Intestinal Schistosomiasis


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Case presentation of liberian immigrant with intestinal schistosomiasis

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  • Abd pain lasting for 1 hr prior to spontaneous resolution Calabar swelling=transient swelling a/w Loa Loa Sowda=oncerciasis localized to one limb. A/w prutitis, swollen, darkened skin
  • Left with father to Lofa county: mixed jungle savannah. Wologasi Mts on border of Liberia/Guinea
  • Colonoscopy performed with notable vascular pattern of rectum. Hyperemia and puntuate hemorrhage. Mucosal biopsies taken along with biopsy of 8 mm pedunculated polyp in ascending colon
  • (40x)Bx of submucosa showed parasitic egg c/w schistosomiasis. Granulomatous inflammation and prominent eosinophilic infiltrate? Hematoxylin and eosin stain with magnification 100x Rectum bx (15 Feb 08): -chrnoic colitis, -shistosoma mansoni eggs ident in mucosa, -no dysplasia identified
  • 100x: visualization of rectum lamina propria. Lymphocytic and monocytic invasion. Mild degree of inflammation. Acute pathology. No histopathologic evidence of granulomatous formation.
  • 50-60um in length. Viable miracidia survive for 2-3 weeks.
  • S. Mansoni much of sub saharan afrcia, northeast brazil, suriname, venezuela the caribbean, lower and middle egypt, the arabic peninsula S. haematobium-SSA, nile valley in egypt and sudan, the maghreb, the arabian peninsula S. japonicum-along the central lakes and river Yankgtze, Mindanao, Leyte, and Phillipines S. mekongi-central mekong basin in laos and cambodia S. Interclatum pockets in w. and central africa
  • DALY=one lost year of healthy life Schistosomiasis was 3 rd larges loss of tropical disease worldwide Mortality due to schistosomiasis by direct mortality and not due to renal failure, bladder cancer, cirrhosis or colon cancer
  • Epg=eggs per gram Diarrhea/bloody diarrhea/abd pain – 2 episodes lasting one day or more in past 2 mos
  • 35% of bloody diarrhea due to S. mansoni. For diarrhea, 9% attributable to S. mansoni Prevalence of abd pain high 82% cohoha lake nd 72% rusizi plain
  • 50-60um in length. Viable miracidia survive for 2-3 weeks.
  • GBD: from epidemiologic model. 2-Prevalence=extrapolation from historical prevalence data. 3-Morbidityand mortality estimates that quantified prevalence of infection and prevalence of selected morbid outcomes.
  • (oxadiazole—targets enzyme TGR) identified as effective against S. mansoni
  • Intestinal Schistosomiasis

    1. 1. Greater Washington Infectious Diseases Society Conference October 20, 2008 Temujin T. Chavez, MD LCDR MC USN National Capitol Consortium
    2. 2. Case <ul><li>CC </li></ul><ul><ul><li>Diarrhea and abdominal pain </li></ul></ul><ul><li>HPI </li></ul><ul><ul><li>Insidious onset of intermittent, sharp, crescendo-decrescendo, non-radiating right flank pain since Spring 2005 </li></ul></ul><ul><ul><li>Melena June 2005 </li></ul></ul><ul><ul><ul><li>EGD with Helicobacter pylori gastritis </li></ul></ul></ul><ul><ul><li>CT A/P October 2006 </li></ul></ul><ul><ul><ul><li>Normal </li></ul></ul></ul><ul><ul><li>Fall 2007, pain worsens </li></ul></ul><ul><ul><li>Diarrhea with occasional rectal bleeding </li></ul></ul><ul><ul><li>Gastroenterology evaluation February 2008 </li></ul></ul>
    3. 3. Case <ul><li>PMHx </li></ul><ul><ul><li>Latent Mycobacterium tuberculosis Oct 2007 </li></ul></ul><ul><ul><li>Helicobacter pylori gastritis 2006 </li></ul></ul><ul><li>FamHx </li></ul><ul><ul><li>Brother deceased from cerebral malaria </li></ul></ul><ul><li>SurgHx </li></ul><ul><ul><li>Pilonidal cyst I&D May 2006 </li></ul></ul><ul><ul><li>Colonoscopy Feb 2008 </li></ul></ul><ul><li>NKDA </li></ul><ul><li>Medications </li></ul><ul><ul><li>Isoniazid 300 mg po daily </li></ul></ul><ul><ul><li>Pyridoxine 50 mg po daily </li></ul></ul>
