Intestinal Schistosomiasis Masquerading as Irritable Bowel Syndrome

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Intestinal Schistosomiasis Masquerading as Irritable Bowel Syndrome

 

Delano Fabor, Jr., D.O.

Parisa Ann Suthun, M.D.

Peter R. McNally, D.O.

 

 

 

 

Keywords

 

Colitis, irritable bowel syndrome (IBS), schistosomiasis

 

 

Disclaimer

 

Dr. Fabro and Dr. Suthun are affiliated with the Department of

Internal Medicine, Wright-Patterson Medical Center at Wright-Patterson

Air Force Base, Ohio. Dr. McNally is affiliated with the Department of

Gastroenterology, Evans Army Hospital in Colorado. The views expressed

in this article are those of the authors and do not reflect the

official policy or position of the United States Air Force, Department

of Defense, or the US Government. The corresponding author is Parisa

Ann Suthun, M.D. She may be contacted at Parisa.Suthun.

 

 

 

Introduction

 

Irritable bowel syndrome (IBS) is a common medical disorder, reported

to occur in 10-20% of the adult US population (1). It is twice as

common in women and age of onset is usually second decade (2).

Although 1/3 of all cases of IBS involve men, they less frequently

seek medical attention (2).

 

The Rome II criteria have become the standard for the clinical

diagnosis of this disorder, see Table 1 (2,3). With the absence

warning signs or " red flags " indicating systemic illness, national

guidelines recommend an abbreviated evaluation to include laboratory

tests and endoscopy with biopsy, Tables 2 and 3 (2,3).

 

 

Table 1: Rome II Criteria for Irritable Bowel Syndrome (IBS) At least

12 weeks of abdominal discomfort or pain in the preceding 12 months

that has two of the three following associated features:

 

Relief of symptoms with defecation

 

Looser or more frequent stool ( > 3 per day)

Harder or less frequent stool (< 3 per week)

 

 

Table 2: Red Flags Suggesting Non-IBS Etiology for Symptoms

Progressive weight loss

Onset in old age

Fever

 

Rectal bleeding

Steatorrhea

Dehydration

 

 

Table 3: Recommended Baseline Testing for Suspected IBS

 

Complete Blood Count

Erythrocyte Sedimentation Rate

Chemistry

 

Sensitive Thyroid Stimulating Hormone

 

Celiac Antibody Screen

 

Stool for Ova and Parasites

 

Sigmoidoscopy & Biopsy ( > 50 yr Colonoscopy)

 

 

 

Endemic to 74 countries in South America, Asia, and Africa,

schistosomiasis affects 200 million people. However, cases of

intestinal schistosomiasis reported in the United States are rare,

almost exclusively seen among travelers to highly endemic areas. We

report a case of a male with chronic abdominal pain and diarrhea

thought to be due to IBS. Unique in his history was a trip to Uganda,

where he spent time kayaking in the Nile River. Otherwise the patient

exhibited no history, physical of laboratory evidence of " red flags "

suggesting non IBS etiology.

 

 

 

Methods for Image Capture/Processing

 

An Olympus EVIS Endoscopy System was used.

 

 

 

Case/Body

 

A 24-year-old male without previous bowel problems reported a oneyear

history of diarrhea upon return from Uganda, where he went white water

rafting along the Nile. He complained of non-bloody, watery diarrhea,

abdominal discomfort, subjective fevers and pruritic rash to his lower

back. Initially, his physical exam findings were unremarkable, and

laboratory findings to include complete blood cell count, chemistries,

and stool studies for ova and parasites were unrevealing. In the

ensuing months, his fever and rash resolved. Without " red flags " , a

diagnosis of Irritable Bowel Syndrome by Rome II criteria was

rendered. However, persistent diarrhea of up to ten watery stools per

day prompted a referral to gastroenterology. Repeat laboratory tests

revealed a normal celiac antibody panel, and total leukocyte count,

but the differential showed 20% eosinophilia. Colonoscopy was

remarkable for subtle yellow 1-2mm; flat, yellow-white lesions seen

most frequently in the ascending and sigmoid colon, see Figure 1.

Biopsy of the ascending colon revealed eosinophilic infiltration of

the lamina propria, and biopsy of the rectosigmoid colon revealed

multiple giant cell granulomas in the muscularis mucosa and a single

Schistosoma egg as seen in Figure 2. Schistosoma antibody was positive

at 8.75 units (<1 unit negative). He was treated for schistosomiasis

with a one-day course of praziquantel 40 mg/kg. Nine months later,

patient's peripheral eosinophilia resolved. Repeat colonoscopy showed

normal mucosal appearance and histology was unremarkable.

