Intrahepatic venous shunt and splenic artery aneurysm in hepatosplenic schistosomiasis

Abstract

A 66-year-old woman had been living in an area endemic for schistosomiasis in the northeast of the State of Minas Gerais, Brazil, since childhood. Over the last 10 years, she presented two episodes of hematemesis (1999 and 2008). Small-caliber esophageal and gastric varices were observed during upper digestive endoscopy. She has been receiving beta-blockers for prophylaxis of digestive tract hemorrhage since 2008. Liver function tests were normal. Abdominal ultrasound revealed that the liver surface was slightly lobular. Magnetic resonance imaging of the liver showed hyperintense periportal thickening compatible with Symmers fibrosis. The serological markers for hepatitis B and C tested negative. An intrahepatic venous shunt with communication between the right portal branch and the right hepatic vein was documented (Figure A -arrow). Saccular aneurysmal dilatation of the splenic artery was also observed. A helical CT scan with 3D reconstruction showed the splenic artery aneurysm and the intrahepatic venous shunt ( Figures B and C -arrows). Out of 82 patients with hepatosplenic schistosomiasis evaluated in our hospital using imaging techniques, this was the first case (1.2%) of splenic artery aneurysm and intrahepatic shunt. These findings were not seen during ultrasound examination. The patient refused surgical treatment and is being followed up in the outpatient clinic.A paciente, de 66 anos, vive desde a infância em área endêmica de esquistossomose no nordeste de Minas Gerais, Brasil. Ela apresentou, nos últimos 10 anos, dois episódios de hematêmese (1999 e 2008). Observou-se à endoscopia digestiva alta, varizes esofagianas e gástricas de fino calibre. Ela está em uso de beta-bloqueador para profilaxia de hemorragia digestiva desde 2008. A função hepática era normal. À ultrassonografia abdominal, o fígado apresentava contorno levemente lobulado. À ressonância magnética do fígado notou-se espessamento hiper-intenso periportal compatível com fibrose de Symmers. Os marcadores sorológicos para hepatites virais (B e C) resultaram negativos. Descreveu-se shunt venoso intra-hepático: comunicação do ramo portal direito com a veia hepática direita (Figura A -seta). Evidenciou-se, também, dilatação aneurismática sacular da artéria esplênica. A tomografia computadorizada helicoidal com reconstrução em três dimensões mostra o aneurisma da artéria esplênica e o shunt venoso intra-hepático (Figuras B e C -setas). De 82 pacientes com esquistossomose hepatoesplênica examinados pelos métodos de imagem em nosso hospital, este é o primeiro caso (1,2%) de aneurisma da artéria esplênica e shunt intra-hepático. Os achados não foram vistos ao ultra-som de abdômen. A paciente recusou tratamento cirúrgico e é acompanhada em nosso ambulatório. 2. Lambertucci JR, Silva LC, Andrade LM, de Queiroz LC, Pinto-Silva RA. Magnetic resonance imaging and ultrasound in hepatosplenic schistosomiasis mansoni.

Blood Flukes and Arterial Damage: A Review of Aneurysm Cases in Patients with Schistosomiasis

“…Aneurysm occurred also in patients with known chronic schistosomiasis [ 12 ], in an advanced stage with clinically manifest complications, such as oesophageal varices [ 14 ], hepato-splenic schistosomiasis [ 16 , 24 , 25 ], in one case waiting for liver transplant [ 16 ] and in pulmonary schistosomiasis [ 12 ].…”

“…In these cases, the diagnosis of Schistosoma infection was reached by serological investigations [22], stool sample assessment, rectal biopsy [19], and histology of lung [17] or of liver and testis [23]. Aneurysm occurred also in patients with known chronic schistosomiasis [12], in an advanced stage with clinically manifest complications, such as oesophageal varices [14], hepato-splenic schistosomiasis [16,24,25], in one case waiting for liver transplant [16] and in pulmonary schistosomiasis [12].…”

“…Interestingly, this physiopathological mechanism is shared by other infectious diseases associated with thoracic aortic aneurysms, such as tertiary syphilis [28]. Visceral aneurysms may also share physiopathological mechanisms behind pulmonary lesions through hemodynamic impairment due to hepatic fbrosis and portal hypertension or as direct damage to the artery wall due to local infammation [14,15]. In the monocentric experience by Lambertucci et al, which included 82 patients with hepatosplenic schistosomiasis, only one case (1.2%) of visceral aneurysm (splenic artery aneurysm and intrahepatic shunt) was observed, a fnding that was at frst missed during ultrasound examination [14].…”

“…Aneurysms have been described in patients with other diseases of parasitological interest, such as amoebiasis [7] or hydatidosis [8,9]. Cardiovascular system damage has been reported also in Schistosoma infection in the form of cerebrovascular events leading to stroke [10] or aneurysm involvement of several arterial districts [11][12][13][14][15][16][17][18][19].…”