Giant schistosomal granuloma mimicking rectum neoplasia: case report

CASE REPORT

Giant schistosomal granuloma mimicking rectum neoplasia: case report

Luiz Eduardo Correia Miranda^I; Eduardo Carvalho^II; Diego Laurentino Lima^III

^IAdjunct Professor of Abdominal Surgert at Faculdade de Ciências Médicas of Universidade de Pernambuco (UPE) – Recife (PE), Brazil

^IIDoctor of the Endoscopy Service at Hospital Geral Octávio de Freitas – Recife (PE), Brazil

^IIIMedical student at Faculdade de Ciências Médicas of UPE – Recife (PE), Brazil

^{Correspondence to}

ABSTRACT

We report the case of a young man from an area where schistosomiasis is endemic, in the state of Pernambuco, who presented with hemorrhage. Initially diagnosed as rectum neoplasia, subsequent investigation demonstrated rectal giant schistosomal granuloma. The diagnoses and clinical aspects of the case are discussed in this study.

Keywords: schistosomiasis; granuloma; neoplasm; rectum; general surgery.

RESUMO

Nós relatamos o caso de um homem, jovem, proveniente de uma área endêmica para esquistomossomose, no Estado de Pernambuco, e que apresentou hematoquezia. Inicialmente diagnosticado como neoplasia do reto, a investigação subsequente demonstrou um granuloma esquistossomótico gigante do reto. O diagnóstico e os aspectos clínicos do caso são discutidos.

Palavras-chave: esquistossomose; granuloma; neoplasia; reto; cirurgia geral.

INTRODUCTION

Schistosomiasis mansoni is a chronic infection caused by the direct contact with fresh water that contains cercaria, the larval form of the parasite. The disease is endemic in Brazil, being prevalent in the Northeast region and spread to the West and South; there are serious consequences to the people who are infected¹. Hyperplastic manifestations of schistosomiasis are uncommon and may present in different clinical forms, including the pseudotumoral form. In this paper, we report the case of a rectal schistosomal pseudotumor.

CASE REPORT

A 24-year-old man presented symptoms of constipation for a long period and rectal bleeding for one month. He denied using any type of medication, as well as weight loss, anorexia, hematemesis, jaundice or fever. He comes from an endemic area of schistosomiasis, and did not present with acute suffering.

Phisical examination: abdomen was flat, not tender, no masses, no hepatomegalies or splenomegalies. No clinical findings were related to hepatic insufficiency or portal hypertension. His blood tests were normal, except for mild microcytic anemia and eosinophilia. Colonoscopy demonstrated a mass measuring from 3 to 4 cm, bleeding in the anterior rectal wall, 6 cm from the anal margin (Figure 1);

Pathological report showed chronic rectal mucosa inflammation and granulomas consisting of epithelioid cells and some nucleus Langhans giant cells, involving eggs with long lateral spine, which suggested rectal schistosomal granuloma (Figure 2). Patient was treated with praziquantel and colonoscopy after 90 days showed the clinical resolution of the granuloma.

DISCUSSION

The pseudotumoral form of schistosomiasis mansoni has hyperplastic manifestations in which the egg of the parasite (antigen) causes exaggerated response, with a granulomatous inflammatory reaction². The schistosomal granuloma is the most uncommon type of hyperplastic manifestation³. The incidence in the intestinal form of schistosomiases are more frequent in the rectum, sigmoid and descending colon. Differential diagnosis of granuloma are adenocarcinoma, sarcoma, polyps, tuberculosis and lymphoma. The chronic disease is caused by a granulomatous inflammation that occurs in response to the deposit of eggs in the tissue⁴.

The clinical presentation of the intestinal form of the schistosomal granuloma may vary from dyspeptical symptoms to schistosomal proctocolitis, abdominal pain, nausea, tenesmus, mucous-bloody diarrhea and transrectal bleeding². Santana and Lima¹ described a schistosomal granuloma of the colon in the descending sigmoid junction, simulating malignant neoplasm. Lantsberg et al.⁵ described the rectal pseudotumor of an Ethiopian man who presented with rectal bleeding and received praziquantel after the disease was diagnosed by a rectal biopsy. The conclusion is that the diagnosis of the pseudotumoral form of schistosomiasis should be considered for patients who come from endemic areas for schistosomiasis with rectal mass. Praziquantel heals 60 to 90% of these patients, and endoscopic findings may induce to a diagnostic error of rectal neoplasm.

Submitted on: 08/02/2010

Approved on: 19/09/2010

Financing source: none

Conflict of interest: nothing to declare

Study carried out at the University Hospital Oswaldo Cruz – Recife (PE), Brazil

• 1. Santana HJ, Lima CA. Pseudotumor esquistossomótico de cólon Relato de um caso. Rev bras Coloproct 1985;5(1):17-21.
• 2. Kalil M, Battisti Netto O, Vieira LCA, Cintra LC. Forma pseudotumoral intra-abdominal da esquistossomose mansônica. Ver Col Bras Cir [Internet] 2006 Mai-Jun; 33(3). Available from: http://www.scielo.br/rcbc
• 3. Prata A. Esquistossomose mansoni. In: Doenças infecciosas e parasitárias. 6Ş ed. Rio de Janeiro: Guanabara-Koogan; 1976.
• 4. Neto JB. Manifestações hiperplásicas da esquistossomose mansônica. J Bras Med 1983;45(5):37-40.
• 5. Lantsberg L, Khodadadi J, Krugliak P. Schitosomal granuloma mimicking adenocarcinoma of the rectum. J Clin Gastroenterol 1987;9(4):489-90.

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Sept 2011

History

• Received
  08 Feb 2010
• Accepted
  19 Sept 2010