Recurrent Hematochezia in a Returning Traveler | Gastroenterology | JN Learning | AMA Ed Hub [Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.204.227.34. Please contact the publisher to request reinstatement.
[Skip to Content Landing]

Recurrent Hematochezia in a Returning Traveler

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 28-year-old man presented to his primary care physician for hematochezia. He had previously lived for a few years in Uganda and frequently swam in the Nile River. After returning to the US, he experienced recurrent diarrhea. In April 2018, he had an appendectomy for acute appendicitis. In February 2019, 22 months after his return from Uganda, he developed intermittent hematochezia. He had no vomiting, fever, or weight loss during this time. On evaluation, vital signs were normal and abdominal examination showed a soft, nontender abdomen. Rectal examination was normal. A complete blood cell count and comprehensive metabolic panel were notable for a normal hemoglobin level and an absolute eosinophil count of 304 cells/μL. Results of testing including stool microscopy, HIV fourth-generation assay, hepatitis B serologies, and a rectal swab for gonorrhea and chlamydia were negative. A colonoscopy demonstrated granular mucosa in the rectum. Internal hemorrhoids were present, but there were no masses, vascular malformations, or other abnormalities. A biopsy of rectal tissue was obtained; histopathologic features are shown in the Figure.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Schistosomiasis

A. Prescribe praziquantel without further diagnostic testing

The key to the correct diagnosis in this patient is the histopathologic finding of granulomas containing schistosome eggs (Figure, black arrows) with lateral spines (Figure, blue arrow), consistent with Schistosoma mansoni, for which praziquantel is indicated (choice A). Although stool microscopy (choice B) is an appropriate first step, returning travelers often have low parasite burdens, so additional stool samples are low yield. The presence of schistosome eggs argues against tuberculosis as the cause of the granulomatous inflammation, so tuberculosis testing (choice C) and treatment (choice D) are not warranted.

Schistosomiasis is a parasitic infection caused by flukes. Schistosoma mansoni, found in Africa and the Arabian Peninsula, resides in mesenteric venules, leading to intestinal, hepatic, and/or pulmonary disease as a result of an immune response to migrating eggs that deposit in these organs.1 Infection is acquired through freshwater contact, from which larvae infect humans via skin penetration.2 Exposure to upper Nile River water is a risk factor for S mansoni acquisition. In one study, 17% of persons exposed to Ugandan Nile River water developed acute schistosomiasis.3

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: Shana Gleeson, MD, Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, PO Box 208022, New Haven, CT 06519 (Shana.gleeson@yale.edu).

Published Online: March 5, 2021. doi:10.1001/jama.2021.0368

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share his information.

References
1.
Gray  DJ , Ross  AG , Li  YS , McManus  DP .  Diagnosis and management of schistosomiasis.   BMJ. 2011;342:d2651. doi:10.1136/bmj.d2651PubMedGoogle ScholarCrossref
2.
Clerinx  J , Van Gompel  A .  Schistosomiasis in travellers and migrants.   Travel Med Infect Dis. 2011;9(1):6-24. doi:10.1016/j.tmaid.2010.11.002PubMedGoogle ScholarCrossref
3.
Morgan  OW , Brunette  G , Kapella  BK ,  et al.  Schistosomiasis among recreational users of Upper Nile River, Uganda, 2007.   Emerg Infect Dis. 2010;16(5):866-868. doi:10.3201/eid1605.091740PubMedGoogle ScholarCrossref
4.
Gryseels  B , Polman  K , Clerinx  J , Kestens  L .  Human schistosomiasis.   Lancet. 2006;368(9541):1106-1118. doi:10.1016/S0140-6736(06)69440-3PubMedGoogle ScholarCrossref
5.
Botes  SN , Ibirogba  SB , McCallum  AD , Kahn  D .  Schistosoma prevalence in appendicitis.   World J Surg. 2015;39(5):1080-1083. doi:10.1007/s00268-015-2954-3PubMedGoogle ScholarCrossref
6.
Helleberg  M , Thybo  S .  High rate of failure in treatment of imported schistosomiasis.   J Travel Med. 2010;17(2):94-99. doi:10.1111/j.1708-8305.2009.00387.xPubMedGoogle ScholarCrossref
7.
Branda  JA , Lin  TY , Rosenberg  ES , Halpern  EF , Ferraro  MJ .  A rational approach to the stool ova and parasite examination.   Clin Infect Dis. 2006;42(7):972-978. doi:10.1086/500937PubMedGoogle ScholarCrossref
8.
Whitty  CJ , Mabey  DC , Armstrong  M , Wright  SG , Chiodini  PL .  Presentation and outcome of 1107 cases of schistosomiasis from Africa diagnosed in a non-endemic country.   Trans R Soc Trop Med Hyg. 2000;94(5):531-534. doi:10.1016/S0035-9203(00)90077-4PubMedGoogle ScholarCrossref
9.
Schistosomiasis: resources for health professionals. Centers for Disease Control and Prevention. Published April 11, 2018. Accessed September 23, 2020. https://www.cdc.gov/parasites/schistosomiasis/health_professionals/index.html#tx
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close