Hepatosplenic Disease Research Articles

A rare case of hepatosplenic cat scratch disease

A female patient in her 60s, treated with oral corticosteroids for scleroderma diagnosed 11 years ago, visited our hospital complaining of a persistent fever and liver dysfunction. She was treated with antibiotics, but her fever continued. Abdominal ultrasonography revealed multiple hypoechoic splenic masses. Splenic masses revealed multiple masses with no contrast effect in arterial and portal phases and nuclear in equilibrium phase by contrast computed tomography study, as well as hyperintensity masses with low signal areas in magnetic resonance imaging T2-weighted images. Liver tissue was obtained by percutaneous liver biopsy, and histological findings showed epithelioid cell granulomas without tumor cells. Further interview and physical examination revealed scratch scars from domestic cats and left axillary lymph node swelling. Hence, a cat scratch disease was suspected. She was diagnosed with cat scratch disease by serum indirect immunofluorescence. Her fever was resolved with minocycline administration. Therefore, persistent fever with splenic masses should be suspected of hepatosplenic cat scratch disease.

Cat Scratch Disease in Children

The aim of this paper is to provide information on the clinical manifestations, diagnosis and treatments of Bartonella henselae infection in children. Cat scratch disease (CSD) is a zoonosis caused by Bartonela henselae. Cat fleas are responsible for spreading the bacterium among cats. Bacteria can be transmitted to humans from the site of a cat bite or scratch. The typical manifestation of CSD is regional lymphadenopathy with a pustule at the site of inoculation, usually self-limiting. Atypical CSD has a wide range of clinical manifestations (hepatosplenic disease, pulmonary infiltrates, encephalitis, skin or bone involvement, endocarditis), some of which are life-threatening. Atypical presentations mainly occur in immunocompromised children, but have also been described in immunocompetent children.Conclusion − In recent years the number of households with a pet is growing and the number of children visiting a pediatrician with CSD is growing.

Helminth Infections in Children.

Helminth Infections in Children.

Rationale and design of a screening study to detect schistosomiasis-associated pulmonary hypertension in Ethiopia and Zambia.

Schistosomiasis is a major cause of pulmonary arterial hypertension (PAH) worldwide, but the prevalence and risk factors for schistosomiasis‐associated PAH (SchPAH) development are not well understood. Schistosomiasis‐associated hepatosplenic disease (SchHSD) is thought to be a major risk factor for PAH development. Herein, we describe our plans for prospectively screening SchHSD subjects for clinical evidence of PAH at two major academic medical centers and national referral hospitals in Addis Ababa, Ethiopia and Lusaka, Zambia. The screening study will primarily be conducted by echocardiography, in addition to clinical assessments. Plasma samples will be drawn and banked for subsequent analysis based on preclinical animal model rationale. If successful, this study will demonstrate feasibility of conducting prospective cohort studies of SchPAH screening in schistosomiasis‐endemic regions of Africa, and provide initial data on clinic‐based disease prevalence and potential mechanistic biomarkers underlying disease pathogenesis.

Hepatosplenic Cat Scratch Disease: Description of Two Cases Undergoing Contrast-Enhanced Ultrasound for Diagnosis and Follow-Up and Systematic Literature Review.

Cat scratch disease (CSD) is a disease usually characterized by self-limited lymphadenopathy of the young man. Rarely CSD, however, can manifest itself as an unusual hepatosplenic form (HS-CSD) in immunocompetent patients. HS-CSD diagnosis is generally based on clinical features, imaging, and serologies, but sensitivity of serologies is very variable, like that of other diagnostic methods, as Warthin-Starry silver stain and isthology. Also there are no specific markers for the follow-up. The use of the CEUS (abdominal contrast-enhanced ultrasound) in HS-CSD is not previously described in literature examined, but we think that CEUS can be of help to diagnosis and follow-up of these patients, even after an initial CT scan, because it is a sensitive method, as seen in other diseases associated with granulomas, such as sarcoidosis. We describe 2 new cases of HS-CSD, and we performed a systematic review of the clinical cases reported in the past 10 years in the literature associated to an analysis of clinical, diagnostic, and therapeutic aspects of the disease.

Schistosomes in the Lung: Immunobiology and Opportunity.

