Bilharzial heart disease in Egypt; cor pulmonale due to bilharzial pulmonary endarteritis.

Of the various pathological causes of pulmonary endarteritis and right heart failure, schistosomiasis is probably the least familiar outside Egypt and other countries where the disease is endemic. It has long been known that bilharzia ova are sometimes deposited in the lungs (Belleli, 1885; Turner, 1909), and that adult worms of S. haematobium, often coupled males and females, may be found in the pulmonary vessels (Symmers, 1905; Day, 1937). In 1928, Sorour reported pulmonary bilharziasis as a common post-mortem finding in Egypt, and describedsmall fibrous nodules due to ova deposited in the lungs, which he named bilharzial tubercles because of their semblance to the tubercles caused by Koch's bacillus. He also described a verminous lobular pneumonia due to the presence of dead bilharzial worms, and an " endobronchitis obliterans." Under the term " bilharzial atheroma," Sorour described deposits of ova in the intima of the pulmonary vessels resulting in endothelial proliferation, and he mentioned the wealth of new capillaries in the thickened intima, since recognized as a characteristic feature of bilharzial pulmonary endarteritis. In 1932 S. Azmy Pasha, of Cairo, recorded the first case of bilharzial heart disease observed clinically and pathologically. He described two cases with cardiac enlargement, gross dilatation of the pulmonary artery and pulmonary incompetence, associated with bilharzial hepatosplenomegaly. Necropsy was performed in one case and showed deposits of bilharzia ova in the lungs, obliterative endarteritis of the small pulmonary vessels, atheroma and dilatation of the main pulmonary trunks, and hypertrophy with dilatation of the right side of the heart; in addition, there were bilharzial lesions of the bladder and cirrhosis of the liver. Similar cases were later reported by Clark and Graef (1935) in a Porto Rican and by Day (1937) in Egypt. By far the most important contribution to the subject was made by Bernard Shaw and Ghareeb (1938) who described very fully the pathological changes of pulmonary schistosomiasis with special reference to the arterial lesions and to " Ayerza's disease." Cor pulmonale with gross dilatation of the pulmonary artery is by no means a rare clinical finding in Egypt, certainly far more common than in England. It is usually encountered in young adults suffering from advanced visceral bilharziasis (Egyptian hepato-splenomegaly) or from severe genito-urinary infection with S. haematobium. Cor pulmonale occurred in 0-8 per cent of 520 consecutive cases of visceral bilharziasis admitted to the Kasr-el-Aini Hospital, and was found in 2-1 per cent of 282 consecutive autopsies on cases of schistosomiasis (Shaw and Ghareeb). The clinical diagnosis of " Bilharzial Ayerza's disease " is not infrequently made in the wards, and cases have been shown at clinical meetings (Mousa, 1942), yet the number of cases on record, in which both clinical and pathological findings are given, is scanty. The following new case is therefore reported.