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Schistosomiasis in an HIV-Positive Patient Presenting as an Anal Fissure and Giant Anal Polyp

Schistosomiasis in an HIV-Positive Patient Presenting as an Anal Fissure and Giant Anal Polyp Report of a Case In January 2005, a 29-year-old Cameroonian woman living in Germany since December 2004 presented with newly diagnosed human immunodeficiency virus (HIV) infection (Centers for Disease Control and Prevention classification A2). At this time she was completely free of complaints. Owing to her stable virologic state (viral load, 2.3 × 104/mL) and immunologic state (CD4 cell count and percentage, 323/μL and 25%, respectively), no antiretroviral therapy was initiated. Ten months later, the patient developed intense pain during defecation. No diarrhea was reported. The proctologic examination revealed an anal fissure at the 6-o’clock dorsosacral position and a 1-cm anal polyp in the region of the anorectal line. During the course of 7 months, she complained of relapsing undulating abdominal pain. Abdominal sonographic findings were normal. A pelvic examination revealed a uterus myomatosis to which the pain was referred. In September 2006, the patient was hospitalized for fissurectomy and excision of the anal polyp under general anesthesia. During the procedure, the anal polyp, now grown to 4 cm (Figure 1), was excised. Histologic analysis showed multiple calcified ova of Schistosoma. According to their lateral spine they were classified as Schistosoma mansoni (Figure 2). Figure 1. View LargeDownload Intraoperative view of the 4-cm anal polyp (asterisk) in the region of the anorectal junction, pulled out with forceps for demonstration. Figure 2. View LargeDownload Histologic analysis of the fibrous anal polyp bounded by keratinized, stratified, squamous epithelium with focally accentuated chronic inflammation. In the stroma, calcified ova of Schistosoma mansoni with the characteristic lateral spine (arrowhead) were discovered (hematoxylin-eosin, original magnification ×20). During the reported period, the patient's immunologic and virologic states were stable. Laboratory findings revealed a mild anemia (hemoglobin level, 9.2 g/dL) and eosinophilia (eosinophil differential count, 9.6%). (To convert hemoglobin to grams per liter, multiply by 10.0; to convert eosinophil differential count to a proportion of 1.0, multiply by 0.01.) Findings of repeated stool examinations for ova, cysts, and parasites were negative as were the findings of a focal and parenchymal indirect immunofluorescent antibody test (IIFT) and an enzyme-linked immunosorbent assay (ELISA) of the serum using Schistosoma antigen. Owing to the histologic findings, a diagnosis of schistosomal anal polyposis was made. The patient was treated with a single oral dose (40 mg/kg) of praziquantel (Cysticide; Merck & Co, Whitehouse Station, New Jersey). After the combination of praziquantel treatment and surgery, the patient had no further complaints. Egg excretion results as well as IIFT and ELISA findings remained negative. The eosinophil differential count normalized (1.8%) 3 months after therapy. Comment Schistosomiasis is a trematode parasitic infection with a complex life cycle.1 The trematode is geographically distributed mainly