Case Presentation: A 19-year-old male with a past medical history of malaria and recent immigration to the U.S. from Somalia presented with a witnessed episode of tonic-clonic seizure. He had no history of seizure disorder, recent trauma, new medications, alcohol use, fevers or chills. He was afebrile with stable vital signs. Physical exam including neurological evaluation was unremarkable except for tongue bite. Basic labs including complete blood count, basic metabolic panel and liver function tests were all unremarkable except for peripheral eosinophils of 10% and urinalysis with 155 red blood cells. Computerized tomography (CT) of the head revealed a small right parietal hematoma with surrounding edema. Subsequent magnetic resonance imaging (MRI) showed an enhancing non-hemorrhagic lesion with vasogenic edema favoring a glial neoplasm (Figure 1). The patient was treated with dexamethasone for the inflammatory changes and levetiracetam for seizure prevention. Further studies including brain biopsy showed a noncaseating granuloma with terminal spiked eggs (Figure 2A). A diagnosis of neuroschistosomiasis secondary to S. hametobiumwas made based on the characteristic egg appearance (Figure 2B). Further confirmation was completed with positive serology for schistosoma antibodies. Ultrasound of the liver did not show hepatic involvement. Finally, the patient was treated with praziquantel and discharged home on levetiracetam.

Discussion: Schistosomiasis is the second most socioeconomically devastating parasitic disease worldwide and nearly 800 million people are currently at risk of developing this parasitic infection. From the three major types, Schistosoma mansoni and Schistosoma japonicum can both cause brain involvement, but is rarely seen with S. haematobium. CNS symptoms are present only in less than 5% of patients with schistosomiasis. Neuroschistosomiasis involving the spinal cord leads to the development of myelopathy, whereas cerebral lesions often present with a wide variety of symptoms including seizures, motor and/or sensory impairment, or a cerebellar syndrome. The most definitive diagnostic findings include schistosomal eggs in the urine, stool or tissue. Serological testing is useful in non-endemic areas. Blood examination often reveals eosinophilia but this may be absent.This case showed a brain lesion that had the appearance of a glial neoplasm but additional testing including a detailed history and the presence of eosinophilia suggested the consideration of an infectious etiology. Serology and brain biopsy confirmed the definitive diagnosis with identification of the S. haematobiumova (Figure 4) with urogenital involvement. Treatment of cerebral schistosomiasis is highly effective and includes the use of praziquantel and corticosteroids. 

Conclusions: Due to globalization, the geographic boundaries are getting closer and awareness of atypical presentations of common diseases that are rare in the United States is needed. Schistosomiasis should be considered in the differential diagnosis of a patient presenting with unexplained central nervous system symptoms that has either lived or even traveled to an endemic area. Treatment is effective with an overall good prognosis.