5 Discussion:
This case report highlights the importance of a thorough investigation
of patients presenting with gastrointestinal symptoms, such as
hematemesis and melena. Particularly for those live or had recent visit
to areas hyper-endemic with intestinal parasites. This underscores the
need for raising awareness among the local communities and visitors
about the locally endemic diseases through improving reporting and
timely sharing of health data publicly. This will further guide
healthcare providers in improving their differential diagnosis and
advice for those who plan to travel to endemic area about precautions
and prophylaxis they should take.
In this case report, the young male was admitted to the hospital with
signs of liver and spleen enlargement, coupled with low blood cell
counts. While the liver function tests showed no abnormality, the stool
exam confirmed triple infections with S. mansoni , and hook worm
eggs and Rhabditiform first-stage larvae of S. stercoralis .
Interestingly, the Hepatosplenic schistosomiasis observed in this case,
represents the severe complicated type of S. mansoni infection,
with the development of hemorrhaging from esophageal varices [31].
This is the most commonly encountered and critical complication.
Based on the initial differential diagnosis of this patient’s symptoms,
could have concluded various syndromes, which include hepatitis, liver
cirrhosis, or even malignancy [32,33]. However, the ultrasound
showed a distinct central sonolucencies and the absence of a true
cirrhotic pattern. The patient’s viral screening and liver function
tests were unremarkable. The etiology of the patient’s symptoms and
unique shift in the clinical manifestations could be attributed to the
interplay between the triple infections and the body immuno-response.
Although the patient is an immigrant from South Sudan, however, prior to
the separation in 2010, South Sudan and Sudan were a single country, and
both countries are heavily endemic with intestinal parasites, therefore,
it could not be exclusively confirmed that his acquired these infections
at his home country [34]. Specially that, schistosomiasis and
strongyloidiasis both can persist in patients for a long while
undetected.
The final diagnosis of chronic hepatosplenic schistosomiasis was
established based on the following criteria: 1) Identification ofS. mansoni egg in the stool sample; 2) presence of portal
hypertension and esophageal varices with normal liver function test and
no evidence of hepatic cirrhosis; 3) Travel and residency history of the
patient in hyper endemic countries.
The early detection of these triple infections was challenged by the
fact that infection with S. stercoralis can happen without
symptoms, especially in areas of high endemicity [35]. This is
exactly the case with our patient indicated by that; the larva was
detected incidentally in his stool sample. The presence of this
additional parasitic infection was indicated confirmed through stool
examination and there is no dermatologic evidence of Strongloides (such
as Larva currens), as well as the lack of pulmonary or gastrointestinal
manifestations like steatorrhea, malabsorption or protein losing
enteropathy. This indicates that the triple infections has altogether
altered the clinical presentation of symptoms to look non-like any of
these infections separately.
In Sudan, both of these infections are endemic, and schistosomiasis
affects around 50% of the population in certain regions [36]. In
order to improve public health measures relating to parasitic infections
like S. mansoni , hook worm and S. stercoralis , several key
steps are essential. The first and most important measure is to raise
awareness among communities at risk and healthcare providers regarding
the local risk, prevalence, and mode of transmission, personal
protection and prevention measures from these parasitic infections
[37]. Public health education campaigns should implemented
complemented with massive and social media sessions to engage the
community and emphasize the importance of proper sanitation, hygiene,
and safe practices for food, water, and defecation [37]. These
interventions should be particularly intensified among populations
living in crowded settings and suboptimal conditions such as camps for
refugees and internally displaced persons (IDPs) to reduce the risk of
infection. Additionally, this should be supported with systematic
screening and treatment programs or massive drugs administration (MDA)
program for treatment and prevention among people at high-risk either
due to previous or current exposure to sources of potential
contamination [38]. Specially that, the currently ongoing war in the
country has distributed the originally fragile health system including
diagnostic services, surveillance system, and healthcare and medication
services throughout the country [39,40,41]. While on the hand, it
has created a suitable environment for the emergence of invasive
pathogens and vectors, intensified the transmission and dynamic of
infections, and increased the vulnerability of the forcibly displaced
persons that represents over 85% of the country population
[39,40,41]. In the current situation it would be more strategic to
invest in a multisectoral collaborative framework that develop and
implement a One Health strategy. The One Health strategy implements
cost-effective strategic planning and intervention for improving human,
animal, and the environment health through capitalizing on prevent and
control interventions and reduce the exposure of vulnerable population
to risk factors rather than curative medicine [42]. This
multisectoral framework should bring health, agricultural, animal
resources, metrological and climate, education, humanitarian, and
development sectors altogether to maximize the impacts through
prioritization, integration, for a better use of resources.
In conclusion, this case documents the complications of having multiple
infections on the same time and how this alter the clinical presentation
of diseases. It also highlights the importance of considering
co-infection and/or multiple infections especially for parasitic
infections that have similar manifestation. Therefore, it might be a
good strategy for healthcare providers to keep going with the
differential diagnosis after making the first detection particularly
among patients presenting with gastrointestinal symptoms in endemic
areas. Although this might seems to cost more resources, however,
considering that the golden standard tool for the diagnosis of
intestinal parasites, implementing comprehensive screening for
additional infection will not cost anything more than a few
extra-minutes. Considering the zoonotic nature of parasitic infections,
implementing One Health strategy will substantially reduce the resources
needed for the surveillance, prevention, and control of these infections
among human, animal, and the environment. This will improve the health
and socioeconomic of poor communities and animals.