technique after culture in agar plates Culture techniques are the most sensitive, but are not routinely available in the West. In the UK, culture is available at either of the Schools of Tropical Medicine in Liverpool or London. Direct examination must be done on stool that is freshly collected and not allowed to cool down, because hookworm eggs hatch on cooling and the larvae are very difficult to distinguish from Strongyloides. Finding Strongyloides in the stool is negative in up to 70% of tests. It is important to undergo frequent stool sampling as well as duodenal biopsy if a bad infection is suspected. The duodenal fluid can be examined using techniques such as the Enterotest string or duodenal aspiration. Larvae may be detected in sputum from patients with disseminated strongyloidiasis. Given the poor ability of stool examination to diagnose Strongyloides, detecting antibodies by ELISA can be useful. Serology can cross-react with other parasites, remain positive for years after successful treatment or be falsely negative in immunocompromised patients. Infected patients will also often have an elevated eosinophil count, with an average of absolute eosinophil count of 1000 in one series. Eosinophilia of a gastrointestinal infection may fluctuate in response to larval output, or may be permanently lacking in some disseminated infections. Hence lack of eosinophilia is not evidence of absence of infection. The combination of clinical suspicion, a positive antibody and a peripheral eosinophilia can be strongly suggestive of infection. It would be greatly useful to have significant advances in the sensitivity of the means of diagnosis, as it would also solve the challenging problem of proof of cure. If definitive diagnosis is solved then it stands to reason that proof of cure becomes easily realizable. Treatment The consensus drug of choice for the treatment of uncomplicated strongyloidiasis is ivermectin. However, even if it is considered the main drug of choice, recent studies have illustrated the challenges in ivermectin curing strongyloidiasis. Ivermectin does not kill the Strongyloides larvae, only the adult worms, therefore repeat dosing may be necessary to properly eradicate the infection. There is an auto-infective cycle of roughly two weeks in which ivermectin should be re-administered; however, additional dosing may still be necessary as it will not kill Strongyloides in the blood or larvae deep within the bowels or diverticula. Other drugs that can be effective are albendazole and thiabendazole (25 mg/kg twice daily for 5 days—400 mg maximum