Greater Washington Infectious Greater Washington Infectious Diseases Society ConferenceDiseases Society Conference
October 20, 2008October 20, 2008
Temujin T. Chavez, MDTemujin T. Chavez, MDLCDR MC USNLCDR MC USN
National Capitol ConsortiumNational Capitol Consortium
CaseCase CCCC
• Diarrhea and abdominal painDiarrhea and abdominal pain HPI HPI
• Insidious onset of intermittent, sharp, crescendo-Insidious onset of intermittent, sharp, crescendo-decrescendo, non-radiating right flank pain since Spring decrescendo, non-radiating right flank pain since Spring 20052005
• Melena June 2005Melena June 2005 EGD with EGD with Helicobacter pylori Helicobacter pylori gastritisgastritis
• CT A/P October 2006CT A/P October 2006 NormalNormal
• Fall 2007, pain worsensFall 2007, pain worsens• Diarrhea with occasional rectal bleedingDiarrhea with occasional rectal bleeding• Gastroenterology evaluation February 2008Gastroenterology evaluation February 2008
Case
PMHxPMHx• Latent Latent Mycobacterium Mycobacterium
tuberculosis tuberculosis Oct 2007Oct 2007• Helicobacter pylori Helicobacter pylori
gastritis 2006gastritis 2006
FamHxFamHx• Brother deceased from
cerebral malaria
SurgHxSurgHx• Pilonidal cyst I&D May Pilonidal cyst I&D May
20062006• Colonoscopy Feb 2008Colonoscopy Feb 2008
NKDANKDA
MedicationsMedications• Isoniazid 300 mg po dailyIsoniazid 300 mg po daily• Pyridoxine 50 mg po dailyPyridoxine 50 mg po daily
Travel HistoryTravel History
Born Monrovia, LiberiaBorn Monrovia, Liberia
Lofa county 1-16 yo Lofa county 1-16 yo
Bong county 17-18 yoBong county 17-18 yo
Wologisi mountains during Wologisi mountains during Liberian civil warLiberian civil war
Immigrated to US 2001Immigrated to US 2001
Philadelphia, PA until 2004 Philadelphia, PA until 2004 when enlisted in USMCwhen enlisted in USMC
CaseCase
T=97.4, BP=120/72, P=71, R=16T=97.4, BP=120/72, P=71, R=16
Gen: Gen: NAD. Non-cachectic NAD. Non-cachectic Heent: Heent: Sclera anictericSclera anicteric Lymph: Lymph: NormalNormal CV: CV: NormalNormal Pulm: Pulm: NormalNormal Abd: Abd: NABS. Soft. Non-tender. No NABS. Soft. Non-tender. No
hepatosplenomegalyhepatosplenomegaly Derm: Derm: No hypopigmentation / nodulesNo hypopigmentation / nodules
CaseCase
LabsLabs
• WBC=4.4 (42% PMN, 46% Lymph, 3.6% Eos), Hgb=16 WBC=4.4 (42% PMN, 46% Lymph, 3.6% Eos), Hgb=16
(MCV=89), PLT=180 (MCV=89), PLT=180
• Na=143, K=4.3, Cl=106, Co2=31, BUN=19, Cr=1.3Na=143, K=4.3, Cl=106, Co2=31, BUN=19, Cr=1.3
• Alb=4.6, AlkPhos=64, AST=26, ALT=21, TB=0.9Alb=4.6, AlkPhos=64, AST=26, ALT=21, TB=0.9
• Amylase=147, Lipase=30Amylase=147, Lipase=30
• UA=NormalUA=Normal
• HBsAg & HBsAb= non reactive, HBcAb= reactiveHBsAg & HBsAb= non reactive, HBcAb= reactive
• HIV-1 Ab=negativeHIV-1 Ab=negative
Differential DiagnosisDifferential Diagnosis
Immunocompetent native Immunocompetent native
Liberian male h/o latent MTb Liberian male h/o latent MTb
with 2 year history of chronic with 2 year history of chronic
abdominal pain with diarrheaabdominal pain with diarrhea
Differential DiagnosisDifferential Diagnosis
InfectiousInfectious• GiardiasisGiardiasis• StrongyloidiasisStrongyloidiasis• Entamoeba histolyticaEntamoeba histolytica• Tropical SprueTropical Sprue• Mycobacterium Mycobacterium
tuberculosis tuberculosis enteritisenteritis• SchistosomiasisSchistosomiasis
Non-infectiousNon-infectious• Inflammatory bowel Inflammatory bowel
diseasedisease• Eosinophilic enteritisEosinophilic enteritis• PancreatitisPancreatitis• AmyloidosisAmyloidosis• LymphomaLymphoma• Acute intermittent Acute intermittent
