Nodular lymphoid hyperplasia by Giardia lamblia.

Clinical features of giardiasis vary greatly between individuals and may range from asymptomatic infection to severe malab− sorption syndrome. Whereas individuals with various forms of hypogammaglobu− linemia may show more severe disease and damage to the intestinal villi, AIDS patients do not appear to be at increased risk of severe giardiasis [1]. We present a case of duodenal giardiasis in a patient with IgA deficit. A 59−year−old woman came to the clinic with asthenia. Laboratory tests showed macrocytosis, hypersegmentation of neu− trophils, vitamin B12 < 60 pg/mL, iron de− ficiency, and IgA deficit. Upper endoscopy was performed and this revealed several 2 ±3−mm nodules in the duodenum (l" Fig. 1) that were also observed under water (l" Fig. 2); she also presented two linear ulcers on the duodenal bulb. A biopsy of the duodenum revealed acute and chronic inflammation of the mucosa with lymphoid follicles and abundant eo− sinophils. The patient presented subtotal atrophy of the villi and Giardia lamblia (l" Fig. 3 and 4), and was treated with metronidazole. A check−up at 6 months showed that the nodules and the subtotal atrophy of the villi had disappeared (l" Fig. 5). Diagnosis of Giardia infection is made by examination of the feces. Enzyme−linked immunosorbent assay procedures for the presence of Giardia antigen in the stool are reported to be more sensitive than microscopic examination [1]. Conven− tional studies may not be efficacious in asymptomatic patients or patients with anemia, and duodenal biopsy by endos− copy enables a diagnosis to be made. In the case described above, the endoscopic image that appears because of giardiasis is very interesting. The nodules are per− fectly defined by standard endoscopy and water immersion. The diagnosis was confirmed by the duodenal biopsy [2]. Fi− nally, we must remember that Giardia can persist when there is an IgA deficit with nodular lymphoid hyperplasia [3,4], and that it can lead to a picture of associated malabsorption.