Schistosomiasis: A Schistosomiasis: A Common Diagnosis in Common Diagnosis in

Tanzania Tanzania

Anna Person, MDAnna Person, MD

PGY-3PGY-3

43 year old male presents to Kilimanjaro 43 year old male presents to Kilimanjaro Christian Medical Centre in Moshi, Christian Medical Centre in Moshi,

Tanzania…Tanzania…

One week of melenaOne week of melena Progressive abdominal distensionProgressive abdominal distension One day of hemetemesisOne day of hemetemesis No hx of fever, cough, diarrheaNo hx of fever, cough, diarrhea Works as a farmer in the rice paddiesWorks as a farmer in the rice paddies No past medical historyNo past medical history No medicationsNo medications

ExamExam

BP 86/50, HR 121, Temp 36.5 C, RR 21BP 86/50, HR 121, Temp 36.5 C, RR 21 Thin male in mild distressThin male in mild distress HEENT- pale conjunctivaHEENT- pale conjunctiva CV- regular rate and rhythm, no murmursCV- regular rate and rhythm, no murmurs Pulm- clear to ascultation bilaterallyPulm- clear to ascultation bilaterally Ab- distended, dullness to percussion, Ab- distended, dullness to percussion,

palpable, enlarged liver and spleenpalpable, enlarged liver and spleen Ext- no edemaExt- no edema

StudiesStudies

Hb- 5, Hct- 15Hb- 5, Hct- 15

Abdominal US- markedly enlarged spleen, Abdominal US- markedly enlarged spleen, somewhat enlarged liver, heterogenous in somewhat enlarged liver, heterogenous in appearanceappearance

Endoscopy (available at KCMC)- bleeding Endoscopy (available at KCMC)- bleeding esophageal varices identifiedesophageal varices identified

SchistosomiasisSchistosomiasis

Trematode infecting over 200 million Trematode infecting over 200 million worldwideworldwide11

Transmitted through skin while wading in Transmitted through skin while wading in freshwaterfreshwater

S. hematobium S. hematobium (Africa and Middle East)(Africa and Middle East) kidney and bladderkidney and bladder

S. mansoni S. mansoni (Africa, ME, Carribean, S. America),(Africa, ME, Carribean, S. America), japonicum japonicum (Asia),(Asia), mekongi mekongi (Asia)(Asia) liver liver

Life Cycle of SchistosomesLife Cycle of Schistosomes

Life CycleLife Cycle

Females produce eggs which release Females produce eggs which release larvae into waterlarvae into water

Larvae seek out snails and become Larvae seek out snails and become sporocyts and then cercarial larvaesporocyts and then cercarial larvae

Cercarial larvae leave the snail and Cercarial larvae leave the snail and penetrate intact skin of humanspenetrate intact skin of humans

TransmissionTransmission

•www.humanillnesses.com/.../Schistosomiasis.html

Transmission, cont.Transmission, cont.

Once in humans they become schistosomulaeOnce in humans they become schistosomulae

These migrate into the arterial circulationThese migrate into the arterial circulation

Then they reach the liver and mature into adults Then they reach the liver and mature into adults (within 4 weeks)(within 4 weeks)

Worms can live up to 30 yearsWorms can live up to 30 years22

Acute Schistosomiasis (Katayama Acute Schistosomiasis (Katayama fever)fever)

Usually occurs 14-84 days from initial Usually occurs 14-84 days from initial contactcontact

Fever, headache, myalgias, bloody Fever, headache, myalgias, bloody diarrhea, abdominal pain, hivesdiarrhea, abdominal pain, hives

Respiratory symptoms can occur in up to Respiratory symptoms can occur in up to 70% of those infected with 70% of those infected with S. mansoniS. mansoni33

A clinical diagnosisA clinical diagnosis antibody titers can antibody titers can take 3 months to be positivetake 3 months to be positive55

Acute schistosomiasis: case reportAcute schistosomiasis: case report44

16 patients between ’94-’95 16 patients between ’94-’95 All had been in sub-Saharan AfricaAll had been in sub-Saharan Africa Dominant symptoms were fever, lethargyDominant symptoms were fever, lethargy Symptoms began on average 36 days Symptoms began on average 36 days

after exposureafter exposure 14/16 had eosinophilia, 12/16 had 14/16 had eosinophilia, 12/16 had

negative stool microscopynegative stool microscopy All were treated with praziquantel, 8 All were treated with praziquantel, 8

required further courses of txrequired further courses of tx

Chronic SchistosomiasisChronic Schistosomiasis

Long-term sequelae caused by granuloma Long-term sequelae caused by granuloma formation (immune response to antigens formation (immune response to antigens from schistosome)from schistosome)66

Small subset with high burden of Small subset with high burden of organisms (organisms (S. mansoniS. mansoni and and S. japonicumS. japonicum) ) develop periportal fibrosisdevelop periportal fibrosis causes portal causes portal hypertension, esophageal varices, etchypertension, esophageal varices, etc

Chronic Schistosomiasis, cont.Chronic Schistosomiasis, cont.

