Case Report: Ovarian Schistosomiasis in a Regional Australian Healthcare Setting

We present the case of a 53-year-old postmenopausal migrant woman who presented in late 2022 with severe, chronic pelvic pain and dyspareunia.  The pain was long-standing.  At the time of presentation, she was noted to have had a cholecystectomy one year earlier for gall stones demonstrated on abdominal ultrasound in the setting of persistent epigastric pain.  The scan had also shown small, bilateral ovarian cysts thought to be consistent with chronic endometriomas.    In 2017, she had had laparoscopic cystectomy confirming the diagnosis.  Interestingly, the histology of adjacent stromal tissue identified calcified ova with giant cell infiltration likely to be reminiscent of non-active Schistosomiasis.   It was noted that the patient had grown up on farmlands in the Philippines which were subject to flooding, before emigrating to Australia in 2009.  Both she and other family members had been treated with Praziquantel for Schistosomiasis.   She was now living in rural Victoria, working as a seasonal labourer.

On current examination, liver function tests showed mildly elevated ALP and GGT.  Ultrasound of the right upper quadrant demonstrated heterogeneous changes within the liver consistent with chronic infection or inflammation.  Liver function and inflammatory markers were otherwise normal and non-specific.   Pelvic imaging showed the persistence of the ovarian cysts noted the previous year.  There was no significant change in size, with the largest still measuring less than 25x 21 x 17mm.  Serum tumour markers were normal - CEA 3.3 CA 125: 14 CA19-9: <2 AFP 2.8.  She was diagnosed with persistent, chronic endometriosis associated with ovarian cyst formation.  She was offered the option of either conservative surveillance or surgical management.  She requested the latter and was booked for bilateral oophorectomy with salpingectomy and total hysterectomy.  The procedure was commenced laparoscopically but was converted to an open procedure following the discovery of dense intra-peritoneal adhesions between the posterior uterus and the small bowel.  The procedure continued uneventfully, and she made a complete recovery and was discharged on day four following surgery for outpatient review.

The uterus, endometrium and cervix showed histological changes consistent with age and parity.  The right ovary measured 30 x 22 x 20mm and was almost entirely comprised of a blood-filled endometrioma.  The left ovary was smaller and contained another haemorrhagic cyst.  There was no evidence of atypia, hyperplasia or malignancy in the samples.  There were, however, multiple small, calcified oval-shaped bodies with distinct capsules scattered through the parenchyma of both ovaries.  These were also found in the walls of the fallopian tubes.  Occasional foreign body giant cells were also present.  The findings were highly suggestive of quiescent Schistosomiasis.  The patient was referred for review by the Infectious diseases team.   She was seen approximately one month later and arrived in good health.  She had recovered fully from surgery and reported significant improvement in her symptoms of abdominal pain and coital discomfort.  Urine and faecal samples showed no trace of ova or parasites.   Her blood, including CRP and inflammatory markers, were normal though her liver function tests continued to demonstrate some mild elevation, though not to be significant.   No further treatment for Schistosomiasis was required.