A 28-year-old woman comes to the office due to several months of progressive abdominal pain and intermittent diarrhea. She denies fever or chills but has lost weight due to poor appetite. The patient works for an organization that installs wood pellet cookstoves in rural villages in Central Africa and has spent much time in the region over the last 5 years. Temperature is 37.8 C (100 F) , blood pressure is 126/72, and pulse is 86. BMI is 19 kg/m². Physical examination is normal. Laboratory results are as follows: An intestinal biopsy sample is shown in the exhibit.

Which of the following is the most appropriate treatment for this patient?

Question

A 28-year-old woman comes to the office due to several months of progressive abdominal pain and intermittent diarrhea. She denies fever or chills but has lost weight due to poor appetite. The patient works for an organization that installs wood pellet cookstoves in rural villages in Central Africa and has spent much time in the region over the last 5 years. Temperature is 37.8 C (100 F) , blood pressure is 126/72, and pulse is 86. BMI is 19 kg/m². Physical examination is normal. Laboratory results are as follows:

An intestinal biopsy sample is shown in the exhibit.

Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

11ec160b_3bfc_3b51_9249_f90dc163adf9_MD0001_00 This patient's travel history, chronic intestinal symptoms, eosinophilia, and biopsy findings suggest schistosomiasis, a parasitic blood fluke infection primarily seen in rural parts of sub-Saharan Africa and East Asia. Exposure occurs when humans swim or bathe in freshwater that contains contaminated snails (the intermediate host). Cercariae from the snails penetrate human skin and migrate to the liver, where they mature into adult worms. Adult worms then travel through the portal circulation to the mesenteric venules (S mansoni and S japonicum) or the venous plexus of the bladder (S haematobium). Adult worms release eggs through host tissue to be excreted in feces or urine. Although most patients are asymptomatic, eggs can trigger a significant granulomatous inflammatory response, leading to manifestations in the gastrointestinal tract (eg, diarrhea, weight loss, anorexia, anemia), bladder (eg, terminal hematuria), or periportal system (eg, portal hypertension, splenomegaly). Eosinophilia is common early in the disease course as eosinophils release granules that are toxic to adult worms. Diagnostic confirmation requires the identification of round/oval eggs with a characteristic terminal (S. haematobium) or lateral (S. mansoni) spine on stool/urinary testing or tissue biopsy. Treatment with praziquantel, which alters parasite digestion and calcium transport, is generally curative. (Choice A) Artemisinin-based combination therapy is used for chloroquine resistant malaria. Malaria can cause gastrointestinal symptoms, but patients are usually acutely ill (eg, fever, chills, myalgia, headache). Giemsa-stained blood smear generally reveals intraerythrocytic ring-shaped trophozoites, not eggs with a spine. (Choice B) Bacterial infection of the gastrointestinal tract is common when traveling to countries with poor sanitation and water control systems. Ciprofloxacin is sometimes used for treatment. However, most cases are brief in duration, eosinophilia is not generally seen, and eggs would not be present. (Choice C) Ganciclovir can treat cytomegalovirus colitis, which frequently causes diarrhea and abdominal pain. However, most cases arise in patients that are severely immunocompromised. Furthermore, fever is usually present and biopsy would show intracytoplasmic and intranuclear inclusions, not eggs. (Choice D) Metronidazole plus paromomycin is used to treat Entamoeba histolytica, which is a common cause of dysentery (eg, diarrhea, fever, abdominal pain) in travelers. However, the presence of several months of symptoms, eosinophilia, and eggs on biopsy make this diagnosis unlikely. Educational objective: Schistosomiasis is a blood fluke infection that occurs when humans bathe or swim in freshwater that contains contaminated snails. Adult worms mature in the liver, lodge in the mesenteric venules or vesicular venous plexus, and secrete eggs into feces or urine. Eggs can trigger granulomatous inflammation, leading to symptoms in the gastrointestinal, urinary, or periportal tract. Diagnosis is typically made when round or oval eggs with a terminal or lateral spine are identified in urine, feces, or biopsy.

A 28-Year-Old Woman Comes to the Office Due to Several