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SN Comprehensive Clinical Medicine e-ISSN 2523-8973 CCMDOI 10.1007/s42399-018-0003-x

A Case Report of Schistosomiasis inEritrean Man: from Hypothesis toDiagnosis

Valerio Spuntarelli, E. Bentivegna,M. B. Mariani, M. Rocchietti March &P. Martelletti

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MEDICINE

A Case Report of Schistosomiasis in Eritrean Man:from Hypothesis to Diagnosis

Valerio Spuntarelli1 & E. Bentivegna1 & M. B. Mariani1 & M. Rocchietti March1& P. Martelletti1

Accepted: 22 August 2018# SpringerNature 2018

Introduction

Hypereosinophilia (HE) is caused by several kind of diseases,and it is always a challenge for physicians to reach the finaldiagnosis [1, 2]. They are often transitory or benign forms,mostly related to allergic diathesis especially in industrializedcountries. However, there are some cases in which HE causeschronic damages to a variety of organic systems [3]. Avoidinga detailed differential diagnosis of HEs that is beyond thescope of this report, we can briefly distinguish the following:reactive HE, hereditary HE (some cases of autosomal domi-nant transmission HEs are known. It is present at birth andremains asymptomatic in most of family members), neoplasticHE (where there is a clonal expansion of cells often associatedwith rearrangements of PDGFR or FGFR), and HE of uncer-tain significance (it refers to patients who have persistent HE,inexplicable by the other causes described below, not accom-panied by any organ damage or symptoms).

The first is largely the most frequent. Among the clinicalconditions that can cause reactive HE, we recognize the fol-lowing: helmintic parasite infections, fungal infections (in par-ticular Coccidioides infection and Aspergillus infection in theform of allergic bronchopulmonary aspergillosis), and allergicor immuno-rheumatological diseases (like allergic rhinitis andasthma, atopic dermatitis, and Churg-Strauss disease) [4].

A careful and methodical anamnesis is fundamental to ori-ent among these causes: as already said, HE is a commonmanifestation of parasitic diseases. In travelers returning froma tropical area, common causes of HE are ankylostomiasis andstrongyloidiasis. In children, due to their propensity to put

fingers in their mouths after touching the ground, ascaridiasisand toxocariasis should be excluded.

In migrants, the two most important HE causes to be inves-tigated are Strongyloides and Schistosoma, especially in pa-tients with dyspepsia, diarrhea, and hepatopathy [5].

A case of a young Eritrean man affected by Schistosomiasis,in spite of a scarce symptomatology, is described, along withdiagnostic sequence and confounding factors that caused a de-layed diagnosis.

Case Summary

A 25 young Eritrean man accessed to emergency roomreporting from several months asthenia, weight loss, itch,and low-grade fever. Patient has got no medical history, andno allergies were declared. He was underweight (BMI16.4 kg/m2) with normal vital signs. Physical examinationwas completely normal except for scratch wounds along thesides. Blood tests showed a considerable eosinophilia (3.500and 35% in absolute and relative values respectively). ChestX-ray and electrocardiogram were normal. He acceded to ourInternalMedicine ward for the investigation of the case. Bloodand urine cultures, sputum examination, HIV test, and auto-immune antibodies were negative. QuantiFERON-TB Goldwas weekly positive. RISTwas > 5000 kUa/L. Serum proteinelectrophoresis did not show monoclonal component. He alsoperformed two-dimensional cardiac ultrasound and full-bodyCT-scan, both negative. Hematology specialist suggestedbone marrow biopsy and aspiration suspecting lymphoprolif-erative disease. Infectious disease specialist hypothesized par-asitosis considering patient’s origin. Thus, stool culture testwas sent; in the meanwhile, esophagogastroduodenoscopyand colonoscopy were made: the last one showed widespreadmucosa’s erythema (Fig. 1), and some mucosal biopsy wasmade. Filariasis, toxocariasis, and strongyloidiasis were ex-cluded by ELISA serological investigations. After bowel his-tological examination, some egg worms were found in

This article is part of the Topical Collection on Medicine

* Valerio Spuntarellivaleriospuntarelli@gmail.com

1 Internal Medicine Department, Sant’Andrea Hospital, Via diGrottarossa 1035, Rome, Italy

SN Comprehensive Clinical Medicinehttps://doi.org/10.1007/s42399-018-0003-x

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sigmoid colon wall (Fig. 2), and direct microscopic observa-tion of stool revealed S. mansoni eggs (Fig. 3). Urine culturedid not show any eggs. Patient was successfully treated withtwo Praziquantel tablets bid una tantum.

Discussion

Schistosomiasis—also called Bilharzia—is the most impor-tant trematode infection. In terms of impact in the world, itis second only to Malaria. Approximately 500 million peopleare at risk of infection [6]. It is very common in countries withpoor sanitation where people usually swim or bath in water

containing infectious Cercariae that are produced by seasnails.

Cercariae cross the skin of the man within a few minutesafter exposure, and they turn into Schistosomula. Then,Schistosomula develop to reach the form of sexually activeworms in the intestinal veins or in the venous plexus of thegenitourinary tract, depending on the species. Eggs appear instool or urine after 1–3 months from penetration of Cercariae.Life estimates of an adult worm oscillate in a range of 3–37 years.

The main Schistosomiasis are as follows:

& S. haematobium: it mainly affects genitourinary system,and it is widespread in all Africa.

& S. mansoni: it spreads in Africa and in some areas of thewestern hemisphere (Brazil, Venezuela and Caribbeanislands).

& S. japonicum: it is confined in Asia (China andPhilippines).

The main manifestation of this clinical case was the pres-ence of an important hypereosinophilia in an African youngboy. As a first measure, we would have thought about allergicor hematological disorders, if he had been western world ori-gin. Considering a chronic Schistosomiasis infection, clinicalmanifestations depend on host response to localized eggs inissues. Our patient had no bloody diarrhea or any pulmonaryor hepatic granulomatous lesions, and no portal hypertensionwas found. Symptomatology was quite nuanced, and it madeus think of a hematological disease in a young boy. Full-bodyCT-scan helped us to exclude the presence of enlarged lymphnodes or thorax bulky. Endoscopic examinations were deci-sive together with a careful examination of stool. Actually, thediagnosis is essentially based on the direct microscopic iden-tification of the specific eggs by expert laboratory technicians.

Fig. 2 Microphotograph of Schistosoma egg in left colonmucosa (H & Estain)

Fig. 3 Direct microscopic observation of stool that revealed S. mansoniegg (the presence of the lateral spine is typical of this variety ofSchistosoma)

Fig. 1 Widespread mucosa’s erythema observed during pancolonoscopy

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Despite the extensive use of Praziquantel in the treatmentof Schistosomiasis, resistant drug strains are emerging [7].

The lack of knowledge of Schistosomiasis in our countrydue to the sporadicity of cases was a negative factor. Thispathology, although being common in tropical countries, isvery rare in developed countries causing less than 1 deathper million persons every year in countries like Europe andNorth America. Furthermore, it is classically known as a ruraldisease. The minority of cases found in urban areas generallyhappenwhere there is rapid and disorganized urbanization likein Mali, Bamako, and West Africa.

In the light of the present high migratory flows, this reportsuggests the need for an in-depth knowledge of tropical infec-tions even for physicians working in developed countries. Insome anamnestic contexts, in fact, these diseases should beplaced in differential diagnosis together with more commondiseases in our countries.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflict ofinterest.

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