 

Figure 1

 

Figure 2

 

 

 

 

 

Discussion

 

The global impact of schistosomiasis is tremendous. It is estimated

that 200 million people or roughly 1 in 30 persons in the world are

infected with schistosomiasis (5). The disease is caused by a

parasitic blood fluke that resides in fresh water. Schistosomal

cercariae penetrate human skin, enter the blood and lymph vessels,

then are carried to the heart, migrate through the pulmonary

capillaries, and are ultimately spread systemically.

 

The initial schistosomiasis infection can produce a maculopapular

eruption at the sites of skin penetration of the cercariae. This may

develop within a few hours or up to a week after cutaneous

infiltration. Swimmer's itch is a more intense dermatitis caused by

re-exposure to cercariae in sensitized persons. Acute schistosomiasis

illness, otherwise known as Katayama fever, occurs between two to

twelve weeks after infection. It is characterized by fever, abdominal

pain, headache, generalized myalgias, and diarrhea. Hepatosplenomegaly

can also occur. At this stage in the schistosomal infection, not all

persons will shed eggs; however, most will have a peripheral

eosinophilia, which may be one of the only clues to this diagnosis.

 

Schistosomiasis has been reported among returned travelers who visited

endemic areas (6) and in travelers who went river rafting (7). In

these cases, a travel history, fever, and eosinophilia raised the

index of suspicion of schistosomiasis, which was confirmed by stool

evaluation for ova and parasites and/or serology. Although our patient

likely had acute schistosomiasis or Katayama fever, his stool

evaluation was negative dissuading his clinicians to consider

schistosomiasis initially. Perhaps the use of concentration techniques

could have increased yield of his stool evaluation (8).

 

In a prospective study of patients who lived in Saudi Arabia, an

endemic area of schistosomiasis, 49 of 228 (17%) patients who reported

lower gastrointestinal tract symptoms, similar to our patient's

symptoms, were found to have schistosomiasis (9). Had the patient

lived in an endemic area, the index of suspicion may have been higher

initially. However, persistent diarrhea symptoms prompted further

investigation, which included colonoscopy. Macroscopic features of

schistosomiasis colitis can be subtle and easily overlooked as

illustrated in Figure 1. Mucosal biopsy is an essential requirement in

the work up of patients with " IBS with diarrhea. " The findings of

eosinophils in the intestinal mucosa and granulomatous colitis also

warrant investigation for parasitic diseases.

 

The early diagnosis and treatment of schistosomiasis may be important

in preventing serious sequelae such as transverse myelitis, periportal

fibrosis, and bladder cancer (9). We report a case of intestinal

schistosomiasis masquerading as IBS. With ever increasing global

travel, clinicians should carefully inquire about travel patterns and

be alert to the traveler returning with chronic diarrhea and always be

mindful that endoscopy with biopsy is mandatory in the evaluation of

these patients, even when other " red flags " are negative.

 

 

 

References

 

 

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Ther 1997;11:3-15.

 

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technical review for practice guidelines. Gastroenterology

1997;112:2120-37.

 

3. Drossman DA, Corazziari E, Talley NJ, Thompson WG, Whitehead WE, et

al. Rome II: A multinational consensus document on functional

gastrointestinal disorders. Gut 1999; 45(Suppl. II):II1-II81.

 

4. Acute Schistosomiasis in U.S. Travelers Returning from Africa. MMWR

1990; 39(9):141-2,147-8.

 

5. Shekhar KC. Schistosomiasis drug therapy and treatment

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6. Schistosomiasis among River Rafters -- Ethiopia. MMWR.

1983;32(44):585-6.

 

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Microbiology Press, 1999:1336-54.

 

8. Al-Freihi HM, Al-Idrissi HY, Al-Quorain A, Al-Mohaya SA, Al-Hamdan

AR, Ibrahim EM. The pattern of colonic diseases in the Eastern

Province of Saudi Arabia. J Trop Med Hyg. 1986;89(1):23-7.

 

9. Ross AGP, Barley PB, Sleigh AC, Olds GR, Li Y, Williams GM, et.al.

Schistosomiasis. NEJM 2002;346(16):1212-20.