Life-threatening Variceal Bleeding from Chronic Schistosomal Liver Disease

Abstract

Purpose: To present a rare case of Schistosoma mansoni infection causing chronic liver disease, portal hypertension, variceal bleeding, and hemorrhagic shock. Case Report: The patient was a 20-year-old pre-medical student who migrated to the U.S. from Kenya 6 years ago. He grew up in Nairobi, but spent summers in Western Kenya around the Lake Victoria basin. The patient presented with two days of diffuse abdominal pain, nausea, vomiting, and multiple melenic stools. His hemoglobin was 8 and dropped to 7 within 1.5 hours. He became hypotensive with blood pressure of 70/50 and heart rate of 120. He vomited a large amount of fresh blood and had syncope for a few minutes. He was transferred to the ICU and resuscitated with IV fluid, pantoprazole drips, and octreotide drips. Blood works showed BUN 28, creatinine 0.8, total protein 5.7, albumin 3, bilirubin 1.5, AST 106, ALT 121, alkaline phosphatase 372, INR 1.2, and platelet 56. An abdominal sonogram showed a small, heterogeneous liver and an enlarged spleen. The rest of the comprehensive liver work-up was negative. The patient underwent an EGD that showed hypertensive portal gastropathy and multiple large esophageal varices. Seven ligation bands were placed for hemostasis. A liver core biopsy showed marked fibrosis with expansion of portal tracts and formation of septae, highly suggestive of chronic Schistosoma masoni infection. Due to the endemic area of his childhood, the life-threatening presentation at a young age, the liver biopsy results, and the lack of other risk factors for chronic liver disease, the patient was started on Praziquantel. One month later, he had another EGD that showed improved esophageal varices. Six more bands were placed. He was started on propranolol. He will have more variceal bandings until resolution of varices and close monitoring until normalization of liver function tests. Conclusion: Schistosoma masoni is a waterborne trematode found predominantly in Africa, South America, the Caribbean, and Middle East. The parasite can live for more than 20 years in the human host. Eggs are laid in the intestinal walls, enter the portal vein, and are trapped in the venules of the portal triads of the liver causing a granulomatous reaction and eventually portal hypertension. Variceal hemorrhage is the most lethal complication of this chronic infection. Praziquantel is the drug of choice for eradication. Clinicians should consider hepatic Schistosoma masoni disease as a cause of variceal bleeding in immigrants and travelers from endemic areas.