RNT lecture schistosomiasis 2012 pdf small


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RNT lecture schistosomiasis 2012 pdf small

  1. 1. Schistosomes and other flukesRahajeng N. Tunjungputri, MD, MSc Department of Parasitology Faculty of Medicine Diponegoro University - 2012
  2. 2. Case A 22-year-old student from Sulawesi presented at the hospital with acute haematemesis Physical examination revealed marked hepatosplenomegalyOesophageal and gastricvarices were identified atupper gastrointestinalendoscopy  portalhypertension
  3. 3. S. mansoni Human schistosomiasis/ Schistosomes S. japonicum bilharziasis S. hematobium Clonorchis sinensisTrematodes Liver flukes Opistorchis sp. Fasciola hepatica Intestinal Fasciolopsis buski, Metagonimus flukes yokogawai, Heterophyes heterophyes
  4. 4. Human schistosomiasis: epidemiology 200 million persons infected with schistosomes in 74 countries 120 million persons have symptoms, 20 million have severe disease, and 100,000 die each year Higher infection rate and infection burden in children  amount of water exposure, partial acquired immunity, age, and genetic susceptibility
  5. 5.  Water resource development projects and population movements have spread the disease to non-endemic areas
  6. 6. Global distribution
  7. 7. Schistosomiasis in Indonesia 1975: highest prevalence  72% Domestic and wild animals maintain transmission cycle: eg deer, cow, buffalo, rats 2001: increased prevalence due to Poso unrest  population movement
  8. 8. Snail habitat
  9. 9. Schistosomes morphology Male  9,5mm x 19,5 mm  Canalis gynecophorus Female : 16 mm x 26 mm  Thin-shaped
  10. 10. S. mansoni Habitat  Mesenteric and portal veins  V. mesenterica inferior
  11. 11. S. mansoni
  12. 12. S. mansoni male adult: tegument
  13. 13. S. japonicum Habitat  Mesenteric and portal veins  V. mesenterica superior
  14. 14. S. haematobium Habitat  V. vesicalis
  15. 15. Life cycleVideo
  16. 16. Cercariae penetration Intensity of infection Severity of diseaseIn snails: sporocyst I sporocyst II  cercaria
  17. 17.  Transmission
  18. 18. Clinical manifestationPeriod Affected organ ManifestationImmediate Skin Dermatitis: A maculopapular eruption at the site of penetration In migrants or tourists: skin reactions (hours), a rash (up to one week later)Acute Systemic A history of contact with contaminated water 2-6 weeks beforeSchistosomiasis Gastrointestinal (in travellers) Lungs Mediated by the immune complexKatayama fever Liver, spleen Majority of cases begin with the deposition of an egg into host tissues Fever, headache, generalized myalgias, right-upper-quadrant pain, and bloody diarrhea, respiratory symptoms Tender hepatomegaly, splenomegaly, aseptic meningitis. Not all patients shed eggs, but all have eosinophilia and most have positive serologic testsChronic Especially in people with longstanding infection in poor areasshistosomiasis Gastrointestinal and Liver Disease Genitourinary Disease Neurologic and Other Manifestations
  19. 19. Pathogenesis Egg production commences four to six weeks after infection and continues for the life of the worm — usually three to five years. Shed in fecesEggs in blood Pass the Tissue (S.m, S.j) and vessels mucosa urine (S.h)
  20. 20. Gastrointestinal and liver disease Intestinal disease: Eggs in the gut wall  inflammation, hyperplasia, ulceration, microabscess formation, and polyposis  Light infections: fatigue, intermittent abdominal pain, and diarrhea  Heavy infections: anemia, intestinal polyps Liver disease  presinusoidal inflammation, periportal fibrosis & collagen deposits, progressive obstruction of blood flow, portal hypertension, hepatomegaly  Early chronic: granuloma infiltration around eggs in small venulae  In 5-10%: periportal fibrosis in years after infection
