Schistosomal appendicitis with portal hypertension.

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Dear Editor: Schistosomiasis is a waterborne acute and chronic parasitic disease resulting from infection by species of the trematode genus Schistosoma. Species of Schistosoma are prevalent in tropical and sub-tropical areas where poor and rural communities lack access to clean water. For instance, Schistosoma mansoni and Schistosoma haematobium is common in Africa and the Middle East, while Schistosoma japonicum is common in parts of China, Indonesia, and the Philippines. Although transmission is reported from 78 countries, it is rare in developed countries [1]. Schistosomiasis manifests itself mainly in the intestinal and urogenital system of the infected human body [1, 2]. In particular, acute appendicitis is a known but rare manifestation of intestinal schistosomiasis [2]. We report a case of appendiceal schistosomiasis in a 46-year-old Filipino foreign worker who presented in Singapore with clinical signs and symptoms of acute appendicitis as well as radiologic evidence of portal hypertension. The patient is a 46-year-old Filipino woman who works in Singapore. She presented with a day’s history of right iliac fossa pain. The pain was constant and associated with nonbloody, non-bilious vomiting. It was not associated with preceding fever or change of bowel habits. She did not have pyrexia. On examination of the abdomen, there was right iliac fossa tenderness and also rebound tenderness with voluntary guarding. Digital rectal examination was unremarkable. Her full blood count showed only thrombocytopenia (129× 10 μL), with normal total white, neutrophil, and eosinophil counts. Computed tomography (CT) scan of her abdomen and pelvis showed a slightly thickened appendiceal wall with wall enhancement of the appendix and minimal peri-appendiceal fat stranding, suggestive of early appendicitis. Cavernous transformation of the liver with chronic thrombosis in the hilar and right portal vein was evident, resulting in a lobulated liver with an atrophic right hepatic lobe with early evidence of portal hypertension represented by a tortuous splenic vein and splenomegaly. In view of the above findings, she underwent an open appendectomy for likely acute appendicitis on the same day as her CT scan. Intraoperative examination revealed a minimally inflamed and thickened appendix, measuring 5 cm in length. There was minimal clear peritoneal fluid noted. Postoperatively, the patient recovered uneventfully and was discharged 3 days later. Histological examination of the resected appendix revealed an infiltrate of neutrophils and eosinophils extending to the serosal surface from the ulcerated mucosa, consistent with acute appendicitis. There was no evidence of malignancy. Of note, there were multiple ova of a parasite in the lamina propria of the resected appendix, some of which exhibited granulomatous change with surrounding fibrosis. The most likely causative organism was identified to be S. japonicum. The patient was referred to an infectious disease specialist and was treated with praziquantel (60 mL/kg in three doses). Stool examination did not show any evidence of ova, cysts, or parasites. No schistosomal eggs were seen on urine examination. An ultrasound of the hepato-biliary system 2 months later showed coarse underlying echogenicity of the liver as well as prominence of the portal vein wall. R. Wijaya (*) :A. S. Wong Department of General Surgery, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore e-mail: ramesh_wijaya@cgh.com.sg