Schistosome infection is a major cause of global morbidity, particularly in sub-Saharan Africa. However, there is no effective vaccine for this major neglected tropical disease, and re-infection routinely occurs after chemotherapeutic treatment. Following invasion through the skin, larval schistosomula enter the circulatory system and migrate through the lung before maturing to adulthood in the mesenteric or urogenital vasculature. Eggs released from adult worms can become trapped in various tissues, with resultant inflammatory responses leading to hepato-splenic, intestinal, or urogenital disease – processes that have been extensively studied in recent years. In contrast, although lung pathology can occur in both the acute and chronic phases of schistosomiasis, the mechanisms underlying pulmonary disease are particularly poorly understood. In chronic infection, egg-mediated fibrosis and vascular destruction can lead to the formation of portosystemic shunts through which eggs can embolise to the lungs, where they can trigger granulomatous disease. Acute schistosomiasis, or Katayama syndrome, which is primarily evident in non-endemic individuals, occurs during pulmonary larval migration, maturation, and initial egg-production, often involving fever and a cough with an accompanying immune cell infiltrate into the lung. Importantly, lung migrating larvae are not just a cause of inflammation and pathology but are a key target for future vaccine design. However, vaccine efforts are hindered by a limited understanding of what constitutes a protective immune response to larvae. In this review, we explore the current understanding of pulmonary immune responses and inflammatory pathology in schistosomiasis, highlighting important unanswered questions and areas for future research.

Use of a Tablet-Based System to Perform Abdominal Ultrasounds in a Field Investigation of Schistosomiasis-Related Morbidity in Western Kenya.

ABSTRACTChronic intestinal schistosomiasis can cause severe hepatosplenic disease and is a neglected tropical disease of public health importance in sub-Saharan Africa, including Kenya. Although the goal of control programs is to reduce morbidity, milestones for program performance focus on reductions in prevalence and intensity of infection, rather than actual measures of morbidity. Using ultrasound to measure hepatosplenic disease severity is an accepted method of determining schistosomiasis-related morbidity; however, ultrasound has not historically been considered a field-deployable tool because of equipment limitations and unavailability of expertise. A point-of-care tablet-based ultrasound system was used to perform abdominal ultrasounds in a field investigation of schistosomiasis-related morbidity in western Kenya; during the study, other pathologies and pregnancies were also identified via ultrasound, and participants referred to care. Recent technological advances may make it more feasible to implement ultrasound as part of a control program and can also offer important benefits to the community.

Atypical bartonellosis in children: What do we know?

To characterise Bartonella infections in a paediatric population requiring hospital admission and review its treatment. Longitudinal observational retrospective data analysis of children and adolescents admitted with Bartonella infection at a paediatric tertiary hospital from 2010 to 2019. We identified 16 cases of bartonellosis, with a mean age of 8.0 ± 4.5 years old, no sex predominance and 14 had contact with cats. Most of the cases occurred in fall and winter. Clinical presentations included osteomyelitis/arthritis (n= 9), hepatosplenic disease (n= 2), lymphadenitis (n= 2), neuroretinitis (n= 2) and encephalitis (n= 1). Clinical diagnosis was confirmed by serology (n= 16) and Bartonella DNA detection in patient's lymph nodes/hepatic lesion (n= 3). Therapeutic approach varied according to the clinical presentation: azithromycin in lymphadenitis, rifampicin plus ciprofloxacin in hepatosplenic disease, rifampicin and doxycycline in neuroretinitis, ceftriaxone in encephalitis and azithromycin, cotrimoxazole or rifampicin plus azithromycin, cefuroxime, ciprofloxacin or doxycycline in osteomyelitis/arthritis. Immunodeficiency was excluded in seven patients. Seven patients' cats were screened by veterinarians and treated when infected (n= 5). In these clinical presentations, where other infections may be involved, a high index of suspicion is necessary, with emphasis on the epidemiological context. The association of systemic forms with immunodeficiency did not occur in our study. The lack of recommendations for treatment of atypical infection makes the approach of these cases a challenge. Randomised control studies are essential to define the best approach in each case.