in tropical and subtropical regions of Sub-Saharan Africa, Asia, and South America. Polyposis is a well-known complication of chronic S mansoni infection. Several cases of intestinal,1 colonic,2 and rectal3 polyposis have been described in the literature. The interactions between HIV infection and schistosomiasis have been summarized previously.4 The progression of HIV infection does not seem to be affected by schistosomiasis,5 and the presence of HIV coinfection has no influence on the extent of schistosomiasis. However, HIV infection leads to lower egg excretion, which can be decreased even more in patients with lower CD4 cell counts.6 In addition, owing to the immunologic incompetence of HIV-positive patients, serologic test findings are less likely positive. Further reports of schistosomal polyposis in both HIV-negative1,7 and HIV-positive2 patients report negative egg detection. In our case, results of repeated stool examinations, IIFT, and ELISA serum tests were negative too. In rare cases of coinfected patients, initiation of antiretroviral therapy can cause an immune reconstitution syndrome, which can lead to a new clinical presentation or deterioration of schistosomiasis.8 Because our patient had never undergone antiretroviral therapy, this immunologic mechanism can be excluded. The first therapeutic option in the treatment of schistosomiasis is a single oral dose of praziquantel, 40 mg/kg. The efficacy in HIV-positive patients is as high as in immunocompetent patients.6 Correspondence: Dr Gholam, Department of Dermatology, University Heidelberg, Voßstrasse 2, 69115 Heidelberg, Germany (patrick.gholam@med.uni-heidelberg.de). Financial Disclosure: None reported. References 1. Segun AOAlebiosu COAgboola AO et al. Schistosomiasis—an unusual cause of abdominal pseudotumor. J Natl Med Assoc 2006;98 (8) 1365- 1368PubMedGoogle Scholar 2. Javid BAliyu SHSave VE et al. Schistosomal colonic polyposis in an HIV-positive man. AIDS 2007;21 (3) 386- 388PubMedGoogle ScholarCrossref 3. Abe YInamori MFujita K et al. Gastrointestinal: rectal polyp associated with schistosomiasis. J Gastroenterol Hepatol 2006;21 (7) 1216PubMedGoogle ScholarCrossref 4. Secor WE Interactions between schistosomiasis and infection with HIV-1. Parasite Immunol 2006;28 (11) 597- 603PubMedGoogle Scholar 5. Brown MKizza MWatera C et al. Helminth infection is not associated with faster progression of HIV disease in coinfected adults in Uganda. J Infect Dis 2004;190 (10) 1869- 1879PubMedGoogle ScholarCrossref 6. Karanja DMBoyer AEStrand M et al. Studies on schistosomiasis in western Kenya: II. Efficacy of praziquantel for treatment of schistosomiasis in persons coinfected with human immunodeficiency virus-1. Am J Trop Med Hyg 1998;59 (2) 307- 311PubMedGoogle Scholar 7. Yasawy MIEl Shiekh Mohamed ARAl Karawi MA Comparison between stool examination, serology and large bowel biopsy in diagnosing Schistosoma mansoni. Trop Doct 1989;19 (3) 132- 134PubMedGoogle Scholar 8. Lawn SDWilkinson RJ Immune reconstitution disease associated with parasitic infections following antiretroviral treatment. Parasite Immunol 2006;28 (11) 625- 633PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Schistosomiasis in an HIV-Positive Patient Presenting as an Anal Fissure and Giant Anal Polyp

