A 35-year-old woman presented to the gastroenterology clinic for evaluation of dull abdominal pain. The abdominal pain started insidiously 2 years previous, was intermittent in nature, and located in the epigastric and left lower quadrant. The patient also complained of concomitant diarrhea, flatulence, and bloating. She denied melena, hematochezia, nausea, vomiting, fevers, chills, or weight loss. She had an upper endoscopy and colonoscopy 2 years earlier with no significant findings. She had a medical history notable for type 1 diabetes mellitus and a previous benign bladder tumor with unknown pathology that was surgically resected. She was born and raised in the United States and had lived in multiple cities within the United States. Her only travel outside of the United States had been during her childhood on vacation to the Bahamas, the Cayman Islands, and Mexico. She denied any wading or swimming in any freshwater source outside of the United States. She denied any cigarette smoking, alcohol use, or illicit drug use.\nHer abdominal examination revealed no distention, no scars, normal bowel sounds, no tenderness, no organomegaly, and normal tympani. The rest of her physical examination was unremarkable. Her laboratory testing was within normal limits. Abdominal ultrasound was performed at a later time due to abdominal pain showed a 9-mm indeterminate hepatic lesion. Abdominal magnetic resonance with and without contrast showed multiple hyperenhancing liver lesions. The hepatic lesions were biopsied. It revealed non-necrotizing granulomas composed of multinucleated giant cells and cuffs of lymphocytes; moderate hepatic steatosis was present.\nUpper endoscopy was performed to reveal a 40-mm pedunculated polyp with no bleeding in the second part of the duodenum; this was resected (Figure ). The esophagus and stomach were normal. Colonoscopy revealed a 6-mm sessile polyp in the sigmoid colon; this was resected. Pathology from the duodenal polyp revealed adenomatous changes arising in a hamartomatous polyp (Peutz-Jeghers type); there was also the presence of parasite organisms present in the crypts of the polyp consistent with schistosomiasis with tissue eosinophilia (Figure ). Pathology of the colon polyp revealed hyperplastic changes. The patient was diagnosed with a hamartomatous duodenal polyp due to Schistosoma mansoni. The patient was referred to infectious disease. She was prescribed praziquantel 20 mg/kg/dose 3 times per day for 1 day. The patient followed up with gastroenterology after treatment with praziquantel. Her diarrhea had resolved, but she continued to have intermittent left lower quadrant abdominal pain, attributed to irritable bowel syndrome. Repeat endoscopy showed no evidence of duodenal hamartomatous polyp.
A 14-year-old male student presented to our hospital with 5-week history of fever, rigors, cough and malaise for 1 month after returning from a visit to Albaha province (south of Saudi Arabia). He had been evaluated initially in a local hospital and diagnosed with community-acquired pneumonia. He received IV antibiotics and was discharged home on oral antibiotics.\nDuring hospitalization, he had an extensive work-up for fever of unknown etiology that included multiple blood cultures, urine analysis and culture, sputum for acid-fast bacilli (AFB), routine sputum cultures, serology for brucellosis, Monospot test and blood film for malaria. His clinical examination was unremarkable; complete blood count (CBC) and differential count, renal functions and serum electrolytes, chest X-ray and transthoracic echocardiogram were all unremarkable. His liver profile was mildly deranged with aspartate aminotransferase (AST) activity of 48 U/L and alanine aminotransferase (ALT) activity of 82 U/L. He was discharged home and given outpatient appointment for follow-up.\nHe was re-admitted again 16 days later because of persistence of his symptoms. His clinical examination was also unremarkable. His laboratory investigations, however, were as follows: WBC count 8.1×109/L (eosinophils 30%; lymphocytes 35%; monocytes 7%; neutrophils 25%; and bands 3%), Hb=121 g/L, and platelets 438×109/L)\nHis chest X-ray showed ill-defined infiltrate. Thus, a chest computed tomography (CT) was requested and revealed peripheral nodular and patchy infiltrates in both lung fields []. There was evidence of splenomegaly in the lower cuts of the scan.\nRepeated CBC and differential count was significant for increasing peripheral blood eosinophil count to 63%, with an absolute count of 9.4×109/L and WBC of 14.9×109/L. Blood, urine, sputum cultures and sputum for AFB were negative. Two stool samples for microscopy were negative for parasite. Serum IgE level was 334 U/L, (normal <200 U/L), ANCA-P test was negative, and renal functions and liver function tests were unremarkable.\nBronchoscopy was performed. Bronchoscopic alveolar lavage (BAL) fluid analysis showed marginally elevated eosinophils (7%); however, microbial studies (including AFB, fungal and routine bacterial cultures) were negative. A transbronchial biopsy showed tissue eosinophilia.\nThe patient underwent video-assisted thoracoscopic lung biopsies from the left lower lobe which showed a schistosomal ovum within a well-formed granuloma []. Subsequently, the test for schistosoma antibodies serology came positive. The diagnosis of acute pulmonary schistosomiasis was then made.\nThe patient was given praziquantel (20 mg/kg body weight) twice daily for 2 days. Two days later, he reported to our emergency department with high-grade fever and rigors. His symptoms subsided with the addition of a short course of prednisolone. After this, he visited our outpatient clinic for follow-up and was free of symptoms and had a normal chest X-ray.