A 60-year-old healthy asymptomatic female underwent screening colonoscopy with findings of yellowish rectal subepithelial nodules (measuring up to 5 mm in diameter) (). The patient was referred for endoscopic ultrasound. The patient lived in an endemic area for schistosomiasis in Brazil and had a positive history of freshwater bathing.\nEndoscopic examination was performed under sedation and monitored by an anesthesiologist. A multifrequency radial endoscope was used. Ultrasound revealed the presence of deep mucosal nodular lesions with calcified/hyperechoic inclusions (). There were no alterations in the deeper colonic wall layers. A diagnosis of schistosomal granulomas was considered and biopsies were performed.\nHistologic analysis revealed fragments of colonic mucosa showing increased cellularity in the lamina propria, with mononuclear inflammatory infiltrate and lymphoid follicles. In addition, granulomas in the healing phase were noted with hyaline fibrosis and calcified areas of Schistosoma mansoni. There were no viable eggs noted in the histologic evaluation. The final diagnosis was chronic schistosomal colitis (). The patient was treated with praziquantel (40 mg/kg body weight).
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.