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• W2332367723 abstract "Meckel's diverticulitis is an unusual cause of abdominal pain in spite of the prevalence of the abnormality in the population. Schistosoma mansoni causing Meckel's diverticulitis is rare. A 5-year-old Tanzanian boy with Meckel's diverticulitis associated with Schistosoma mansoni infection is described. This highlights the need for increased awareness of the appearance of diseases in nonendemic areas. Schistosomiasis is one of the main causes of morbidity in the tropics, and symptoms may appear long after exposure to infection. Schistosomiasis in association with Meckel's diverticulitis has rarely been diagnosed in the United Kingdom, and we know of only one case report in this country (1). Forty years ago a single case was reported in America (2). Increasing modern travel has led to unusual occurrences of disease in nonendemic areas (3-5). Increased awareness of schistosomiasis causing abdominal pain and other ill-defined symptoms in the immigrant population or in travelers is required. Screening of family members resulted in treating asymptomatic persons. Case Report A 5-year-old boy was admitted in an emergency with a 48-hour history of central abdominal pain. The pain was periumblical with left iliac fossa radiation and was intense and colicky with intermittent pain-free periods. There was also a 48-hour history of nonbilious vomiting after eating. There was no history of haematemesis. There was no significant medical history. The parents with their five children had immigrated from Tanzania 11 months earlier. Immunisation was complete. On examination he was apyrexial and was intermittently rolling in bed with pain. He was mildly dehydrated with weight between the 10th and 25th percentiles. The abdomen was diffusely tender, maximally in the left iliac fossa. There was a feeling of fullness in the left iliac fossa with no guarding or rebound tenderness. The rectum was empty. Abdominal radiograph showed a central lower abdominal mass with adjacent dilated loops of small bowel. Ultrasound of the abdomen showed a 3.5-cm cystic mass superior to the bladder, immediately beneath the abdominal wall with internal septation and fluid levels. There was another 1 × 3-cm lesion that was closely related to the bladder and anterior abdominal wall. There was a small amount of fluid between bowel loops. Surgical review was requested, and the patient underwent exploratory laparotomy. A Meckel's diverticulum cyst was identified lying superior to the urinary bladder and adherent to the small bowel on its antimesenteric border. It was excised without bowel resection. Macroscopically, it was a 9-cm long blind-ending structure of dumbbell shape. Proximally, it measured 3 cm in length with a diameter of 1.5 cm. It continued with a narrow neck of 0.5 cm followed by a distal 6 cm, which was distended to a diameter of 4 cm. This distended area contained cloudy fluid. These two cystic parts corresponded to the ultrasound appearances. There was no evidence of abdominal sepsis or bowel wall thickening. Appendectomy was performed. Histology confirmed the structure as a Meckel's diverticulum, showing acute and chronic inflammatory cell infiltrate in the serosa. Granulomata surrounded by fibrosis with a central calcified area were noted. In the mucosa, submucosa, and muscle layers there were multiple granulomata with giant cells in the centre reacting to foreign material. One of the blocks showed a large cystically dilated structure lined by flattened attenuated epithelium, mildly inflamed with multiple granulomata containing foreign structures, some calcified, with a giant cell reaction. The appearances of structures in the centres of the granulomata were highly suggestive of schistosomiasis; Ziehl-Neelsen stain showed the outer layer to be staining strongly positive (Fig. 1). The appendix contained one focus of foreign body-type giant cells, presumably relating to the same disease process.FIG. 1: Schistosoma ovum lying in tissues with associated foreign body-type giant cell.Stool and urine were repeatedly negative for ova, cysts, and parasites by formalin ether concentration tests. Spun urine with resuspension of the deposit was similarly negative. Peripheral blood film showed hypochromic microcytic anaemia but no eosinophilia. He was treated with praziquantel. The remainder of the family, both parents, two sisters aged 15 and 11 years, and two brothers aged 13 and 8 years, were asymptomatic. They were screened for schistosomiasis by obtaining stool and urine samples, which were negative for ova, cysts, or parasites. In all family members except the mother (who had not been swimming in Lake Malawi with her husband and children), there was peripheral eosinophilia. Schistosoma serology (by enzyme-linked immunosorbent assay) was positive at level 2 to level 4 (showing a likelihood of infection of 72-82%). The father and other children were therefore treated with praziquantel. DISCUSSION Schistosoma species, S. mansoni, S. japonicum, and S. haematobium, are blood flukes that infect humans. Man is the natural host, and the fresh water snail acts as an intermediate host. Human schistosomiasis is widely distributed in 74 countries especially in Africa (6). The World Health Organization estimates 200 million people are infected with Schistosoma and 500 to 600 million people are at risk of infection (6). S. mansoni is endemic in Egypt, North and South Africa, some of the West Indies, and the northern two thirds of South America. The disease is usually characterised by chronic infection over a period of 10 to 20 years from early childhood onward, resulting in fibrosis in the intestines and liver or in the bladder and urinary tract. S. mansoni causes liver and colon disease resulting in abdominal pain and bloody diarrhoea. Granulomata secondary to egg deposition cause hepatosplenomegaly, cirrhosis, and periportal fibrosis leading to portal hypertension and upper GI haemorrhage (7). Bleeding from oesophageal varices is a main cause of morbidity and mortality. Most patients with schistosomiasis have a chronic form of the infection that is caused by a granulomatous response surrounding the ova, caused by soluble antigens released from them (7-8). Katayama fever is a manifestation of acute shistosomiasis (5,9). Typical features include fever, an urticarial rash, enlarged liver and spleen, and bronchospasm. It is thought to be an immune complex phenomenon initiated by eggs laid by maturing schistosomes (9). Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. It arises as a result of incomplete dissolution of the vitellointestinal duct and occurs in 2% to 4% of the population. Clinical signs are often absent, and complications occur in 4% of cases (haemorrhage, occlusion, inflammation, and [rarely] malignant change). The reasons for abdominal pain remain varied, but given the prevalence of schistosomiasis in endemic areas and the common finding of eggs of S. mansoni in the gastrointestinal tract, it is surprising that the association with Meckel's diverticulitis has not been recognised more often. A high index of suspicion is required to diagnose this frequently occurring cause of abdominal pain in the immigrant population and in travelers to endemic areas. The final diagnosis in our case and in the other two cases was made by histologic examination (1-2). The finding of a Ziehl-Neelsen stain-positive outer egg covering indicates a diagnosis of schistosomiasis mansoni (10). It is important that other family members be investigated diligently when an index case has been identified in a returning traveler, most particularly if they have been swimming in infected waters, because such a devastating disease can remain latent for years." @default.
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• W2332367723 title "Meckel's Diverticulitis Associated With Schistosoma mansoni" @default.
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