S2092 When Your Colonoscopy Was Just a "Fluke": A Rare Case of Diagnosing Schistosomiasis (S. Mekongi) Based on Colon Biopsy

INTRODUCTION: Schistosomiasis is caused by a family of parasites known as “blood flukes”. An important cause of disease in Africa and Southeast Asia, they are classified as a Neglected Tropical Disease (NTD) by the CDC and are responsible for acute and chronic syndromes affecting the GI and urinary tracts.Schistosoma mekongi is the endemic fluke of the Lower Mekong River basin with primary human tropisms in the liver and intestines. The acute phase of disease usually includes diarrhea or constipation and hematochezia, with chronic manifestations resulting from the host’s immune response to schistosome eggs: bowel wall ulceration, polyposis, and periportal liver disease. Often, those infected do not receive treatment, and the diagnosis is made either incidentally or when evaluating chronic hepatosplenic disease. CASE DESCRIPTION/METHODS: A 63-year-old female originally presented to GI clinic for standard screening colonoscopy. She primarily resides in the Philippines for at least 6 months of every year, and reported only a single visit to the Mekong River basin decades earlier. She had no complaints of diarrhea, constipation, abdominal pain, or other systemic symptoms, and her prior screening colonoscopy 10 years prior was unremarkable. This colonoscopy revealed multiple lesions in the distal sigmoid colon, originally described as “sessile but benign-appearing polyps” ranging from 1–2 mm in size. Pathology results returned as “calcified eggs deposited in the submucosa… most consistent with S. mekongi.” She was counseled on the importance of treating this chronic infection, started on Praziquantel, and returned to the Philippines in good condition. DISCUSSION: This asymptomatic patient was diagnosed with schistosomiasis based on a routine screening colonoscopy discovering parasite eggs. In this highly unusual case, it is likely that she had a chronic mild infection, as she later said she had intermittent problems with diarrhea but never pursued diagnosis or treatment. At this juncture, it is still important to treat this patient to prevent complications from the chronic inflammatory state, such as potentiating acute viral hepatitis or fibrotic changes leading to end-stage liver disease and cirrhosis. Overall, this case illustrates a rare but effective method of diagnosing an undertreated disease with preventable late-stage complications.Figure 1.: Sessile but benign-appearing polyp, ∼1mm, sigmoid colon.Figure 2.: Another similar polyp in the distal sigmoid colon.Figure 3.: Biopsy from sigmoid colon showing submucosal round to oval calcified eggs.

Plasma Endotoxin Levels Are Not Increased in Schistosoma mansoni–Infected Women without Signs or Symptoms of Hepatosplenic Disease

Elevated circulating endotoxin levels in the plasma of patients with advanced hepatosplenic schistosomiasis caused by Schistosoma mansoni have been reported, possibly caused by parasite egg-induced intestinal mucosal breaches facilitating bacterial access to the bloodstream. Neither endotoxin levels in people with S. mansoni but without hepatosplenic disease nor the impact of treatment on endotoxin levels have been described. We used a methodically optimized Limulus amebocyte lysate assay to measure plasma endotoxin in community-dwelling women from an S. mansoni-endemic area without clinical hepatosplenic disease. We found no difference in baseline mean plasma endotoxin levels between those with (n = 22) and without (n = 31) infection (1.001 versus 0.949 EU/mL, P = 0.61). Endotoxin levels did not change in schistosome-infected women after successful treatment (1.001 versus 1.093 EU/mL, P = 0.45) and were not correlated with circulating anodic antigen or stool egg burden. Our findings do not support the hypothesis that translocating eggs in S. mansoni infection introduce bacterial sources of endotoxin to the circulation.

Quantitative assessment of hepatic and splenic blood flow status in patients with hypersplenism of different degrees based on multi-slice spiral CT whole-liver perfusion imaging

