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Unusual Presentations of Gastrointestinal Bilharziomas

Yussuf M Abdulkadir1* and Taoheed A Atanda2

1Department of Medicine, Aminu Kano Teaching Hospital, Bayero University, Kano
2 Department of Histopathology, Aminu Kano Teaching Hospital, Bayero University, Kano

*Corresponding author

*Yussuf Maisuna Abdulkadir, Department of Medicine, Aminu Kano Teaching Hospital, PMB 3452, Kano

Abstract

Introduction: Schistosomiasis is a common disease of the tropics, an estimated 200 million or more individuals are affected worldwide and causing about 500,000 deaths every year. Gastrointestinal tract schistosomiasis is a common tropical parasitic infection. In Nigeria, Kano state is one of the hyperendemic zones for the disease. The disease occurs when larvae penetrate the skin during contact with contaminated freshwater, eventually migrating to the gastrointestinal tract. Infected individuals may experience abdominal pain, diarrhea, haematochezia, and, in chronic cases, significant intestinal and liver damage. Method: A review of clinical and pathological archival records of patients diagnosed with schistosomiasis in a tertiary teaching hospital in Kano state, Nigeria. The final report and clinical data including age, gender, site and major clinical signs and symptoms were summarized and presented in tabular form. Result: In the 11 years study period, there were 36 cases of gastrointestinal tract schistosomiasis confirmed by histology representing 13.5% of 266 suspected cases of schistosomiasis diagnosed. The ages ranged from 10 to 70 years with a mean age of 29±2 years and M:F ratio 11:1, Gender-related Chi-Squared Statistic = 22.16, p-value = 0.0046. The clinical presentations including appendicitis, rectal pathologies, and perforated ulcers. Discussion: The higher frequency among children and adolescents may centered around greater participation in recreational water activities and exposure of a greater surface area to contaminated water. A wide range of presentation in Gastro-intestinal schistosomiasis has been reported and studies have shown that these variations are influenced by the location of egg deposition, intensity of the infection, and host response to infection and cutting across all age groups, a preponderance of schistosomal appendicitis was found in our study. Schistosomal appendicitis has been found to have a prevalence ranging between 0.02 and 6.3%, and represents 28.6% of severe appendicitis cases in such endemic regions. Conclusion: Gastro-intestinal Schistosomiasis remains an important disease in many parts of the tropics, and this is particularly important in endemic areas where they may masquerade as a sinister lesions leading to misdiagnosis and avoidable surgeries.

Keywords: Schistosomiasis, Bilharziomas, Granulomas, GIT, Appendicitis, Hyperendemic

Introduction

Schistosomiasis is a common disease of the tropics, an estimated 200 million or more individuals are affected worldwide and causing about 500,000 deaths every year [1]. World Health Organization (WHO) regards the disease as a neglected tropical disease (NTDs), with an estimated 732 million persons being vulnerable to infection worldwide in renowned transmission areas [2]. Schistosomiasis is the second most common NTDs after hookworm and Sub-Saharan Africa accounts for 93% (192 million) of the world estimated 207 million cases of schistosomiasis. The highest prevalence of this infection is seen in Nigeria (29 million) [3].

Similarly, Schistosome eggs are highly resistance and partly contributed to the persistence of the disease. The eggs have been identified in both Egyptian and Chinese mummies [4]and the presence of hematuria presumably as a result of Schistosoma hematobium infection, was noted repeatedly in Egyptian pharonic writing [5]. The increasing prevalence of the infestation are largely attributable to the increased irrigation in areas with inadequate waste disposal and breakdown in public health infrastructure [6]. Most of the complications associated disease are initiated by the chronic egg deposition. The extensive inflammatory response of both humoral and cellular reactions to the schistosome eggs results in lesions composed of T cells, Antibodies and other inflammatory cells. These lesions progress to form granulomas (Bilharzomas) made of T- and B-lymphocytes and large monocytes. Ultimately, non-caseating granulomas are formed [7,8].

Gastrointestinal tract is a prominent system affected by the infection, the preferred home of S. mansoni, S. japonicum, and the less commonly encountered S. intercalatum and S. mekongi, is the venous splanchnic vasculature. The adult worms move through the vessels, the female lays numerous eggs, again the root of pathology in this disease. The eggs produce a local inflammatory response, which can be massive. Some of the eggs, however, remain trapped within intestinal tissue and cause intestinal pathology [9].

