Spinal schistosomiasis: differential diagnosis for acute paraparesis in a U.S. resident

Abstract

Background: Spinal schistosomiasis is a severe presentation of Schistosoma mansoni infection, which is endemic in South America, the Middle East, and sub-Saharan Africa. With increasing international travel, a disease can spread from an endemic area to another part of the world easily.

Objectives: To present a case of a US resident who developed acute paraparesis due to spinal schistosomiasis after traveling to sub-Saharan Africa.

Participant: A 45-year-old woman presented with abdominal pain radiating into the bilateral lower extremities. She was diagnosed with a pelvic mass and underwent an urgent hysterectomy with right salpingo-oopherectomy. Postoperatively, she developed progressive weakness with worsening pain in her bilateral lower extremities and neurogenic bladder. Magnetic resonance imaging showed an abnormal T2 hyperintense signal in the entire spinal cord below the T3 level with abnormal contrast enhancement from T9 through the conus medullaris. Spinal fluid analysis showed lymphocytic pleocytosis and elevated protein. The patient was diagnosed with transverse myelitis. Subsequently, a detailed history revealed a visit to Ethiopia 2 years earlier. Tests for S mansoni were positive. After treatment with praziquantel and prednisone, her neurologic function began to improve.

Conclusions: An increasing incidence of international travel is increasing the likelihood of US physicians' encountering this treatable condition. Travelers with spinal schistosomiasis may not have symptoms of systemic infection. Therefore, it is important to include spinal schistosomiasis in the differential diagnosis of acute inflammatory myelopathy, particularly with a history of travel to endemic areas.

Figure 1

T2-weighted magnetic resonance image of the cervical (A) and thoracic (B) spine demonstrates hyperintense signal in the lower thoracic spine.

Figure 2

Gadolinium-enhanced sagittal T1-weighted magnetic resonance image of the thoracolumbar junction shows patchy enhancement with scattered focal nodular enhancement of the expanded distal spinal cord and conus.

Figure 3

T2-weighted magnetic resonance images of the cervical (A), thoracic (B), and lumbar (C) spine demonstrate a decrease in hyperintense signal within the lower thoracic spinal cord after 9 months.