Eggs, Worms, or Both? Chronic Active Schistosomiasis Presenting as Cirrhosis and Colonic Polyps.

CASE REPORT

A 49-year-old Eritrean man living in the United States for the past 20 years presented to his primary care physician after he was found to have elevated blood pressure at a local pharmacy. He was also noted to have leukopenia (2.6 K/uL), eosinophilia (13.5%), and severe thrombocytopenia (41 K/uL). Hepatosplenomegaly was noted; however, the patient lacked classic cirrhosis features. Abdominopelvic computed tomography revealed a cirrhotic-appearing liver and evidence of portal hypertension (Figure 1). He was referred to hepatology for colonoscopy, given the presence of eosinophilia, and the management of cirrhosis.

Figure 1.

A/P axial section CT demonstrating a cirrhotic-appearing liver with pericholecystic varices (blue arrows), splenomegaly measuring 19.1 cm, and perisplenic varices (yellow arrows).

Esophagogastroduodenoscopy revealed large nonbleeding esophageal varices (>5 mm) and moderate portal hypertensive gastropathy. A decision was made to band the varices given his low resting heart rate. Colonoscopy demonstrated nonbleeding rectal varices and 4 polyps in the transverse colon and cecum, ranging in size from 8 to 15 mm, which were successfully removed with a hot snare polypectomy technique (Figure 2).

Figure 2.

Colonoscopy revealed 4 polyps located in the transverse colon (A and B) and cecum. Medium-sized, nonbleeding rectal varices were also found (C).

Astonishingly, pathology of the removed polyps demonstrated abundant eosinophilia, chronic granulomatous inflammatory reaction, and the presence of a parasite (both eggs and worms seen), morphologically consistent with Schistosoma mansoni (Figures 3 and 4). The sections of the worms depict the classical tuberculate surface with both male and female morphologies depicted within the different plane sections. Given these findings, he was treated with praziquantel, the treatment of choice,[1] with subsequent improvement in eosinophilia.

Figure 3.

Hematoxylin and eosin stain of colonic polyps. A coronal section of an adult male worm enfolding an adult female worm to form a gynecophoral canal assisting in sperm transfer.

Figure 4.

Hematoxylin and eosin stain of colonic polyps. A characteristic Schistosoma egg, measuring ∼110 um by ∼70 um, surrounded by dense eosinophilic infiltrate.

Hepatointestinal schistosomiasis is a devastating parasitic disease endemic to Africa, the Middle East, and the Caribbean.[2] Although infection is typically acquired in childhood, chronic complications may occur. Fibrotic/chronic hepatic schistosomiasis may develop from diffuse, massive collagenous deposition in the periportal spaces, leading to occlusion of the portal veins, resulting in splenomegaly, varices, and portal hypertension.[3] Schistosoma polyp formation is a rare finding in advanced stages of infection.[4] Our patient was unexpectedly found to have chronic active intestinal schistosomiasis, noted by the presence of worms and eggs with active inflammation in the colonic polyps. It is unusual for schistosomiasis to have evidence of infection after the fibrotic phase has occurred. Rarely, worms may be found alive, mating, or dead within the inflammatory reaction[5]; however, this is the first case to describe colonic polyps with male and female worms and associated eggs on histology. It is remarkable to have an active infection years after living in a nonendemic region. When evaluating patients originating from endemic countries for portal hypertension, there should be high suspicion of Schistosoma infection.

DISCLOSURE

Author contributions: G. Karim wrote the manuscript and is the article guarantor. O. Adeyemo helped perform the procedure. A. Dinani helped perform the procedure and manuscript revision. K. Bilal developed the histological images. All authors revised and edited the final manuscript. Gres Karim, MD, is the article guarantor.

Financial disclosure: A. Dinani: Speaker for Intercept Pharmaceutical; Advisor Gilead, NASHNET. Other authors declare no conflicts of interest.

Informed consent was obtained for this case report.