    4. 4. Travel History <ul><li>Born Monrovia, Liberia </li></ul><ul><li>Lofa county 1-16 yo </li></ul><ul><li>Bong county 17-18 yo </li></ul><ul><li>Wologisi mountains during Liberian civil war </li></ul><ul><li>Immigrated to US 2001 </li></ul><ul><li>Philadelphia, PA until 2004 when enlisted in USMC </li></ul>
    5. 5. Case <ul><li>T=97.4, BP=120/72, P=71, R=16 </li></ul><ul><li>Gen: NAD. Non-cachectic </li></ul><ul><li>Heent: Sclera anicteric </li></ul><ul><li>Lymph: Normal </li></ul><ul><li>CV: Normal </li></ul><ul><li>Pulm: Normal </li></ul><ul><li>Abd: NABS. Soft. Non-tender. No hepatosplenomegaly </li></ul><ul><li>Derm: No hypopigmentation / nodules </li></ul>
    6. 6. Case <ul><li>Labs </li></ul><ul><ul><li>WBC=4.4 (42% PMN, 46% Lymph, 3.6% Eos), Hgb=16 (MCV=89), PLT=180 </li></ul></ul><ul><ul><li>Na=143, K=4.3, Cl=106, Co2=31, BUN=19, Cr=1.3 </li></ul></ul><ul><ul><li>Alb=4.6, AlkPhos=64, AST=26, ALT=21, TB=0.9 </li></ul></ul><ul><ul><li>Amylase=147, Lipase=30 </li></ul></ul><ul><ul><li>UA=Normal </li></ul></ul><ul><ul><li>HBsAg & HBsAb= non reactive, HBcAb= reactive </li></ul></ul><ul><ul><li>HIV-1 Ab=negative </li></ul></ul>
    7. 7. Differential Diagnosis <ul><li>Immunocompetent native Liberian male h/o latent MTb with 2 year history of chronic abdominal pain with diarrhea </li></ul>
    8. 8. Differential Diagnosis <ul><li>Infectious </li></ul><ul><ul><li>Giardiasis </li></ul></ul><ul><ul><li>Strongyloidiasis </li></ul></ul><ul><ul><li>Entamoeba histolytica </li></ul></ul><ul><ul><li>Tropical Sprue </li></ul></ul><ul><ul><li>Mycobacterium tuberculosis enteritis </li></ul></ul><ul><ul><li>Schistosomiasis </li></ul></ul><ul><li>Non-infectious </li></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Eosinophilic enteritis </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Amyloidosis </li></ul></ul><ul><ul><li>Lymphoma </li></ul></ul><ul><ul><li>Acute intermittent porphyria </li></ul></ul>
    9. 13. Human Schistosomiasis <ul><li>Trematode parasitic infection </li></ul><ul><li>Species affecting humans </li></ul><ul><ul><li>S. mansoni </li></ul></ul><ul><ul><li>S. japonicum </li></ul></ul><ul><ul><li>S. mekongi </li></ul></ul><ul><ul><li>S. intercalatum </li></ul></ul><ul><ul><li>S. haematobium </li></ul></ul><ul><li>Geographic distribution limited to areas with fresh water snails </li></ul>
    10. 14. Schistosomiasis – Geographic distribution
    11. 15. Schistosomiasis – Global disease burden <ul><li>Infects more than 200 million people </li></ul>WHO World Health Report 2002
    12. 16. Schistosomiasis - Liberia <ul><li>S. mansoni half as prevalent as S. haematobium </li></ul><ul><li>S. mansoni with prevalence of 24.8% (Bong County) </li></ul><ul><li>Rates of infection vary with season </li></ul><ul><ul><li>Higher during dry season (Dec-Feb) </li></ul></ul><ul><li>Age groups (Bong county) </li></ul><ul><ul><li>S. mansoni similar prevalence across age groups </li></ul></ul><ul><ul><li>S. haematobium with disproportionate prevalence ages 0-15 yo </li></ul></ul>Acta Trop 1983;40:205-209 Acta Trop 1980;37:53-62
    13. 17. Schistosomiasis mansoni – Clinical spectrum <ul><li>Acute </li></ul><ul><ul><li>Cercarial dermatitis </li></ul></ul><ul><ul><li>Katayama fever </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>Intestinal </li></ul></ul><ul><ul><ul><li>Large bowel </li></ul></ul></ul><ul><ul><ul><ul><li>Chronic or intermittent abdominal pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diarrhea in 3-55% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bloody diarrhea in 11-50% </li></ul></ul></ul></ul><ul><ul><li>Hepatosplenic </li></ul></ul><ul><ul><li>Glomerulonephritis </li></ul></ul><ul><ul><li>Neuroschistosomiasis </li></ul></ul>Lancet 2006;368:1106-1118
