1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Brendon G Tillman Affiliation: Uniformed Services University

2. MedPix No: 9692 - History Pt Demographics: Age = 51 y.o. Gender = woman A 51-year-old woman presents with chronic left flank and pelvic pain. Her past medical history is remarkable for a remote liver biopsy. She reports prior travel to several Asian countries. Surgical history is notable for a prior cesarean section. Downloaded by (-1)

3. MedPix No: 9692 - EXAM & LABS The physical examination shows a nondistended abdomen and nonspecific lower abdominal pain and was otherwise noncontributory. Abdominal radiography and CT of the abdomen and pelvis were obtained.

4. Schistosomiasis Japonicum AP abdomen Downloaded by (-1)

5. Schistosomiasis Japonicum Schematic lifecycle of Schistosomiasis. Source of image is: - http://www.dpd.cdc.gov/DPDx/HTML/Schistosomiasis.asp?body=Frames/S- Z/Schistosomiasis/body_Schistosomiasis_page1.htm - - http://www.cdc.gov/ncidod/dpd/parasites/schistosomiasis/default.htm - http://www.cdc.gov/ncidod/dpd/parasites/schistosomiasis/moreinfo_schistosomiasis.htm Downloaded by (-1)

6. Schistosomiasis Japonicum Anteroposterior abdominal radiograph shows subtle linear densities in the pelvis and left lower quadrant (arrows) Downloaded by (-1)

7. Schistosomiasis Japonicum Magnified AP abdominal radiographic image shows that these densities may be thin linear calcifications that have a tram track-like appearance (arrows). Downloaded by (-1)

8. Schistosomiasis Japonicum Axial intravenous contast-enhanced CT image at the level of the lower abdomen Downloaded by (-1)

9. Schistosomiasis Japonicum Axial intravenous contrast-enhanced CT image shows thin mucosal calcification (arrow) along a length of the descending colon, corresponding to the radiographically-identified linear densities within the left lower quadrant. Downloaded by (-1)

10. Schistosomiasis Japonicum Axial intravenous contrast-enhanced CT image through the pelvis Downloaded by (-1)

11. Schistosomiasis Japonicum Axial intravenous contrast-enhanced CT at a lower level in the pelvis shows similar tram-track calcificaton pattern of the mucosal surface of the sigmoid colon (arrows). Downloaded by (-1)

12. Schistosomiasis Japonicum Axial CT image of the liver and magnified image of the right hepatic lobe shows thin hepatic capsular calcifications. Note also the prominence of the portal vein, the slightly shrunken overall appearance of the liver, and the mildly nodular hepatic surface, findings indicative of chronic liver disease. Downloaded by (-1)

13. Schistosomiasis Japonicum Axial CT image of the liver and magnified image of the right hepatic lobe shows thin hepatic capsular calcifications (arrows). Note also the prominence of the portal vein, the slightly shrunken overall appearance of the liver, and the mildly nodular hepatic surface, findings indicative of chronic liver disease. Downloaded by (-1)

14. FINDINGS Abdominal radiography showed subtle curvilinear densities overlying in the left lower quadrant and central within the pelvis. This was confirmed on intravenous contrast- enhanced abdominopelvic CT to be the caused by thin mucosal surface calcifications within the descending and sigmoid colons. Incidental note is made of thin right hepatic lobe capsule calcifications.

15. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Schistosomiasis Japonicum - Tuberculosis (TB) - Alkaline encrustation cystitis - Primary amyloidosis - Radiation

16. Diagnosis: Schistosomiasis Japonicum Dx Confirmed by: Liver Biopsy

17. DISCUSSION Bladder calcifciation was not present on remainder of pelvis CT (images not included). These colonic and hepatic calcifications are characteristic of Schistosomiasis infection of the gastrointestinal tract. Liver biopsy confirmed Schistosomiasis japonicum infection. - - Imaging is useful for showing the extent of involvement and identifying complications of disease. Definitive diagnosis is achieved with serologic testing or tissue biopsy. Drug therapy is the primary form of treatment and can lead to rapid clinical improvement. - - - More images of Schistosomiasis: - http://images.google.com/images?q=schistosomiasis+usuhs&btnG=Search&svnum=10&hl=e n&lr=