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.
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.