A 28 years old Yemeni male working as a house painter and living in Jeddah, Saudi Arabia, presented to the department of internal medicine in East Jeddah Hospital complaining of painless bleeding per rectum, which was associated with mucus, episodic abdominal pain, anorexia, and weight loss of four weeks duration. He denied any history of fever, nausea, vomiting, diarrhea, jaundice, headache, skin rash, joint pain, respiratory symptoms, mosquito bites, or swimming while his eating habits were considered unhealthy, eating from local and fast-food restaurants. His past medical and surgical history was unremarkable. Socially, the patient did not drink alcohol but often chewed tobacco and was of intermediate socioeconomic status. Upon further questioning, he reported a travel history to the Republic of Yemen 18 months before the beginning of his symptoms.\nOn physical examination, he was hemodynamically stable but was slightly underweight, with a body mass index of 18.3. There was no clinical evidence of pallor, jaundice, cyanosis, clubbing of fingers, dehydration, or lymphadenopathy. Furthermore, his abdominal examination was insignificant, with a soft abdomen with no tenderness, organomegaly, or ascites. However, his rectal examination showed bright blood mixed with mucus. Laboratory examination revealed a slightly low white blood cell (WBC) count of 2.35 x 103 per microliter (μL), hemoglobin (Hb) 10.3 grams/deciliter (gm/dL) with a hematocrit of 28.8% accompanied by macrocytosis and hypochromia. His platelets were 71.5 x 103/µL, while his coagulation profile, prothrombin time (PT), and partial thromboplastin time (PTT) were all normal. Regarding his liver profile, serum alanine aminotransferase (ALT) was 88 U/L, aspartate transaminase (AST), alkaline phosphatase (ALP), and serum protein and albumin were normal. As for the rest of the blood work, serum urea, creatinine, random blood glucose, and electrolytes were normal, and his serology panel was negative. As a result, examining a blood smear was opted, where it showed leukopenia with anemia and thrombocytopenia without any signs of blast cells. Afterward, stool analysis showed red and pus cells but did not reveal Schistosoma eggs, while his urine analysis was normal with no signs of infection (Table ).\nAbdominal ultrasound revealed a slightly enlarged liver of 14.6 cm with mild surface irregularities that would suggest early signs of cirrhosis with no apparent focal lesions, while the spleen was of normal size of 12 cm with normal echogenicity. In addition, the portal vein diameter was normal. A decision to test the patient for Schistosoma and malaria were because of his travel history. Therefore, an indirect hemagglutination (IHA) kit assay for detection of Schistosoma antibody in the serum (Fumouze laboratories, France) was done and revealed a positive titer of 1:320 (cut-off titer of 1:160). Meanwhile, anti-parietal cell antibodies, anti-intrinsic factor antibodies, and malaria film all were negative. Consequently, colonoscopy was sought to determine the cause of bleeding, and the colonoscope was introduced up to the terminal ileum. Two large sessile polyps located 10 cm from the anal verge were seen, each measuring about 3 cm in size (Figure ). A cross-section of colonic polyps as well as terminal ileum biopsies were taken.\nHistopathological examination by staining the biopsy with hematoxylin and eosin (H&E) showed mild chronic inflammatory infiltrate with a sprinkle of eosinophils, which is a characteristic feature for Schistosoma mansoni eggs, with large prominent lateral spine near the posterior end with no evidence of malignancy (Figure ). These findings confirmed the diagnosis of intestinal schistosomiasis associated with colonic polyps and possible hepatic Schistosoma mansoni infection. A decision to start the patient on praziquantel was recommended by the Internal Medicine Department with further follow-up plans for a colonoscopy, but the patient was lost to follow up.
A 67-year-old woman from the Philippines with a medical history of psoriatic arthritis, hypertension, osteoporosis, and resected left-sided invasive ductal carcinoma of the breast presented with complaints of chronic lower abdominal discomfort associated with constipation alternating with diarrhea for a year, along with decreased appetite and 20 lbs. weight loss. She denied fever, bright red blood per rectum, or melena. She migrated to the United States from the Philippines in 1998. She never had a colonoscopy in the past. Her family history was negative for cancer. Vital signs and physical examination were unremarkable. Laboratory tests were noncontributory other than normocytic anemia with hemoglobin of 11.6 g per deciliter, no eosinophilia.\nSubsequent colonoscopy revealed a malignant appearing obstructing mass in the distal sigmoid, around 20 cm from the entry site (Figure ). Biopsies from the mass revealed fragments of adenocarcinoma. Pelvic computed tomography (CT) revealed bladder wall thickening (Figure ). Thoracic and abdominal CT revealed no distant metastasis. She underwent successful anterior pelvic exenteration, sigmoid resection with primary anastomosis, and ileal conduit creation for sigmoid cancer invading the bladder. Surgical pathology showed invasive, moderately differentiated adenocarcinoma in the sigmoid colon and numerous Schistosoma eggs in the colon, ovaries, posterior cul de sac, and pelvic wall (Figure ). Along with surgical treatment, the patient was treated with praziquantel (60 mg/kg/d in 2 divided doses). Stool microscopic examination after 4 weeks of treatment was negative for ova and parasites.