    14. 18. Intestinal Schistosomiasis mansoni <ul><li>Parasitologic, clinical and anamnestic data over 2 years in Burundi </li></ul><ul><li>Two endemic areas in Burundi sampled </li></ul><ul><ul><li>Cohoha Lake (21%) & Rusizi Plain (33%) </li></ul></ul><ul><li>Parasitologic exam </li></ul><ul><ul><li>Eggs per gram of feces </li></ul></ul><ul><li>Clinical exam </li></ul><ul><ul><li>Abdominal palpation in supine position </li></ul></ul><ul><li>Clinical history </li></ul><ul><ul><li>Diarrhea, bloody diarrhea, abdominal pain, fatigue, and weakness </li></ul></ul>Am J Trop Med Hyg 1995;53(6):660-667
    15. 19. Intestinal schistosomiasis – Clinical features Prevalence (%) of morbidity attributable to S. mansoni in two areas of Burundi Area 5-9 10-19 >/=20 All Bloody diarrhea Cohoha Lake 4.1 5.0 1.1 2.2 Rusizi Plain 3.4 2.8 2.0 2.3 Left liver enlargement Cohoha Lake 1.2 6.4 1.0 1.9 Rusizi Plain 1.1 1.6 0.8 0.9 Spleen enlargement Cohoha Lake 0 3.4 0.4 0.9 Rusizi Plain 0.9 1.3 1.8 1.5 Diarrhea Cohoha Lake 5.1 5.7 0.8 2.5 Rusizi Plain 3.1 2.9 1.9 2.0
    16. 20. Management <ul><li>Intestinal Schistosomiasis mansoni </li></ul><ul><ul><li>Praziquantel 40 mg/kg po </li></ul></ul><ul><ul><li>Repeat treatment in 4 to 6 weeks </li></ul></ul><ul><ul><li>Review CT A/P </li></ul></ul><ul><ul><li>Counseling </li></ul></ul><ul><ul><ul><li>Avoid fresh water </li></ul></ul></ul><ul><ul><ul><li>Water used for washing heated to 50 degrees Celsius or let stand 2 days </li></ul></ul></ul>
    17. 21. Discussion <ul><li>Schistosomiasis has a high global prevalence and a large burden of disease in sub-Saharan Africa </li></ul><ul><li>S. mansoni should be suspected in immigrants of endemic areas who present with lower GI symptoms </li></ul><ul><li>Visualization of S. mansoni eggs on microscopy or histopathology is important diagnostically </li></ul>
    18. 23. Schistosomiasis – Transmission cycle NEJM 2002;346:1212-1220
    19. 24. Schistosomiasis mansoni – Global disease burden WHO World Health Report 2002
    20. 25. Schistosomiasis mansoni – Hepatosplenic <ul><li>Assessed utility of abdominal palpation </li></ul><ul><li>Two rural communities in Brazil </li></ul><ul><ul><li>Highly endemic (66.3% prevalence) </li></ul></ul><ul><ul><li>Nonenemic </li></ul></ul><ul><li>Two physicians performed abdominal palpation </li></ul><ul><li>All aged > 5 yo examined by US </li></ul><ul><li>Exam and eggs in stools unable to adequately detect in endemic community </li></ul><ul><ul><li>Severe peri-portal thickening, portal hypertension and spleen not palpable </li></ul></ul><ul><ul><li>Normal liver with palpable spleen </li></ul></ul>Acta Tropica 2000;77:101-109
    21. 26. Schistosomiasis mansoni - Hepatosplenic <ul><li>Two distinct syndromes of early inflammation and late fibrotic disease </li></ul><ul><li>Inflammatory hepatic schistosomiasis is an early rxn to trapped ova in pre-sinusoidal periportal spaces </li></ul><ul><ul><li>Left lobe enlargement and nodular splenomegaly </li></ul></ul><ul><ul><li>Most cases w/o signs of functional disease </li></ul></ul><ul><li>Fibrotic or chronic hepatic schistosomiasis develops in long-standing intense infection </li></ul><ul><ul><li>Periportal pipestem fibrosis </li></ul></ul><ul><ul><li>Gastro-esophageal variceal bleeding </li></ul></ul>Lancet 2006;368:1106-1118
    22. 27. Schistosomiasis mansoni - Treatment <ul><li>Furoxan – an oxadiazole & possible alternative to praziquantel </li></ul>Lancet Inf Dis 2007;7:218-224 Nature 2008;452:296
    23. 28. Intestinal schistosomiasis – Clinical features <ul><li>Individuals with higher infection intensity at greater risk of morbidity (right) </li></ul><ul><li>Highest risk indicator was bloody stools </li></ul>Trop Med Int Health 1996;1:646-54