granulomas are focal accumulations of epithelioid cells , typically with a rim of lymphocytes and fibroblasts , representing a delayed - type hypersensitivity reaction in response to antigenic stimulation .
this stimulation is usually triggered by exposure to antigen that can not be degraded or in cases of immune dysfunction .
liver granulomas have been reported in 215% of unselected liver biopsies , with the etiology varying according to geography . in the us ,
75% of cases are result in sarcoidosis , mycobacterial infection , primary biliary cirrhosis and drug - induced liver injury .
in other countries , such as iran , mycobacterium tuberculosis and visceral leishmaniosis account for 60% .
studies have shown that 615% of granuloma findings are idiopathic [ 1 , 2 ] .
few histological features associated with certain diseases include caseous necrosis in acid fast bacilli containing granulomas , or ova in schistosoma mansoni .
a 38-year - old male sudanese immigrant pronounced brain dead after a motor vehicle accident became an organ donor for liver and kidneys .
his serology came back positive for hepatitis b core antibody and surface antibody , hbsag negative , hepatitis c and hiv negative .
gross appearance of donor liver gave suspicion of granulomas based on surface heterogeneity ( fig .
his liver biopsy at the donor hospital was consistent with < 5% macro and micro steatosis , no fibrosis but significant for the presence of having multiple granulomas ( fig .
the initial slide review by the pathologist found multiple granuloma , and requested re - biopsy from the donor liver .
the re - biopsy result found parasitic disease in the hepatocyte that later found to be schistosomiasis ( fig .
lack of data regarding the behavior of this disease in the recipient , the biopsy result caused us to decline the liver due to the parasitic liver disease . 

schistosomiasis is a chronic enteral parasitic disease caused by trematode worms of the genus schistosoma .
it is estimated that over 258 million people are affected yearly , with most of its disease burden in africa , south america , the caribbean , the middle east and asia . at the present time , due to increased global mobility , schistosoma may be encountered in non - endemic areas . over 90% of the cases of schistosomiasis
are currently found in sub - saharan africa , where more than 200 000 deaths occur yearly due to the disease .
schistosomiasis is the most prevalent parasitic disease in sudan due to the wide river basin areas and large irrigated agriculture along the nile rivers .
once infection occurs , the adult worms reside in veins releasing eggs that are either shed into the environment through feces or urine , or are retained in host tissues where they induce inflammation and then die .
when schistosoma eggs are trapped in tissues , they activate an immunologic reaction leading to the development of granuloma and fibrosis .
hepatic schistosomiasis leading to severe fibrosis is a well - recognized cause of chronic liver disease and portal hypertension .
it results from the host s granulomatous cell - mediated immune response to the ova antigen and progressing to irreversible fibrosis .
multiple factors influence the development and pathology of schistosomiasis including the type of immune response developed by the host , host genetic background , intensity and number of infections .
most schistosomiasis is caused by schistosoma hematobium ,  s. mansoni and s. japonicum ; however , s. mansoni and s. japonicum tend to cause hepatobiliary disease , while s. hematobium mainly affects the urinary tract .
due to the life cycle of schistosoma , the acute phase of infection is usually asymptomatic , the only chronic sequelae identified via tissue biopsy is necrotic eggs with granuloma formation .
strategies such as living donation , split liver transplantation , domino liver transplantation and the extensive use of marginal donor grafts have been implemented in many countries . as a result of this , there are an increasing number of unusual diseases from asymptomatic donors , including schistosomiasis .
reports have shown schistosomiasis transmission through liver grafts from deceased donors with no consequences for graft or recipient survival . a retrospective study in brazil highlights cases of living donor liver transplantation ( ldlt ) with schistosomiasis diagnosed on post - reperfusion liver biopsy showing granulomatous reaction with  s. mansoni eggs in transplant recipients .
also describe the first intentional transplant with schistosomiasis , where known schistosoma eggs in feces were found in a donor .
after treatment with praziquantel , ldlt with a graft was performed with no donor or recipient complications after 2 years post - operatively .
chronic changes caused by schistosomiasis , leading to granuloma formation to a parasite s egg , might be only a sign of a distant infection .
donor organs from endemic areas who have negative fecal examinations and normal liver function tests may be considered for partial liver donation .
while organ shortages remains a major limitation to liver transplantation , expansion of the donor pool criteria to include patients presented in this case report might allow expansion and allocation of donor livers .
 abstracta shortage of donor organs is a major limitation to liver transplantation . 
 expansion of donor pool criteria to include patients with schistosomiasis diagnosed on liver biopsy might allow the allocation of more transplant livers . 
 schistosomiasis is a chronic parasitic disease affecting millions in endemic areas including sub - sahara africa that might lead to the development of granulomas as a response to the parasite s ova and might cause chronic liver disease and portal hypertension . due to increased mobility globally 
 , schistosomiasis may be encountered in non - endemic areas . 
 currently , the usage of donor livers with known schistosomiasis is not universally defined . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST STATEMENT