S1712 The Machiavellian Passenger

Abstract

INTRODUCTION: Diarrheas affect a great number of individuals worldwide. Chronic diarrheas are defined as increased frequency of loose stools for more than 4 weeks. However, defining the etiology of chronic diarrheas is a challenging task, as ideal strategies for evaluation have yet to be established. Parasitic disease should always be considered as a possible cause in endemic regions. One important parasite to consider is Schistosoma. Clinical manifestations can range from asymptomatic to maculopapular rash, fever, headache, and diarrhea. This is the case of an unusual passenger found in a diagnostic colonoscopy. CASE DESCRIPTION/METHODS: A 77-year-old Puerto Rican male with past medical history of pulmonary sarcoidosis and Hepatitis B exposure presented with watery diarrhea for the last three years. The patient described about three episodes of loose stools daily aggravated by food intake and associated with abdominal pain and bloating. Physical exam was essentially unremarkable without stigmata of liver disease. Blood workup displayed thrombocytopenia and eosinophilia. Liver enzymes, coagulation parameters, and albumin were all within normal limits. Stool ova and parasites and urine and stool cultures were negative. ESR and CRP were not elevated. Abdominopelvic CT scan and abdominal sonogram were solely remarkable for fatty infiltrations with hepatocellular disease and splenomegaly. As a result, a diagnostic colonoscopy was performed. Random biopsies were obtained from the colon and sub centimeter tubular adenoma in the sigmoid colon. Biopsies from the rectum revealed a small non-necrotizing granuloma with a foreign body type giant cell at rectum suggestive of a parasitic infection. Schistosoma antigen was ordered and yielded a positive result. The patient was subsequently treated with praziquantel, which resulted in resolution of diarrhea and improvement in platelet count. DISCUSSION: Schistosomiasis is a serious infection endemic in the Caribbean and other places around the world. Therefore, this parasite should form part of the differential diagnosis when a patient presents with chronic diarrheas, eosinophilia and thrombocytopenia. Despite stool or urine microscopy being the gold standard for the diagnosis of schistosomiasis, our case illustrates how this is not infallible. The importance of combining social history, clinical presentation, histopathology and serum biomarkers should not be overlooked.