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.
Here, we report a 48-year-old Egyptian male farmer who presented to our outpatient clinic with recurrent episodes of fresh bleeding per rectum. The patient had no local causes for rectal bleeding as confirmed by surgical consultation. The laboratory data were as follows: Hb 10.8 g/dL, serum albumin 4.2 g/dL, serum bilirubin 1 mg/dL, serum creatinine 0.9 mg/dL, and negative for hepatitis C virus antibodies. Pan-colonoscopy of the cecum showed a huge polypoidal mass of about 5 cm with broad pedicle 20 cm from the anal verge (Fig. ). Despite the suspicious malignant features of the mass, large size, broad base, eroded surface, and high vasculature, the histopathology showed small bilharzial granulomas (Fig. ), and the patient received a single dose of praziquantel. Six weeks later, a second colonoscopy was performed as the bleeding persisted. No noticeable change in size was observed. The second biopsy was confusing as it did not detect any bilharzial ova or malignancy and showed hyperplastic mucosa. Computed tomography (CT) examination demonstrated the luminal mass and showed circumferential wall thickening in the colon. On these findings, the probability of malignancy could not be excluded, so the patient was referred for surgical resection and anastomosis (Fig. ). The postoperative biopsy proved the pure bilharzial nature of the mass with both fresh and calcified ova.