These letters propose interesting alternative diagnoses for Herod’s illness. Hepatic schistosomiasis occurs when the fluke’s eggs lodge in portal venules, causing granulomatous inflammation, fibrosis, and presinusoidal portal hypertension. The most evident clinical consequences are hepatosplenomegaly, sometimes visible as abdomen fullness, and gastrointestinal hemorrhage from varices.1 Josephus does not mention these features. Since significant cholestasis is absent, pruritus does not occur. Unless other diseases coexist, hepatocellular function remains fairly normal, and hepatic encephalopathy seldom develops. Schistosomiasis, therefore, could not readily explain itching or mental changes.
Hirschmann JV, Richardson P, Kraemer RS, Mackowiak PA. Herod the Great and Polyarteritis Nodosa—Reply. Arch Intern Med. 2004;164(22):2500–2509. doi:10.1001/archinte.164.22.2508-b
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