[1] First, schistosomiasis is associated with eosinophilia in approximately 60% of cases; in fact, eosinophilia in a returning traveler from a Schistosoma-endemic region should be sufficient to suspect infection. Second, Dogon Country has a high prevalence of schistosomiasis, as a result, 44% of cases reported by TropNetEurop since 1999 (412 cases)[2] have come from Dogon Country in Mali

and Lake Tanganyika in Malawi. Third, the febrile episode experienced by the patient during the final part of the trip was likely an acute schistosomiasis. Artemisinin has been reported to be partially effective against Schistosoma and schistosomules.[3] HTS assay Eradication has been achieved in 25% of chronic infections, together with >95% reduction in ova production.[4] Artemisinin is not active in adult schistosomes older

than 6 weeks (given 3 weeks after exposure in our case); however, it may have some activity against immature worms. Thus, artemisinin exposure may have reduced the adult worm burden in our patient resulting in late seroconversion and absence of parasites in the urine microscopies. Serology is more sensitive in returning travelers than urine or stool microscopy. beta-catenin inhibitor Indeed, series describe up to 88% of imported cases of schistosomiasis as being diagnosed with serology, of whom only 44% had parasites in stool or urine.[5] Seroconversion typically occurs from 6 weeks onwards,[6] although late seroconversions (6 months after exposure) have been reported.[7] In this case, the negative IHA serology 5.5 months after exposure together with persistently negative urine microscopy and denial of the epidemiological factor made us question a parasitic etiology, and led us to perform a diagnostic cystoscopy while waiting for the second serology result. Although not a first line diagnostic tool, invasive techniques such as cystoscopy or rectal snips can be helpful in diagnosis of difficult cases; these tests are highly sensitive and typically PIK3C2G demonstrate ova invading the mucosa with the characteristic submucosal granulomatous reaction.[8] In this case, cystoscopy was decisive to reach the final diagnosis, as ova were only released into the urine

after the biopsy, resulting in a pathogen-directed treatment. Despite reasonable doubts about parasitic infection, we are aware that cystoscopy could have been avoided by waiting for the second serology or simply by administering empirical treatment, especially if eosinophilia after returning from an endemic region was assumed to be schistosomiasis, despite the patient’s denial of water exposure. Different techniques were used for the first and second serological determination (IHA and ELISA, respectively). The sensitivity of the techniques varies according to the type of antigen and the stage of the infection. IHA is generally more widely available and recommended as first line assessment, although it is less sensitive than ELISA.