Objective: To investigate the differences and changes of blood flow status of splenic volume, common hepatic artery, splenic arteriovenous, inner diameter of portal vein and hepatic in patients with hypersplenism of different degrees using multi-slice spiral CT whole-liver perfusion model. Methods: 42 cases with hypersplenism of chronic hepatitis B with cirrhosis and 15 cases without hepatosplenic disease were collected as controls. All patients underwent multi-slice spiral CT whole-liver perfusion imaging. (1) The differences of spleen volume, common hepatic artery, splenic arteriovenous, and portal vein diameter between different degrees of hypersplenism and the control group were measured and compared. (2) The correlation between spleen volume and the inner diameter of each related vessels were analyzed and compared. (3) The values of perfusion parameters related to the five lobes of the liver in Couinaud segments based on hepatic artery perfusion (HAP), portal venous perfusion (PVP), total hepatic perfusion (TLP) and hepatic artery perfusion index (HPI) were measured and compared. One-way ANOVA was used to analyze the measurement data. The correlation between the spleen volume and the inner diameter of each blood vessel was analyzed by Pearson's correlation analysis. Results: (1) spleen volume and the inner diameter of splenic artery, splenic vein and portal vein in the cirrhotic hypersplenism group were significantly larger than control group, and the difference was statistically significant (F = 37.108, 17.484, 23.124, 13.636, P < 0.05). (2) spleen volume and the inner diameter of splenic artery, vein and portal vein in the moderate and severe hypersplenism groups were significantly larger than the mild hypersplenism group, and the difference was statistically significant (F = 25.418, 13.293, 15.136, 7.093, P < 0.05), but there was no statistically significant difference between the moderate and severe hypersplenism groups (P > 0.05). (3) The inner diameter of splenic vein, portal vein, and splenic artery was positively correlated with spleen volume (r = 0.680, 0.548, and 0.726). (4) PVP and TLP of the whole liver in hypersplenism group were lower than control group (P < 0.05), and the differences were statistically significant (P < 0.05). HPI in the right posterior lobe of the liver in the moderate and severe hypersplenism group was higher than mild hypersplenism group (F = 3.555, 4.570, P < 0.05), and there was no significant difference in the HAP in the whole liver among the groups (P > 0.05), but the HAP in the whole liver in the severe hypersplenism group was lower than control, mild and moderate hypersplenism group. Conclusion: The inner diameter of the splenic arteriovenous in patients with hypersplenism of different degrees has widened to varying degrees, and is consistent with the increase in spleen volume, particularly in moderate and severe cases. Portal venous perfusion and total liver perfusion in patients with hypersplenism of different degrees have declined and the hepatic arterial perfusion in patients with severe hypersplenism is significantly reduced.

Prevalence and intensity of Schistosoma mansoni infection in pediatric populations on antiretroviral therapy in north-western Tanzania: a cross-sectional study

BackgroundIn areas where HIV and intestinal schistosomiasis are highly endemic, co-infections of the two diseases in a single human host are frequent. Evidence in adult populations indicates that HIV and...

The Schistosomiasis SpleenOME: Unveiling the Proteomic Landscape of Splenomegaly Using Label-Free Mass Spectrometry.

Schistosomiasis is a neglected parasitic disease that affects millions of people worldwide and is caused by helminth parasites from the genus Schistosoma. When caused by S. mansoni, it is associated with the development of a hepatosplenic disease caused by an intense immune response to the important antigenic contribution of adult worms and to the presence of eggs trapped in liver tissue. Although the importance of the spleen for the establishment of immune pathology is widely accepted, it has received little attention in terms of the molecular mechanisms operating in response to the infection. Here, we interrogated the spleen proteome using a label-free shotgun approach for the potential discovery of molecular mechanisms associated to the peak of the acute phase of inflammation and the development of splenomegaly in the murine model. Over fifteen hundred proteins were identified in both infected and control individuals and 325 of those proteins were differentially expressed. Two hundred and forty-two proteins were found upregulated in infected individuals while 83 were downregulated. Functional enrichment analyses for differentially expressed proteins showed that most of them were categorized within pathways of innate and adaptive immunity, DNA replication, vesicle transport and catabolic metabolism. There was an important contribution of granulocyte proteins and antigen processing and presentation pathways were augmented, with the increased expression of MHC class II molecules but the negative regulation of cysteine and serine proteases. Several proteins related to RNA processing were upregulated, including splicing factors. We also found indications of metabolic reprogramming in spleen cells with downregulation of proteins related to mitochondrial metabolism. Ex-vivo imunophenotyping of spleen cells allowed us to attribute the higher abundance of MHC II detected by mass spectrometry to increased number of macrophages (F4/80+/MHC II+ cells) in the infected condition. We believe these findings add novel insights for the understanding of the immune mechanisms associated with the establishment of schistosomiasis and the processes of immune modulation implied in the host-parasite interactions.

