An Unusual Case of Hematochezia in the U.S.

Abstract

Purpose: Schistosomiasis is the second most common parasitic infection in the world after Malaria. Despite an increase in prevalence due to international travelers and migrants, it is still a rare diagnosis in Europe and the U.S.A. Schistosomiasis may present with bowel involvement. Endoscopic findings are usually ulcers and polyps with isolated cases of cecal and jejunal granulomatous pseudotumours (Bilharziomas). We present a rare case of Schistosomiasis presenting as a rectal Bilharzioma. A 23-year-old Brazilian male presented with a 4-month history of rectal bleeding with associated anal discomfort. He was otherwise healthy with no history of abdominal pain, alterations in bowel habit, fevers, weight loss, anorexia, symptoms suggestive of extra-intestinal IBD or liver disease. He had moved to the U.S. from Brazil three years ago with a history of extensive fresh water exposure there. His past medical history was not significant for bowel disease and he denied a family history of malignancies. Abdominal examination was normal and a nodular lesion was palpated on rectal examination. Laboratory tests including a complete blood count were normal with no eosinophilia. A flexible sigmoidoscopy was performed and on retroflexion, a frond-like villous non-obstructing mass measuring 4 cm in length was seen at the anorectal junction [Image]. Multiple cold forceps biopsies were taken revealing ulceration with granulation tissue and numerous eggs consistent with Schistosomiasis mansoni. He was subsequently started on Praziquantel at 40 mg/kg/dose for three doses with improvement in symptoms at follow-up in 4 weeks. A repeat flexible sigmoidoscopy revealed persistence of the lesion, although smaller at 3 cm, with similar pathology. Praziquantel was repeated and a follow up sigmoidoscopy scheduled in 3 months. This is a rare case of a Rectal Bilharzioma reported in the United States of America. With an ever-increasing migrant population and international travel, it highlights the importance of maintaining a broad differential especially including treatable infectious etiologies.Figure: Rectal bilharzioma.