S5079 Double Trouble: Unmasking Parasitic Colitis Mimicking Inflammatory Bowel Disease

Introduction: Cirrhotic patients often develop immune dysfunction, increasing their susceptibility to infections. Parasitic infections such as schistosomiasis and rarely strongyloidiasis can resemble inflammatory bowel disease (IBD), complicating diagnosis. Hepatic schistosomiasis, in particular, can cause periportal fibrosis and worsen cirrhosis through portal hypertension. In those with pre-existing cirrhosis, this can further impair liver function. We present a case of a double parasitic infection in a male with suspected AIH-related decompensated cirrhosis, whose presentation mimicked IBD. Case Description/Methods: A 27-year-old Egyptian man with a history of cirrhosis, initially attributed to autoimmune hepatitis (AIH), presented with persistent abdominal pain and several days of bloody diarrhea. He was diagnosed with AIH in 2016 (ANA/ASMA +, IgG level >3000) and cirrhosis in Egypt in 2022 after developing ascites, hemorrhoids, and GI bleeding. On admission, labs showed elevated liver enzymes (alanine aminotransferase 61 U/L, aspartate aminotransferase 80 U/L, alkaline phosphatase 376 U/L), hypoalbuminemia (2.4 g/dL), and iron deficiency anemia (Hgb 9.9 g/dL, MCV 68.5 fL, ferritin 12 ng/mL); eosinophil counts were normal. Esophagogastroduodenoscopy revealed grade 1 esophageal varices. Colonoscopy showed strictures in the transverse colon, ulcers (including 1 within a stricture), and friable mucosa extending to the cecum. A history of oral ulcers raised concern for IBD. However, biopsies revealed chronic active eosinophilic colitis with crypt distortion and up to 80 eosinophils/HPF, and IBD testing was negative. Given a history of freshwater exposure in a schistosomiasis-endemic region, parasitic infection was suspected. Stool and serologic testing confirmed schistosomiasis and strongyloidiasis. He was treated with albendazole, praziquantel, and steroids, and showed marked improvement. Follow-up endoscopy and colonoscopy were later scheduled. Discussion: This case of a young cirrhotic male with transverse colonic strictures and ulcerations due to coexisting schistosomiasis and strongyloidiasis highlights several challenges in the management of cirrhosis complicated by parasitic colitis. Initially, the unusual transverse colon involvement, history of the oral ulcer and lack of eosinophilia mimicked IBD. Despite absent eosinophilia, serology testing and biopsy-confirmed diagnosis prevented mismanagement and treatment with albendazole and praziquantel led to significant improvement, underscoring the need for early recognition and appropriate therapy.