A Bag of Worms

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A 54-year-old Puerto Rican woman with diabetes mellitus II, hypertension, hyperlipidemia and ulcerative colitis diagnosed on colonoscopy five years prior presented to our outpatient clinic for transfer of care.Family history and social history were non-contributory. Her medications include citalopram, gabapentin, glipizide and mesalamine. She presented with symptoms of vague abdominal discomfort, diarrhea and dyspepsia.An EGD/ileocolonoscopy with ileal and colonic biopsies was performed and both endoscopic and histologic findings were normal. Stool studies including ova/parasites, CBC, LFTs and INR were normal. ASCA was positive, thus a diagnosis of Crohn's was considered.For further small bowel evaluation a capsule endoscopy was done. Three small tubular structures approximated to the jejunum were found, suggestive of a parasitic infection (Picture 1). She was presumptively treated for Ancylostomaduodenale with partial symptom improvement. Approximately two years later, she presented to the ER with diffuse abdominal pain, dyspepsia and diarrhea. She underwent a CT scan revealing enterocolitis, cirrhosis and splenomegaly. An EGD showed esophageal varices (Picture 2). A repeat colonoscopy with biopsies and stool studies were normal. She was found to be positive for both Strongyloides and Schistosoma on serum testing. She was treated with praziquantel and her GI symptoms abated.Figure 1Figure 2Discussion: Schistosomiasis is a tropical parasite known to be a major cause of parasitic morbidity and mortality. The World Health Organization estimates 200 million people are infected worldwide. S. mansoni and S. japonicum are the species known to cause intestinal and hepatosplenic disease, with S. mansoni being the most common species found in South America and the Caribbean. Severe symptoms occur in those with long-standing infection. The eggs travel through host tissues and can become lodged, causing entrapment, inflammation and fibrosis. The eggs can migrate via the splanchnic venous system and may embolize to the liver, lungs, spleen, brain or spinal cord. When eggs become embedded in tissue, they induce a host Th-2 immune response leading to an eosinophilic granulomatous reaction. In the liver, this leads to periportal fibrosis (Symmers' pipestem fibrosis) which can cause portal hypertension and esophageal varices.This case exemplifies the importance of re-considering the diagnosis of IBD in a patient with atypical symptoms and multiple systemic abnormalities.