Small-duct sclerosing cholangitis associated with Schistosoma mansoni

Abstract

A 17-year-old girl presented with a history of elevated alkaline phosphatase and gamma-glutamyl transpeptidase (cGT) levels for several years. She was asymptomatic and did not have jaundice, pruritus, abdominal pain, nausea, vomiting, weight loss, rashes, or diarrhea. Viral hepatitis serologies, autoimmune serologies, and thyroid studies were all normal.She had a past medical history of anxiety, which was treated with Celexa. Otherwise, she was healthy and had no major childhood illnesses or history of substance abuse. She had traveled extensively with her family during her childhood, notably to Northern and Eastern Africa and Southeast Asia. Her physical examination was unremarkable. An abdominal ultrasound examination was performed, and the findings were normal. Magnetic resonance cholangiopancreatography (MRCP) showed mild beading of the intrahepatic ducts consistent with the diagnosis of primary sclerosing cholangitis involving the small ducts. The patient was started on ursodiol (300 mg three times per day), and her alkaline phosphatase and cGT levels promptly normalized.Subsequently, colonoscopy was performed to rule out concomitant inflammatory bowel disease. The mucosa appeared normal on endoscopic examination, but random biopsy samples were taken to rule out quiescent colitis. The pathology specimens revealed schistosoma eggs, and stool studies were positive for Schistosoma mansoni. Percutaneous liver biopsy was then performed to evaluate hepatic involvement. There were Fig. 1. Portal triad demonstrating an intravenular granuloma surrounding a schistosoma egg. Onion-skinning fibrosis impinging on small interlobular ducts can also be noted. The over all histological examination showed minimal portal fibrosis with focal areas of periportal extensions.

First Schistosomal Cholecystitis Complicated by Cholangitis and Liver Abscess: Case Report and Review of Literature

“…In our case, no stones were identified in the CBD by ERCP or MRCP; however, slipped stone to duodenum cannot be excluded as a probable cause. Another speculation is related to schistosomiasis pathogenesis leading to fibrosis and stricture of the CBD [10]. Despite early fibrotic changes of the CBD and/or ampulla being a possible cause in our case, however, we did not have any imaging evidence indicating gross CBD wall thickening or ampullary fibrosis.…”