  21. 21. Adult in mesenteric veins Eggs invenulae/ tissueInflammation
  22. 22. Portal hypertension,variceal bleeding  Hepatomegaly  Varices  Variceal bleeding  Splenomegaly
  23. 23. Genitourinary Disease Dysuria and hematuria (early and late disease) Late manifestations:  proteinuria (often in the nephrotic range)  calcifications in the bladder  obstruction of the ureter  renal colic  hydronephrosis  renal failure  associated risk of bladder cancer Secondary bacterial infection is frequent Genital disease in 1/3 women: vulval and perineal hypertrophic, ulcerative, fistulous, or wart-like
  24. 24. Schistosomal dermatitishttp://img.medscape.com/pi/emed/ckb/pediatrics_general/996090-999469-98.jpg
  25. 25. Schistosomal dermatitis http://upload.wikimedia.org/wikipedia/commons/5/5a/Cercarial_dermatitis_lower_legs.jpg
  26. 26. GU disease 27-year-old man with hematuria and left-sided loin pain who had S. haematobium eggs in his urine
  27. 27. Liver disease ultrasonogram showing gross hepatic fibrosis (arrows) in a 45-year-old man with severe hepatic schistosomiasis
  28. 28. Diagnosis: Schistosomiasis Eggs in stool  Multiple samples Others:  PCR  Serology - ELISA
  29. 29. Schistosomiasis control Indonesia  2 times /year: Human stool survey, Snails survey, Reservoir host survey  Control activity  MDA  Selective drug administration using praziquantel  Snail control: Chemical molluscicide in limited area  Environment: drying / flooding of snails habitats, cleaning of irrigation channels (drainage)  Education Vaccination of reservoir host  research Host population control  satellite tracking
  30. 30. Other liver flukes
  31. 31. Clonorchis sinensis flattened 10-25 mm long by 3-5 mm wide ovary two branches testes habitat: bile ducts
  32. 32. Opistorchis spp. Testes: 2, lobular shape Eggs often indistinguishable from C. sinensis Habitat: bile ducts
  33. 33. Opisthorchiasis and Clonorchiasis 2-3 weeks after exposure  Fever, abdominal pain, hepatomegaly, urticaria, and eosinophilia Chronic infection  inflammation and thickening of bile duct walls and localized obstruction in about 10% of persons with heavy chronic infections  right upper quadrant discomfort, anorexia, and weight loss Heavy infection  Gall stones, recurring cholangitis with bacterial sepsis, cholecystitis, liver abscess, and occasionally pancreatitis
  34. 34.  Infection:  ingesting the metacercariae in raw or inadequately cooked fish
  35. 35. Fasciola hepatica large and broadly-flat up to 30 mm x 15 mm The anterior end is cone- shaped Habitat: bile duct
  36. 36.  ingesting uncooked aquatic vegetation
  37. 37. Clinical syndromes of F. hepatica infection • In 6-12 weeks after infection: Marked eosinophilia, abdominal pain,Acute/ Migratory intermittent high fever, weight loss, phase urticaria • Tender hepatomegaly, jaundice, anemia • eosinophilia • inflammation and intermittent Chronic phase obstruction of bile ducts, cholecystitis, ascending cholangitis
  38. 38. Diagnosis: other liver flukes Finding eggs in stool  Multiple samples
  39. 39. Treatment Schistosomiasis: Praziquantel repeated dose after 4-6 weeks in Katayama fever Niridazol for schistosomiasis due to toxicity
  40. 40. Case: Examination of stool specimens
  41. 41. Serology Enzyme immunoassay high levels of serum antibodies to S. mansoni were subsequently detected
  42. 42. Therapy Endoscopy sclerotherapy Pharmacotherapy
  43. 43. Reference Mandell GL, Bennet JE, Dolin R. Principles and practice of infectious diseases. 2010 Ed. 7 pp. 3595-3605. Ross AG, Bartley PB, Sleigh AC, Olds GR, Li Y, Williams GM, McManus DP. 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.