S. hematobium infectionsS. hematobium infections hematuria, hematuria, fibrosis of bladder and ureters, effects on fibrosis of bladder and ureters, effects on kidneys (protenuria)kidneys (protenuria)

Causes many types of bladder cancerCauses many types of bladder cancer 75% are squamous, 20% are transitional 75% are squamous, 20% are transitional cell, 5% are adenocarcinoma, more cell, 5% are adenocarcinoma, more common in men than womencommon in men than women77

Genitourinary Schistosomiasis: a Genitourinary Schistosomiasis: a study at KCMCstudy at KCMC

Retrospective analysis of pathologic Retrospective analysis of pathologic specimens from 1999-2005 at KCMC in specimens from 1999-2005 at KCMC in Moshi, TanzaniaMoshi, Tanzania88

Schistosomiasis diagnosed histo-Schistosomiasis diagnosed histo-pathologically in 423 specimenspathologically in 423 specimens

125 of these specimens were found in 125 of these specimens were found in female genitourinary tract (cervix in 71 female genitourinary tract (cervix in 71 cases)cases)

Burden of genitourinary Burden of genitourinary schistosomiasisschistosomiasis

Main symptoms reported were bleeding Main symptoms reported were bleeding (48%), ulcer (17%), tumor (20%), lower (48%), ulcer (17%), tumor (20%), lower abdominal pain (11%), and infertility (7%).abdominal pain (11%), and infertility (7%).

Authors conclude that genitourinary Authors conclude that genitourinary schisto is underrecognized cause of schisto is underrecognized cause of disease burden in women in Moshi, disease burden in women in Moshi, TanzaniaTanzania

DiagnosisDiagnosis

Sometimes a clinical diagnosis if other Sometimes a clinical diagnosis if other tests not availabletests not available

Peripheral eosinophilia can be suggestivePeripheral eosinophilia can be suggestive Microscopic examination of feces and Microscopic examination of feces and

urine for eggsurine for eggs sensitivity unknown sensitivity unknown Serologic tests for antischistosomal Serologic tests for antischistosomal

antibodies, ELISA tests reported to be antibodies, ELISA tests reported to be >90% sensitive and >95% specific>90% sensitive and >95% specific

PCR not widespreadPCR not widespread

TreatmentTreatment

Praziquantel. Praziquantel. 20mg/kg po 20mg/kg po bidbid for 1 day (two total doses) for 1 day (two total doses)

for for S. hematobium, intercalatumS. hematobium, intercalatum, and , and mansonimansoni

20mg/kg po 20mg/kg po tidtid for 1 day (three total for 1 day (three total doses) for doses) for S. japonicum and S. mekongiS. japonicum and S. mekongi99

Steroids often used w/ praziquantel in Steroids often used w/ praziquantel in acute schistoacute schisto

Reducing MorbidityReducing Morbidity

Burkina Faso, Mali and NigerBurkina Faso, Mali and Niger annual mass- annual mass-treatments of schoolchildren w/ praziquantel. In treatments of schoolchildren w/ praziquantel. In Burkina Faso, prevalence went from 90% to Burkina Faso, prevalence went from 90% to <5% after one year.<5% after one year.1010

WHO has adopted a Resolution 54.19, which WHO has adopted a Resolution 54.19, which aims to treat 75% of all school-age children at aims to treat 75% of all school-age children at risk for morbidity due to schistosomiasis by risk for morbidity due to schistosomiasis by 201020101111..

ReferencesReferences 1,31,3 Ross, A et al: Current Concepts: Schistosomiasis. N Engl J Med 346:1212, 2002 Ross, A et al: Current Concepts: Schistosomiasis. N Engl J Med 346:1212, 2002 22 Arnon, R. Life span of parasite in schistosomiasis patients. Isr J Med Sci 1990; Arnon, R. Life span of parasite in schistosomiasis patients. Isr J Med Sci 1990;

26:404.26:404. 4,54,5 Doherty, JF et al. Lesson of the Week: Katayama fever: an acute manifestation of Doherty, JF et al. Lesson of the Week: Katayama fever: an acute manifestation of

schistosomiasis. BMJ 1996;313(7064):1071.schistosomiasis. BMJ 1996;313(7064):1071. 66 Boros DL, et al. Delayed hypersensitivity-type granuloma formation and dermal Boros DL, et al. Delayed hypersensitivity-type granuloma formation and dermal

reaction induced and elicited by a soluble factor isolated from Schistosoma mansoni reaction induced and elicited by a soluble factor isolated from Schistosoma mansoni eggs. J Exp Med 1970;132:488-507.eggs. J Exp Med 1970;132:488-507.

77 Ghoneim MA, Radical cystectomy for carcinoma of the bladder: critical evaluation of Ghoneim MA, Radical cystectomy for carcinoma of the bladder: critical evaluation of the results in 1,026 cases. J Urol. 1997 Aug;158(2):393-9.the results in 1,026 cases. J Urol. 1997 Aug;158(2):393-9.

8 8 Swai, B et al. Female genital schistosomiasis as an evidence of a neglected cause Swai, B et al. Female genital schistosomiasis as an evidence of a neglected cause for reproductive ill-health: a retrospective histopathological study from Tanzania. BMC for reproductive ill-health: a retrospective histopathological study from Tanzania. BMC Infectious Disease 2006, 6:134. Infectious Disease 2006, 6:134.

99 Gilbert et al. The Sanford Guide to Antimicrobial Therapy: 36 Gilbert et al. The Sanford Guide to Antimicrobial Therapy: 36 thth Edition, 2006. Edition, 2006. 1010 Garba, A et al. Implementation of national schistosomiasis control programmes in Garba, A et al. Implementation of national schistosomiasis control programmes in

West Africa. Trends in Parasitology. 2006 July; Volume 22, Issue 7, 322-326.West Africa. Trends in Parasitology. 2006 July; Volume 22, Issue 7, 322-326. 1111 http://http://www.who.int/werwww.who.int/wer. Weekly Epidemiological Record, No.16; 2006, 81, 145-164.. Weekly Epidemiological Record, No.16; 2006, 81, 145-164.