CASE REPORT

A Mysterious Case of a Breast Lump in a Woman

From the Philippines
Elissa Rennert-May, MD*, and Devika Dixit, MD, MSc†

examination was remarkable only for a breast lump palpated on

Abstract: We present the case of a 74-year-old woman who recently em-
igrated from the Philippines to Canada, with an unusual etiology for her
breast lump. Based on review of breast histopathology by a pathologist,
as well as parasitology specialist and clinical history, the causative organ-
ism of this breast lump was Schistosoma japonicum. This is an uncommon
manifestation of schistosomiasis, which causes more than 40 million clin-
ical infections annually.
Key Words: breast lump, schistosomiasis, tropical infectious diseases
(Infect Dis Clin Pract 2018;26: 47–49)
CASE REPORT
A 74-year-old woman was seen by her family physician after
recent immigration to Canada from the Philippines. During rou-
tine physical examination, it was discovered that she had a firm,
fixated lump on the left breast, 7 3 cm at the 2-o'clock position.
Her medical assessment including review of symptoms and phys-
ical examination was otherwise fairly unremarkable.
The patient was referred for mammography that revealed an
area of rosette-like calcifications branching in segmental distribu-
tions and involving the upper outer quadrant of the breast and ex-
tending toward the ipsilateral nipple (Fig. 1). These findings were
highly suggestive of ductal carcinoma in situ, and the patient was
referred for core biopsy.
Pathology from an initial core biopsy as well as a repeat bi-
opsy one month later showed benign breast tissue positive for
calcifications. Given ongoing concerns for malignancy, she
was referred to a cancer institute for a mammotome biopsy. Spec-
imens were placed in formalin and fixed for 35 hours.
Hematoxylin-eosin stains were performed on slides of tissue
and examined under the microscope.
Pathology demonstrated microcalcifications in ovoid shapes
gathering in clusters around the breast lobules, and some were
engulfed by giant cells forming small granulomas. The calcifica-
tions corresponded to calcified eggs, given the presence of a
shell, and the eggs were felt to be a type of Schistosoma species
(Figs. 2 and 3).
The patient was subsequently referred to infectious diseases
for further workup. On evaluation, the patient felt well with no
gastrointestinal, urinary, or neurologic symptoms and had no
known personal history of schistosomiasis. She had lived in the
Philippines her entire life and had never left the country other than
to come to Canada 5 months prior. She had no recent exposure to
freshwater but described that she used to swim in the lakes and
streams near her home as a child and young adult. Her physical
From the *Section of Infectious Diseases, Department of Medicine, University
of Calgary, Calgary, Alberta; and †Division of Infectious Diseases, Department
of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
The authors have no funding or conflicts of interest to disclose.
Correspondence to: Elissa Rennert-May, MD, AGW5, SSB Ground Floor,
Foothills Medical Centre, 1403 29 St NW, Calgary, Alberta, Canada
T2N 2T9. E‐mail: elissa.rennertmay@ucalgary.ca.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1056-9103
the upper outer quadrant of the left breast with no associated ery-
thema, warmth, or lymphadenopathy. Her complete blood count
was normal, and she did not have any peripheral eosinophilia.
Her stools were sent for evaluation of ova and parasites and were
negative. Schistosomiasis serology was sent to the National Mi-
crobiology Laboratory for completeness and was negative; how-
ever, the sensitivity of this test for Schistosoma japonicum is
approximately only 50%.1
Slides were initially reviewed by a pathologist and then sent
to a parasitologist for confirmation. The eggs were an average of
50 μm and had only minute or subterminal spines. The eggs were
oval and rounded. These findings were thought to be consistent
with S. japonicum; however, the eggs were smaller than the ex-
pected size of 70 to 100 by 55 to 65 μm. Although the size range
of the eggs would be more in keeping with Schistosoma mekongi,
the geographic distribution of this is limited, and the patient did
not have any travel to the Mekong river; therefore, S. japonicum
was thought to be the most likely diagnosis. There are no known
reported cases of S. mekongi in the Philippines; however, many
parts of the country are endemic for S. japonicum.2,3 The size es-
timations of Schistosoma eggs are based on preserved eggs passed
in the stool, and in this case, as the eggs had probably been present
in the breast for several decades, there was likely some associated
shrinkage, and the eggs were felt to be definitively S. japonicum.
The patient was treated with praziquantel (60 mg/kg divided
into 3 doses as a 1-day treatment course). This medication does
not treat the area of calcifications, but the adult worms of most
species of schistosomiasis live for 3 to 8 years,4 and we were un-
sure when she contracted the parasite, although it was likely due to
a remote exposure.
DISCUSSION
Schistosomiasis is caused by digenetic blood trematodes
that live in freshwater snails.5 The 5 main species causing disease
in humans are geographically distributed and are Schistosoma
haematobium (Africa and the Middle East), S. japonicum (Far
East including the Philippines), Schistosoma mansoni (South
America, the Caribbean, Africa, the Middle East), S. mekongi
(Southeast Asia), and Schistosoma intercalatum (central West
Africa), with the first 3 accounting for the majority of human dis-
ease.5 Infections tend to occur in rural areas with freshwater
ponds, lakes, and rivers that contain the infectious form of the
parasite, cercaria, which emerges from snails, and penetrate hu-
man skin.5 Cercariae penetrate human skin and migrate to the
liver where they mature. The adult worms then move to the
bloodstream (the region varies depending on the species) and de-
posit eggs into the mesenteric veins (for S. japonicum, this is
more frequently the superior mesenteric veins that drain the
small intestine). The worms then migrate to the intestine or blad-
der and are excreted via stool or urine, respectively, depending on
the species.5 The acute schistosomiasis syndrome is known as
Katayama fever. It involves sudden onset of fever, chills, jaundice,
diarrhea, nausea, urticaria, dry cough, and headache, although

