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Bram Goorhuis

on 14 February 2014

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Transcript of Schistosomiasis

Schistosomiasis, bilharzia
S. haematobium eggs shown in mummies
possibly also described as hematuria
“country of the menstruating men”
Schistosomiasis in ancient Egypt
Trematode flatworms
Venules of gastro-intestinal or urinary tract
Intermediate host: freshwater snail
Five species of schistosomes
Infect more than 200 million persons
200 million persons infected in 74 countries
120 million have symptoms
20 million have severe disease
100,000 die each year.
Control programs and socioeconomic development vs. elimination
More than 80% of cases in sub-Saharan Africa
Five species cause human human schistosomiasis or bilharziasis.
A dozen or more other species of animal schistosomes can cause dermatitis in humans.
The snail host is specific for each species
Most infected persons have low worm burdens
A small proportion (children) have heavy infections.
Clinical syndromes
Schistosome dermatitis
Acute schistosomiasis
Chronic schistosomiasis
During penetration of cercariae: prickling sensation
Urticaria and rash after several hours
“Swimmer's itch”
Katayama syndrome: 2-12 week after exposure
Most severe with heavy infections
Fever, malaise, abdominal pain, diarrhea, bloody stools, nonproductive cough, dyspnea, chest pain, lung infiltrates
Enlarged liver, spleen, and lymph nodes
Urticaria, eosinophilia
Symptoms and signs usually disappear after 2 to 10 weeks
Symptoms often mild/absent in light infections
Chronic granulomatous inflammation
Elevated levels of proinflamatory cytokines
Poor caloric intake, undernutrition, anemia of chronic inflammation
Fatigue, intermittent abdominal pain, and diarrhea, hematuria, rectal blood loss, hematospermia
Eosinophilia often present
Hepatomegaly/fibrosis, splenomegaly
Portal hypertension
Increased susceptibility to HIV infection/STD's
Ross AG, Bartley PB, Steigh AC et al. Schistosomiasis. N Engl J Med 2002 Apr 18;346(16):1212-20
Gryseels B, Polman K, Clerinx J, Kestens L. Human schistosomiasis. Lancet 2006 Sep 23;368(9541):1106-18
The case
Healthy woman, 19 years
Macroscopic hematuria, since 9 months
No other complaints
Cystoscopic evaluation elsewhere: "cancer"
13 months earlier (August 2010):
Travel to Mali (school class)
Had swum in fresh water in Dogon area
Itch during and after swimming
Hematuria since December 2010
STD excluded by general practitioner
Additional investigations
Blood: eosinophilia 1,24 billion
Urine (24 hours): eggs of schistosoma haematobium
TFT: no eggs
Serology: both IFA and ELISA strongly positive
All travelers with exposure to the same water as the index patient in the years 2008, 2009 and 2010, were called for testing:
A complete history
full blood count
schistosoma serology (combined IFA and ELISA for both egg and worm antigens)
When positive serology:
testing for egg excretion in urine and stools by microscopic evaluation (24-hours urine sample and triple faeces test).
Active excretion of eggs was found in asymptomatic patients without eosinophilia.
These patients are likely to be missed in a different setting.
Every traveller exposed to fresh water in endemic areas should be screened for schistosomiasis, even in the absence of symptoms
From Mali with...

Bram Goorhuis
AMC, Amsterdam
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