2311. Atypical Cat Scratch Disease Presentations

BackgroundCat scratch disease (CSD) is caused by B henselae, a Gram-negative intracellular bacilli which is transmitted to humans via cat bite/scratch. Typical CSD presents as regional lymphadenopathy and fever. However, there are multiple atypical presentations of cat scratch disease that have been reported including prolonged fever, absence of lymphadenopathy and systemic complications such hepatosplenic disease, osteomyelitis, Parinaud oculoglandular syndrome, neuroretinitis, encephalitis, and bacillary angiomatosis among other rare presentations. The aim of this study was to review the frequency, presentation, and treatment outcomes of aytpical CSD presentations at Nationwide Children’s Hospital (Columbus OH).MethodsThis was a retrospective study performed at Nationwide Children’s Hospital, Columbus, OH. EMR of patients were reviewed between January 2010 and March 2017 using ICD9 or ICD 10 codes for CSD. Patients were identified on the basis of compatible clinical presentation and confirmatory serological test or PCR results for B. henselae. Clinical, radiological, and histopathological findings were collectedResultsA total of 204 patients were serologically diagnosed as having cat scratch disease between January 2010 and July 2017. Of the 204 cases, 166 (81%) had typical CSD and 38 (18.6%) had atypical CSD. Of the atypical manifestations, 20 (52%) patients had no lymphadenopathy, 12 (31%) had osteomyelitis, 12 (31%) patients had hepatic and/or splenic microabscesses, 4 (10.5%) had osteomyelitis and hepatic/splenic involvement, 3 (1.5%) had encephalitis, 2 (5.2%) had neuroretinitis, and there was one case each (2.6%) of Parinaud oculoglandular syndrome, uveitis, pulmonary cavitary lesion, myocarditis, and endocarditis. Fever of unknown origin was present in 28 (75.6%) of the atypical CSD cases. The median duration of antibiotic treatment was 25 days (IQR 31) and median duration of illness in patients with atypical CSD was 51 days (IQR 56). The majority of patients were treated with dual antibiotic therapy that included rifampin.ConclusionIn children with fever of unknown origin, serologic testing for CSD should be performed even in the absence of lymphadenopathy and a search for underlying systemic complications is recommended for prompt diagnosis and appropriate treatment.Disclosures All authors: No reported disclosures.

Schistosomiasis.

Schistosomiasis (bilharzia) is a neglected tropical disease caused by parasitic flatworms (blood flukes) of the genus Schistosoma, with considerable morbidity in parts of the Middle East, South America, Southeast Asia and, particularly, in sub-Saharan Africa. Infective larvae grow in an intermediate host (fresh-water snails) before penetrating the skin of the definitive human host. Mature adult worms reside in the mesenteric (Schistosoma mansoni and Schistosoma japonicum) or pelvic (Schistosoma haematobium) veins, where female worms lay eggs, which are secreted in stool or urine. Eggs trapped in the surrounding tissues and organs, such as the liver and bladder, cause inflammatory immune responses (including granulomas) that result in intestinal, hepato-splenic or urogenital disease. Diagnosis requires the detection of eggs in excreta or worm antigens in the serum, and sensitive, rapid, point-of-care tests for populations living in endemic areas are needed. The anti-schistosomal drug praziquantel is safe and efficacious against adult worms of all the six Schistosoma spp. infecting humans; however, it does not prevent reinfection and the emergence of drug resistance is a concern. Schistosomiasis elimination will require a multifaceted approach, including: treatment; snail control; information, education and communication; improved water, sanitation and hygiene; accurate diagnostics; and surveillance-response systems that are readily tailored to social-ecological settings.

The challenging diagnosis of hepatosplenic cat scratch disease in children

Cat scratch disease (CSD) can present as a systemic disease in 5–10% of cases leading to various entities including hepatosplenic disease with abscesses detected at abdominal imaging in more than 50% of patients. We describe a challenging diagnosis of hepatosplenic CSD, and review of literature. A previously healthy 12 y.o. girl was admitted for prolonged fever. She lived in contact with a cat. She had already received a 7-day unsuccessful antibiotic therapy (amoxicillin-clavulanate/ceftriaxone). Clinical/laboratory examination showed hepatosplenomegaly and no enlarged lymph nodes, CRP = 44 mg/L; ESR = 110 mm/h. An abdominal ultrasound evidenced multiple intrahepatic/intrasplenic hypoechoic lesions compatible with abscesses. Tests for main causes of liver abscesses ruled out included antibodies for Bartonella Henselase (BH) (enzyme immunoassay, EIA), Francisella Tularensis, Echinococcus Granulosus, Brucella spp; Entamoeba Histolitica microscopic identification; Tubercolosis skin tests and interferon-gamma release assays. Cultures, bone marrow aspiration, and alphafetoprotein were also normal. Due to a cat-pet at home CSD was reconsidered. IgG/IgM anti-BH were retested by indirect fluorescence (IFA) and found positive (title > 1:64). BH blood polymerase chain reaction (PCR) was negative. Home cat was found colonized by BH. The combination of contact history, serological, clinical, and imaging criteria were considered compatible with hepatosplenic CSD (Margileth diagnostic criteria). She was prescribed a combination of Azithromycin/Doxycycline with progressive improvement of all parameters.