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Rennert-May and Dixit Infectious Diseases in Clinical Practice • Volume 26, Number 1, January 2018
FIGURE 1. Mammogram image of the breast lump demonstrating
rosette-like calcifications in segmental distribution; an arrow
points to the abnormality.
generally not all symptoms are present. On blood work, there
will be peripheral eosinophilia. Chronic schistosomiasis is more
common in people living in endemic areas. Symptoms depend
on the location or embolization of the eggs. Commonly involved
organs are the liver, spleen, genitourinary tract, lungs, and central
nervous system, depending on species type.5
Ectopic cutaneous schistosomiasis is an uncommon pre-
sentation but has been previously reported in the literature.6 Al-
though the exact mechanism by which ectopic cutaneous
schistosomiasis occurs is not fully elucidated, one theory suggests
anastomosis between venous systems may be one way in which
ova or adult worms migrate to ectopic sites.6 Other possibilities
include the embolization of Schistosoma eggs through arteriove-
nous shunts opened by portal hypertension in the context of
hepatosplenic schistosomiasis.7
Given that our patient came from the Philippines with no
outside travel, the only species she could have been exposed
to was S. japonicum. This is in keeping with identification from
the pathologist and parasitologist.
FIGURE 2. Photograph from the pathology slides of the breast
biopsy stained with hematoxylin and eosin at 200
magnification. There are microcalcifications corresponding to egg
shells. Some of the microcalcifications are surrounded by
granulomas. Arrows point to the egg shells.
48 www.infectdis.com
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FIGURE 3. Photograph from the pathology slides of the breast
biopsy stained with hematoxylin and eosin at 400
magnification. This enlarged photograph demonstrates
calcifications corresponding to egg shells consistent with
S. japonicum.
The egg granulomas and in unusual cases the actual adult
worms of S. japonicum can be found outside the portal venous
system, where they typically migrate to, and potentially can be lo-
cated in any of the body's tissues including breast, muscle, pericar-
dium, esophagus, and kidneys. The main area affected, however, is
the brain, although no population-based data are available to indi-
cate the actual frequency.8
Schistosomiasis of the breast is very rare but has appeared in
the literature previously. A case report from 19969 and another
from 200510 describe very similar presentations to our patient.
In both cases, an asymptomatic female from the Philippines pre-
sented with breast calcifications that on biopsy were found to be
calcified eggs of S. japonicum.
The route by which infection of S. japonicum occurs in the
breast should be considered. A case report of four Japanese
women who had S. japonicum in the breast commented that sim-
ilarly to our patient the eggs were located surrounding the lobules
in the breast, suggesting that they were embolized in the blood-
stream and most likely spread hematogenously.11
CONCLUSIONS
In conclusion, we present an unusual manifestation of an S.
japonicum infection. A breast lump in an elderly woman is not un-
usual. However, the finding in this case is a rare presentation of a
common tropical infectious disease, underscoring the importance
of considering travel and immigration history when investigating
the causes of medical abnormalities.
ACKNOWLEDGMENTS
The authors thank Drs Kinga Kowaleska, Gilbert Bigras,
and Lynora Saxinger for their assistance with this case.
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© 2017 Wolters Kluwer Health, Inc. All rights reserved.
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