In Nigeria, Kano state is one of the hyperendemic zones for the disease [10]. The disease occurs when larvae penetrate the skin during contact with contaminated freshwater, eventually migrating to the gastrointestinal tract. Infected individuals may experience abdominal pain, diarrhea, haematochezia, and, in chronic cases, significant intestinal and liver damage [11]. In Kano, close human-water interaction, age < 18 years and presence of infected family members are significant risk factors that have been associated with acquiring the diasease [12]. Addressing gastrointestinal schistosomiasis is crucial for raising awareness of its clinical presentation, thus avoiding misdiagnosis.

Method and Materials

A review of clinical and pathological archival records of patients diagnosed with schistosomiasis in a tertiary teaching hospital in Kano state, Nigeria was conducted. These included all cases between January, 2013 and December, 2024. The biopsy specimens obtained were placed in bottles containing Formalin or Bouin’s solution. The samples were processed through surgical cut-up, then placed in automated tissue processor containing different strengths of alcohol (ascending grade 75-100%) followed by embedding in paraffin wax, and then sectioned at 3 microns. The processed tissues were then placed on a clean glass slide and DPX mountant was added before covering with a cover slip and then examined under the microscope. The final report and clinical data including age, gender, site and major clinical signs and symptoms are summarized and presented in tabular form.

Results

In the 11 years studied there were 36 cases of gastrointestinal tract schistosomiasis confirmed by histology representing 13.5% of 266 suspected cases of schistosomiasis diagnosed from all sites. The ages ranged from 10 to 70 years and a mean age of 29±2 years. There was a preponderance of males (33 cases; 91.7%) and clinical presentations including appendicitis, rectal pathologies, and perforated ulcers. Female patients accounted for 3 cases (8.3%) and their diagnoses included Appendicitis and Rectal and Small intestinal lesions. The Gender-related Chi-Squared Statistic = 22.16, p-value = 0.0046.

The most common diagnosis was Appendicitis accounting for 63.8% of cases; with most of the patients (21/23) presenting with only RIF (Right Iliac Fossa) pain, a key symptom of appendicitis. The two remaining cases presented with perforation of the organ. Other sites affected in terms of frequency included the rectum accounting for 25.0% of cases. Three patients presented with rectal lesions such as hemorrhoids, polyps, and haematochezia without associated haemorrhoids. Two cases of suspected malignancies one each involving the Ileum and Caecum also turned out to be inflammatory lesions secondary to the parasite. A case of perforated Gastric ulcer secondary to the parasite and a case of gangrenous bowel secondary to torsion were also seen.

An overview of the range of clinical presentations shows that RIF pain, which aligns with the diagnosis of appendicitis was the most common and was seen in 63.8% of patients. Other key clinical findings included haematochezia, seen in 5 (13.9%) of cases; constipation 2 (5.6%), perforations of visci seen in 3 (8.3%), and suspicious masses in 5.6% of cases. The p-values for the Chi-Squared tests for gender, diagnosis, and clinical presentation are all below the significance level of 0.05, suggesting that these variables are statistically significant.

Table 1: Shows the site of the lesions, presentation and gender distribution.

Figure 1: Colonoscopy picture of Rectal Mass with histological confirmation of Bilharzoma (original).

Figure 2: (a) shows polypoid rectal mass exhibiting finger-like growth of the mucosa. (b) shows a live gravid adult schistosome within the intensely inflamed mucosa. Hematoxylin and Eosin x200.

Discussion

Our study shows that of the 266 cases of schistosomiasis histologically diagnosed during the study period. Thirty six (13.5%) of the specimens were from the gastrointestinal tract (GIT) and masqueraded as more serious conditions enough to elicit clinical suspicion, endoscopic biopsy and surgical intervention. Gastrointestinal schistosomiasis was second only to those diagnosed from the urinary tract. Across Africa GI-related schistosomiasis prevalence has ranged from 6.9% to as high as 20.1% [13-16].