porphyriaporphyria
Human SchistosomiasisHuman Schistosomiasis Trematode parasitic Trematode parasitic
infectioninfection Species affecting Species affecting
humanshumans• S. mansoniS. mansoni• S. japonicumS. japonicum• S. mekongiS. mekongi• S. intercalatumS. intercalatum• S. haematobium S. haematobium
Geographic Geographic distribution limited to distribution limited to areas with fresh areas with fresh water snailswater snails
Schistosomiasis – Schistosomiasis – Geographic distributionGeographic distribution
Schistosomiasis – Schistosomiasis – Global disease burdenGlobal disease burden
Infects more than 200 million peopleInfects more than 200 million people
WHO World Health Report 2002WHO World Health Report 2002
Schistosomiasis - LiberiaSchistosomiasis - Liberia
S. mansoni S. mansoni half as prevalent half as prevalent as as S. haematobiumS. haematobium
S. mansoni S. mansoni with prevalence with prevalence of 24.8% (Bong County)of 24.8% (Bong County)
Rates of infection vary with Rates of infection vary with seasonseason• Higher during dry season Higher during dry season
(Dec-Feb)(Dec-Feb) Age groups (Bong county)Age groups (Bong county)
• S. mansoni S. mansoni similar similar prevalence across age prevalence across age groupsgroups
• S. haematobium S. haematobium with with disproportionate disproportionate prevalence ages 0-15 yoprevalence ages 0-15 yo
Acta Trop 1983;40:205-209Acta Trop 1983;40:205-209Acta Trop 1980;37:53-62Acta Trop 1980;37:53-62
Schistosomiasis mansoni –Schistosomiasis mansoni –Clinical spectrumClinical spectrum
AcuteAcute• Cercarial dermatitisCercarial dermatitis• Katayama feverKatayama fever
ChronicChronic• IntestinalIntestinal
Large bowelLarge bowel• Chronic or intermittent abdominal painChronic or intermittent abdominal pain• Diarrhea in 3-55%Diarrhea in 3-55%• Bloody diarrhea in 11-50%Bloody diarrhea in 11-50%
• HepatosplenicHepatosplenic• GlomerulonephritisGlomerulonephritis• NeuroschistosomiasisNeuroschistosomiasis
Lancet 2006;368:1106-1118Lancet 2006;368:1106-1118
Intestinal Intestinal Schistosomiasis Schistosomiasis mansonimansoni
Parasitologic, clinical and anamnestic data over 2 Parasitologic, clinical and anamnestic data over 2 years in Burundiyears in Burundi
Two endemic areas in Burundi sampledTwo endemic areas in Burundi sampled• Cohoha Lake (21%) & Rusizi Plain (33%)Cohoha Lake (21%) & Rusizi Plain (33%)
Parasitologic examParasitologic exam• Eggs per gram of fecesEggs per gram of feces
Clinical examClinical exam• Abdominal palpation in supine positionAbdominal palpation in supine position
Clinical historyClinical history• Diarrhea, bloody diarrhea, abdominal pain, Diarrhea, bloody diarrhea, abdominal pain,
fatigue, and weaknessfatigue, and weakness
Am J Trop Med Hyg 1995;53(6):660-667Am J Trop Med Hyg 1995;53(6):660-667
Intestinal schistosomiasis –Intestinal schistosomiasis –Clinical featuresClinical features
Area 5-9 10-19 >/=20 All
Bloody diarrheaBloody diarrhea Cohoha Lake 4.1 5.0 1.1 2.2
Rusizi Plain 3.4 2.8 2.0 2.3
Left liver enlargementLeft liver enlargement Cohoha Lake 1.2 6.4 1.0 1.9
Rusizi Plain 1.1 1.6 0.8 0.9
Spleen enlargementSpleen enlargement Cohoha Lake 0 3.4 0.4 0.9
Rusizi Plain 0.9 1.3 1.8 1.5
DiarrheaDiarrhea Cohoha Lake 5.1 5.7 0.8 2.5
Rusizi Plain 3.1 2.9 1.9 2.0
Prevalence (%) of morbidity attributable to Prevalence (%) of morbidity attributable to S. mansoni S. mansoni in two in two areas of Burundiareas of Burundi
Management
