Jejunal perforation caused by schistosomiasis

Introduction

Parasitic infections of the intestine remain an important public health problem in tropical countries. Intestinal perforation is a very unusual complication of schistomiasis and, to date, only three cases of colonic perforation associated with schistosoma infection have been reported in English literature.^1–3 We report an unusual case of jejunal perforation in a South Korean patient, associated with adult worm of schistosoma. To our knowledge, small intestinal perforation associated with adult worm of schistosoma has not been previously reported in literature.

Case history

A 49-year-old South Korean man was admitted to the surgical casualty department with acute abdominal pain and associated vomiting that developed over three days. A physical examination revealed a slightly protuberant abdomen with hypoactive bowel sounds. He was afebrile but there was generalized tenderness of the abdomen. His laboratory investigation and abdominal radiogram were noncontributory, except for moderate leukocytosis (18.5 × 10⁹ cells/L). Abdominal laparotomy was performed with a provisional diagnosis of acute abdomen with possible intestinal perforation. A jejunal perforation of about 0.3 cm in length was identified in the jejunum. An enterectomy encompassing the perforated site and jejunojejunal anastomosis was performed. Microscopic examination revealed evidence of perforation with mixed acute and chronic inflammatory infiltrates in the mucosa. In the perforated area, an occasional adult parasite worm, morphologically consistent with the schistosoma, was observed attached to the inflamed ulcerated mucosa (Figure 1). Many adult parasites of similar morphology were also noted in the normal-looking mucosa. Despite an extensive search, schistosoma eggs could not be identified in the histologic sections. Postoperative stool examination failed to detect any parasitic ova. However, serological tests for schistosomiasis were positive (IgG titre 1:200). The patient received a single dose of praziquantel (40 mg/kg body weight) postoperatively and was discharged after a week.

OPEN IN VIEWER

Schistosomiasis is increasingly being reported from non-endemic areas as it is imported by the migrant population and travelers to the endemic regions. ⁴ Our patient was a native of South Korea, which is endemic for schistosomiasis. Most intestinal lesions are caused by Schistosoma mansoni and S. japonicum, but may also be due to S. haematobium. Most of the intestinal lesions are in the form of petechial haemorrhage or circumoval granulomas in the lamina propria or submucosa. ⁵ Eggs retained in the gut wall induces inflammation, ulceration, microabscess formation and polyposis. ⁵

Unlike our case which involved the small intestine, the distal part of the colon is more frequently and seriously affected. ⁵ Intestinal perforation is an extremely unusual presentation associated with schistosomiasis. A review of literature revealed only three cases of colonic perforation associated with intestinal schistosomiasis.^1–3 To our knowledge, jejunal perforation associated with schistosoma has not been previously reported.

Another atypical feature of this case was the demonstration of the adult worm of schistosoma on the mucosal surface. Attachment of the parasite to the ulcerated mucosal surface of the perforation site associated with the local inflammatory reaction led us to believe that the perforation was most likely secondary to the parasitic infection. However, the exact species could not be determined in the present case, as examination of the stool failed to demonstrate schistosoma ova. The tegument of the male schistosoma worm is characterized by the presence of tubercles or spines, which also helps in differentiating the different species. In the present case, the tegument of the parasite demonstrated presence of fine spines (Figure 1, inset), which helped in identification of the parasite. Diagnosis was further confirmed by the demonstration of high serologic titre for schistosoma.

Conclusion

In conclusion, we present a very unusual case of schistosomiasis presenting as acute abdomen due to small bowel perforation. The current case serves as a reminder to the clinicians about the varied presentations of schistosmiasis, which should be borne in mind while evaluating a case of acute abdomen.