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Publisher
American Medical Association
Copyright
Copyright © 2008 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.144.7.950
Publisher site
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Abstract

Report of a Case In January 2005, a 29-year-old Cameroonian woman living in Germany since December 2004 presented with newly diagnosed human immunodeficiency virus (HIV) infection (Centers for Disease Control and Prevention classification A2). At this time she was completely free of complaints. Owing to her stable virologic state (viral load, 2.3 × 104/mL) and immunologic state (CD4 cell count and percentage, 323/μL and 25%, respectively), no antiretroviral therapy was initiated. Ten months later, the patient developed intense pain during defecation. No diarrhea was reported. The proctologic examination revealed an anal fissure at the 6-o’clock dorsosacral position and a 1-cm anal polyp in the region of the anorectal line. During the course of 7 months, she complained of relapsing undulating abdominal pain. Abdominal sonographic findings were normal. A pelvic examination revealed a uterus myomatosis to which the pain was referred. In September 2006, the patient was hospitalized for fissurectomy and excision of the anal polyp under general anesthesia. During the procedure, the anal polyp, now grown to 4 cm (Figure 1), was excised. Histologic analysis showed multiple calcified ova of Schistosoma. According to their lateral spine they were classified as Schistosoma mansoni (Figure 2). Figure 1. View LargeDownload Intraoperative view of the 4-cm anal polyp (asterisk) in the region of the anorectal junction, pulled out with forceps for demonstration. Figure 2. View LargeDownload Histologic analysis of the fibrous anal polyp bounded by keratinized, stratified, squamous epithelium with focally accentuated chronic inflammation. In the stroma, calcified ova of Schistosoma mansoni with the characteristic lateral spine (arrowhead) were discovered (hematoxylin-eosin, original magnification ×20). During the reported period, the patient's immunologic and virologic states were stable. Laboratory findings revealed a mild anemia (hemoglobin level, 9.2 g/dL) and eosinophilia (eosinophil differential count, 9.6%). (To convert hemoglobin to grams per liter, multiply by 10.0; to convert eosinophil differential count to a proportion of 1.0, multiply by 0.01.) Findings of repeated stool examinations for ova, cysts, and parasites were negative as were the findings of a focal and parenchymal indirect immunofluorescent antibody test (IIFT) and an enzyme-linked immunosorbent assay (ELISA) of the serum using Schistosoma antigen. Owing to the histologic findings, a diagnosis of schistosomal anal polyposis was made. The patient was treated with a single oral dose (40 mg/kg) of praziquantel (Cysticide; Merck & Co, Whitehouse Station, New Jersey). After the combination of praziquantel treatment and surgery, the patient had no further complaints. Egg excretion results as well as IIFT and ELISA findings remained negative. The eosinophil differential count normalized (1.8%) 3 months after therapy. Comment Schistosomiasis is a trematode parasitic infection with a complex life cycle.1 The trematode is geographically distributed mainly in tropical and subtropical regions of Sub-Saharan Africa, Asia, and South America. Polyposis is a well-known complication of chronic S mansoni infection. Several cases of intestinal,1 colonic,2 and rectal3 polyposis have been described in the literature. The interactions between HIV infection and schistosomiasis have been summarized previously.4 The progression of HIV infection does not seem to be affected by schistosomiasis,5 and the presence of HIV coinfection has no influence on the extent of schistosomiasis. However, HIV infection leads to lower egg excretion, which can be decreased even more in patients with lower CD4 cell counts.6 In addition, owing to the immunologic incompetence of HIV-positive patients, serologic test findings are less likely positive. Further reports of schistosomal polyposis in both HIV-negative1,7 and HIV-positive2 patients report negative egg detection. In our case, results of repeated stool examinations, IIFT, and ELISA serum tests were negative too. In rare cases of coinfected patients, initiation of antiretroviral therapy can cause an immune reconstitution syndrome, which can lead to a new clinical presentation or deterioration of schistosomiasis.8 Because our patient had never undergone antiretroviral therapy, this immunologic mechanism can be excluded. The first therapeutic option in the treatment of schistosomiasis is a single oral dose of praziquantel, 40 mg/kg. The efficacy in HIV-positive patients is as high as in immunocompetent patients.6 Correspondence: Dr Gholam, Department of Dermatology, University Heidelberg, Voßstrasse 2, 69115 Heidelberg, Germany (patrick.gholam@med.uni-heidelberg.de). Financial Disclosure: None reported. References 1. Segun AOAlebiosu COAgboola AO et al. Schistosomiasis—an unusual cause of abdominal pseudotumor. J Natl Med Assoc 2006;98 (8) 1365- 1368PubMedGoogle Scholar 2. Javid BAliyu SHSave VE et al. Schistosomal colonic polyposis in an HIV-positive man. AIDS 2007;21 (3) 386- 388PubMedGoogle ScholarCrossref 3. Abe YInamori MFujita K et al. Gastrointestinal: rectal polyp associated with schistosomiasis. J Gastroenterol Hepatol 2006;21 (7) 1216PubMedGoogle ScholarCrossref 4. Secor WE Interactions between schistosomiasis and infection with HIV-1. Parasite Immunol 2006;28 (11) 597- 603PubMedGoogle Scholar 5. Brown MKizza MWatera C et al. Helminth infection is not associated with faster progression of HIV disease in coinfected adults in Uganda. J Infect Dis 2004;190 (10) 1869- 1879PubMedGoogle ScholarCrossref 6. Karanja DMBoyer AEStrand M et al. Studies on schistosomiasis in western Kenya: II. Efficacy of praziquantel for treatment of schistosomiasis in persons coinfected with human immunodeficiency virus-1. Am J Trop Med Hyg 1998;59 (2) 307- 311PubMedGoogle Scholar 7. Yasawy MIEl Shiekh Mohamed ARAl Karawi MA Comparison between stool examination, serology and large bowel biopsy in diagnosing Schistosoma mansoni. Trop Doct 1989;19 (3) 132- 134PubMedGoogle Scholar 8. Lawn SDWilkinson RJ Immune reconstitution disease associated with parasitic infections following antiretroviral treatment. Parasite Immunol 2006;28 (11) 625- 633PubMedGoogle Scholar

Journal

Archives of DermatologyAmerican Medical Association

Published: Jul 21, 2008

Keywords: anal fissure,hiv seropositivity,polyps,schistosomiasis,anus

References