Intestinal Intestinal Schistosomiasis mansoniSchistosomiasis mansoni• Praziquantel 40 mg/kg poPraziquantel 40 mg/kg po• Repeat treatment in 4 to 6 weeksRepeat treatment in 4 to 6 weeks• Review CT A/PReview CT A/P• CounselingCounseling
Avoid fresh waterAvoid fresh water Water used for washing heated to 50 Water used for washing heated to 50
degrees Celsius or let stand 2 daysdegrees Celsius or let stand 2 days
DiscussionDiscussion
Schistosomiasis has a high global prevalence and a large burden of disease in sub-Saharan Africa
S. mansoni should be suspected in immigrants of endemic areas who present with lower GI symptoms
Visualization of S. mansoni eggs on microscopy or histopathology is important diagnostically
Schistosomiasis – Schistosomiasis – Transmission cycleTransmission cycle
NEJM 2002;346:1212-1220NEJM 2002;346:1212-1220
Schistosomiasis mansoni Schistosomiasis mansoni – – Global disease burdenGlobal disease burden
WHO World Health Report 2002WHO World Health Report 2002
Schistosomiasis mansoni – Schistosomiasis mansoni – HepatosplenicHepatosplenic
Assessed utility of abdominal palpationAssessed utility of abdominal palpation Two rural communities in BrazilTwo rural communities in Brazil
• Highly endemic (66.3% prevalence)Highly endemic (66.3% prevalence)• NonenemicNonenemic
Two physicians performed abdominal palpationTwo physicians performed abdominal palpation All aged > 5 yo examined by USAll aged > 5 yo examined by US Exam and eggs in stools unable to adequately detect in Exam and eggs in stools unable to adequately detect in
endemic communityendemic community• Severe peri-portal thickening, portal hypertension and spleen not Severe peri-portal thickening, portal hypertension and spleen not
palpablepalpable• Normal liver with palpable spleenNormal liver with palpable spleen
Acta Tropica 2000;77:101-109Acta Tropica 2000;77:101-109
Schistosomiasis mansoniSchistosomiasis mansoni - - HepatosplenicHepatosplenic
Two distinct syndromes of early inflammation and Two distinct syndromes of early inflammation and late fibrotic diseaselate fibrotic disease
Inflammatory hepatic schistosomiasis is an early Inflammatory hepatic schistosomiasis is an early rxn to trapped ova in pre-sinusoidal periportal rxn to trapped ova in pre-sinusoidal periportal spacesspaces• Left lobe enlargement and nodular Left lobe enlargement and nodular
splenomegalysplenomegaly• Most cases w/o signs of functional diseaseMost cases w/o signs of functional disease
Fibrotic or chronic hepatic schistosomiasis Fibrotic or chronic hepatic schistosomiasis develops in long-standing intense infectiondevelops in long-standing intense infection• Periportal pipestem fibrosisPeriportal pipestem fibrosis• Gastro-esophageal variceal bleedingGastro-esophageal variceal bleeding
Lancet 2006;368:1106-1118Lancet 2006;368:1106-1118
Schistosomiasis mansoniSchistosomiasis mansoni - - TreatmentTreatment
Furoxan – an oxadiazole & possible alternative to Furoxan – an oxadiazole & possible alternative to praziquantelpraziquantel
Lancet Inf Dis 2007;7:218-224Lancet Inf Dis 2007;7:218-224Nature 2008;452:296Nature 2008;452:296
Intestinal schistosomiasis –Intestinal schistosomiasis –Clinical featuresClinical features
Individuals with Individuals with higher infection higher infection intensity at greater intensity at greater risk of morbidity risk of morbidity (right)(right)
Highest risk indicator Highest risk indicator was bloody stoolswas bloody stools
Trop Med Int Health 1996;1:646-54Trop Med Int Health 1996;1:646-54