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A Patient with a Solitary Lump in the Sigmoid Colon
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI A Patient with a Solitary Lump in the Sigmoid Colon Lorenz Theilmann and Ahmed Abdel Samie Department of Gastroenterology, HELIOS Hospital, Pforzheim, Germany
Question: A 73-year-old male underwent screening colonoscopy. He has lived for a couple of years in Namibia on his farm and has gone several times on hunting safaris in other African countries. He was not aware of any serious diseases in the past except for fever for 2–3 days and a rash on his back and chest during one of his safaris in Zambia. Colonoscopy was performed on an outpatient basis and documented normal findings except for a 2-cm mass in the distal sigmoid with a normal-appearing mucosa on narrow band imaging (Figure A, B). The mass felt quite firm on touch with a biopsy forceps. Histology showed massive subepithelial eosinophilic cell infiltration (Figure C) as well as granuloma (Figure D). Considering the patient’s history, what is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.05.049
Gastroenterology 2016;150:e11–e12
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 6: Schistosomiasis Figure E shows necrosis in the submucosa with eosinophilic cells and a Schistosoma egg. Laboratory results showed mild peripheral blood eosinophilia (9%) and positive Schistosoma mansion antibodies (dilution 1:320). Urologic examination and abdominal computed tomography scan showed no pathologic findings. The patient was treated with praziquantel for 3 days and his further course was uneventful. Schistosoma infections occur in residents of endemic areas, including tropical, subtropical, and sub-Saharan countries. The infection is acquired by humans via fresh water contact. A papular rash may develop from larvae penetration of the skin. After migration through the lung vessels into the arterial circulation larvae finally reach the liver via the portal vein where they mature into adult worms.1 Schistosoma mansoni migrate to the mesenteric venules of the colon, whereas S haematobium migrate to the vesical venous plexus and start to produce eggs. The immune response of the host to the eggs that are released into the systemic circulation leads to inflammation and formation of granulomas.2 The extent of the disease is mainly related to the overall production of eggs. In addition to a nonspecific peripheral blood eosinophilia, antibodies to Schistosoma antigens can be detected in the vast majority of cases and have a specificity and sensitivity of >90%. Typical manifestations in the colon and rectum are granulomatous inflammation and the development of pseudopolyps and small ulcers that might lead to bloody diarrhea.3 In our patient, the only manifestation was a large single pseudopolyp in the sigma, suggesting that he was lucky to have an infection with probably a small number of parasites leading to a low and perhaps only temporarily production of eggs with no severe clinical symptoms.
References 1. 2. 3.
e12
Barsoum RS, Esmat G, El-Baz T. Human schistosomiasis: clinical perspective: review. J Adv Res 2013;4:433–444. Cheever AW, Hoffmann KF, Wynn TA. Immunopathology of Schistosoma mansoni in mice and men. Immunol Today 2000; 21:465–466. Strickland GT. Gastrointestinal manifestations of schistosomiasis. Gut 1994;35:1334–1337.
Question: A 73-year-old male underwent screening colonoscopy. He has lived for a couple of years in Namibia on his farm and has gone several times on hunting safaris in other African countries. He was not aware of any serious diseases in the past except for fever for 2–3 days and a rash on his back and chest during one of his safaris in Zambia. Colonoscopy was performed on an outpatient basis and documented normal findings except for a 2-cm mass in the distal sigmoid with a normal-appearing mucosa on narrow band imaging (Figure A, B). The mass felt quite firm on touch with a biopsy forceps. Histology showed massive subepithelial eosinophilic cell infiltration (Figure C) as well as granuloma (Figure D). Considering the patient’s history, what is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.05.049
Gastroenterology 2016;150:e11–e12
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 6: Schistosomiasis Figure E shows necrosis in the submucosa with eosinophilic cells and a Schistosoma egg. Laboratory results showed mild peripheral blood eosinophilia (9%) and positive Schistosoma mansion antibodies (dilution 1:320). Urologic examination and abdominal computed tomography scan showed no pathologic findings. The patient was treated with praziquantel for 3 days and his further course was uneventful. Schistosoma infections occur in residents of endemic areas, including tropical, subtropical, and sub-Saharan countries. The infection is acquired by humans via fresh water contact. A papular rash may develop from larvae penetration of the skin. After migration through the lung vessels into the arterial circulation larvae finally reach the liver via the portal vein where they mature into adult worms.1 Schistosoma mansoni migrate to the mesenteric venules of the colon, whereas S haematobium migrate to the vesical venous plexus and start to produce eggs. The immune response of the host to the eggs that are released into the systemic circulation leads to inflammation and formation of granulomas.2 The extent of the disease is mainly related to the overall production of eggs. In addition to a nonspecific peripheral blood eosinophilia, antibodies to Schistosoma antigens can be detected in the vast majority of cases and have a specificity and sensitivity of >90%. Typical manifestations in the colon and rectum are granulomatous inflammation and the development of pseudopolyps and small ulcers that might lead to bloody diarrhea.3 In our patient, the only manifestation was a large single pseudopolyp in the sigma, suggesting that he was lucky to have an infection with probably a small number of parasites leading to a low and perhaps only temporarily production of eggs with no severe clinical symptoms.
References 1. 2. 3.
e12
Barsoum RS, Esmat G, El-Baz T. Human schistosomiasis: clinical perspective: review. J Adv Res 2013;4:433–444. Cheever AW, Hoffmann KF, Wynn TA. Immunopathology of Schistosoma mansoni in mice and men. Immunol Today 2000; 21:465–466. Strickland GT. Gastrointestinal manifestations of schistosomiasis. Gut 1994;35:1334–1337.