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 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.