Osteopontin Is Upregulated in Human and Murine Acute Schistosomiasis Mansoni.

BackgroundSymptomatic acute schistosomiasis mansoni is a systemic hypersensitivity reaction against the migrating schistosomula and mature eggs after a primary infection. The mechanisms involved in the pathogenesis of acute schistosomiasis are not fully elucidated. Osteopontin has been implicated in granulomatous reactions and in acute hepatic injury. Our aims were to evaluate if osteopontin plays a role in acute Schistosoma mansoni infection in both human and experimentally infected mice and if circulating OPN levels could be a novel biomarker of this infection.Methodology/Principal FindingsSerum/plasma osteopontin levels were measured by ELISA in patients with acute (n = 28), hepatointestinal (n = 26), hepatosplenic (n = 39) schistosomiasis and in uninfected controls (n = 21). Liver osteopontin was assessed by immunohistochemistry in needle biopsies of 5 patients. Sera and hepatic osteopontin were quantified in the murine model of schistosomiasis mansoni during acute (7 and 8 weeks post infection, n = 10) and chronic (30 weeks post infection, n = 8) phase. Circulating osteopontin levels are increased in patients with acute schistosomiasis (p = 0.0001). The highest levels of OPN were observed during the peak of clinical symptoms (7–11 weeks post infection), returning to baseline level once the granulomas were modulated (>12 weeks post infection). The plasma levels in acute schistosomiasis were even higher than in hepatosplenic patients. The murine model mirrored the human disease. Macrophages were the major source of OPN in human and murine acute schistosomiasis, while the ductular reaction maintains OPN production in hepatosplenic disease. Soluble egg antigens from S. mansoni induced OPN expression in primary human kupffer cells.Conclusions/SignificanceS. mansoni egg antigens induce the production of OPN by macrophages in the necrotic-exudative granulomas characteristic of acute schistosomiasis mansoni. Circulating OPN levels are upregulated in human and murine acute schistosomiasis and could be a non-invasive biomarker of this form of disease.

Serum osteopontin is a biomarker of severe fibrosis and portal hypertension in human and murine schistosomiasis mansoni

Schistosomiasis is a major cause of fibrosis and portal hypertension. The reason 4–10% of infected subjects develops hepatosplenic schistosomiasis remains unclear. Chronically infected male CBA/J mice reproduce the dichotomic forms of human schistosomiasis. Most mice (80%) develop moderate splenomegaly syndrome (similar to hepatointestinal disease in humans) and 20% present severe hypersplenomegaly syndrome (analogous to human hepatosplenic disease). We demonstrated that the profibrogenic molecule osteopontin discriminates between mice with severe and mild disease and could be a novel morbidity biomarker in murine and human schistosomiasis. Failure to downregulate osteopontin during the chronic phase may explain why hepatosplenic subjects develop severe fibrosis.

A Bag of Worms

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.

Atypical Cat-Scratch Disease in Children: Report of Seven Presentations Ranging From Hepatosplenic Disease to Horner Syndrome

Introduction: Cat scratch disease (CSD) is an infectious disease caused by the Gram-negative rod Bartonella henselae (BH). It usually leads to subacute loco-regional lymphadenitis occasionally associated with fever. In most of the cases, it resolves spontaneously within 4 - 6 weeks. However, CSD has also been associated with other atypical presentations. Case Presentation: We reported a series of seven children with unusual symptoms of CSD. In particular, we described the case of a child with ptosis, miosis and enophtalmy, suggesting Horner syndrome, associated with cervical lymphadenitis. Cat scratch was mentioned in only one patient, while four of them mentioned a recent contact with cats. We reviewed and discussed the incidence of these atypical presentations of CSD as well as the therapeutic approaches recommended and the available diagnostic tools. Conclusions: This paper highlighted the need to exclude CSD in children with unexplained symptoms such as prolonged fever, hepatosplenic lesion and osteomyelitis.