianal itching .
some people develop marked symptoms of increased larval migration , especially gi and respiratory symptoms , with a large number of parasitic larvae detectable in sputum and stool . this is called hyperinfection and is usually noted in persons with a defect in cell - mediated immunity .
patients who have coexisting lymphoma and strongyloides infection often have a fulminant course . in a review by genta et al . of 17 patients with disseminated strongyloides and underlying lymphoma ,
the authors suggested that this parasite should be aggressively sought out and treated prior to initiating immunosuppressive therapy .
hyperinfection of s. stercoralis has occurred in patients on doses as low as 1 mg of dexamethasone daily for 8 weeks . in our patient ,
the diagnosis of strongyloides infection was delayed for an approximate period of 5 months after the onset of symptoms because of low index of suspicion .
fortunately , immunosuppressive chemotherapy and corticosteroid therapy were not administered during this period , which is probably why our patient did not develop hyperinfection syndrome , and the parasite was easily eradicated , once diagnosed .
the diagnosis of strongyloidiasis in humans is usually based on finding rhabditoid larvae in fecal material .
the histologic diagnosis of strongyloidiasis from biopsies and surgical specimens is usually made incidentally in patients undergoing endoscopy for gi disease .
opportunistic parasitic infections represent one of the major challenges in the management of cancer patients .
viral and bacterial infections are readily diagnosed by well - established serologic and microbiologic methods .
in contrast , the diagnosis of parasites requires a high index of suspicion and the use of specialized techniques .
 we report the case of a 49-year - old man with a diagnosis of gastric diffuse large b cell non - hodgkin 's lymphoma , treated with two lines of chemotherapy followed by radiotherapy , and presented about 3 months after completing therapy with recurrent episodes of epigastric pain , gastrointestinal ( gi ) bleeding . computed tomography scan , positron emission tomography scan , and upper gi endoscopy revealed gastric wall thickening and lymphadenopathy . 
 biopsy and histopathology ultimately revealed strongyloides stercoralis infection that was mimicking disease recurrence . 
 opportunistic parasitic infections represent one of the major challenges in the management of cancer patients . 
INTRODUCTION
CASE REPORT
DISCUSSION