The age pattern in this study characterized by a preponderance of young patients, a mean age of 29±2 years and peak affectation in the 3rd decade is similar to reports by others [17-19].The higher frequency among children and adolescents may center around greater participation in recreational water activities and exposure of a greater surface area to contaminated water. Peak intensity of infection has been documented to occur between the ages of 8 and 12 years in highly endemic areas like in thepopulation covered by this study, and older ages in less endemic areas [20]. Cross-sectional studies of in- and out-of School children aged 5–19 years in endemic parts of Africa have reported prevalence ranging from 19.8% to as high as 64.3% [21,22].Adults tend to have lower prevalence and burden of disease due to higher likelihood of having received antischistosoma therapy and, also age-related acquired immunity to the parasite [23].

The frequency of female affected is particularly low in our study (M:F 11:1). This is probably due to the cultural practices in our part of the country where females are not allowed to engage in out-door activities such as swimming and irrigation farming; activities that are risk factors for contact with the vectors [24,25]. The greater frequency among males has also been observed by others [1-19,26].

A wide range of presentation in Gastro-intestinal schistosomiasis has been reported and studies have shown that these variations are influenced by the location of egg deposition, intensity of the infection, and host response to infection [27-29]. Similar to others, [30] and cutting across all age groups, a preponderance of schistosomal appendicitis was found in our study. Schistosomal appendicitis has been found to have a prevalence ranging between 0.02 and 6.3%, and represents 28.6% of severe appendicitis cases in such endemic regions [31,32].

This predilection for the vermiform appendix may reflect a combination of anatomical, physiological, and immunological factors. Schistosoma species, particularly S. mansoni and S. japonicum, deposit eggs in the mesenteric venous plexus and from here the ova migrate to nearby organs, particularly the appendix which has not only has a rich but narrow vascular network, the lumen of the organ is also narrow. Entrapment of ova of the parasite in the organ may then elicit an immune response because of the abundance of lymphoid tissue at this site. This localized inflammation may then lead to appendicitis-like symptoms, particularly right iliac fossa pain, seen in 58.3% of our patients. The cases of perforation of the appendix reported in 2 of the patients may also be explained by the tendency for luminal obstruction by the parasite, accumulation of mucous secretions and resultant inflammatory reaction.

Acute symptoms are often nonspecific and may include bloody mucoid diarrhea, tenesmus, abdominal pain, bowel obstruction, fever, and weight loss [27]. Chronic infestation leads to granulomatous polyp formation. Large, mass-like lesions called bilharziomas may cause intestinal obstruction [28] or be misdiagnosed as GI malignancy [29,30]. These modes of presentation were also found among our patients. Intra-luminal polypoid lesions as seen in 2 of our cases has also been reported by others as common finding in intestinal disease and may cause diffuse polyposis in up to 20% of cases [33]. The polyps are inflammatory in nature may be confused with Adenomatous Polyposis or neoplastic polyps and may lead to chronic gastrointestinal bleeding and protein loss. Treatment with antischistosomal medications have been reported to reduce the density and number of polyps [34,35]. In severe cases, these manifestations may require surgical intervention or endoscopic polypectomy in addition to antischistosomal chemotherapy [36].

Histopathologic findings of the infective agent in biopsies submitted for other clinical impressions underscores the need for submission of all biopsies for histopathological examination. The lesions are often characterized by granulomata around the ova and occasionally the adult form may be seen as observed in one of our cases in a 16 year old boy presenting with a 3cm polypoid rectal mass (figures 2a and 2b).

Conclusion

Gastro-intestinal Schistosomiasis remains an important disease in many parts of the tropics, and physicians need to develop a high index of suspicion for this parasitic infestation. This is particularly important in endemic areas where they may masquerade as more ominous lesions uncharacteristic in young patients, leading to misdiagnosis and avoidable surgeries.

Acknowledgement: All praise is to the Almighty who made it possible for me to complete this work and profound gratitude to the management of Aminu Kano Teaching Hospital, Kano

Authors Contributions

  1. Yussuf M. Abdulkadir: Writing of the manuscript, Questionnaire administration and Endoscopy procedures
  2. Taoheed A. Atanda: Development of the concept, Data Presentation and analysis, Histological assessment and Supervision

 Disclosure: None

Funding: Self sponsor

Ethical approval: Not Necessary

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