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Greater Washington Infectious Diseases Society Conference October 20, 2008 Temujin T. Chavez, MD LCDR MC USN National Capi...
Case <ul><li>CC </li></ul><ul><ul><li>Diarrhea and abdominal pain </li></ul></ul><ul><li>HPI  </li></ul><ul><ul><li>Insidi...
Case <ul><li>PMHx </li></ul><ul><ul><li>Latent  Mycobacterium tuberculosis  Oct 2007 </li></ul></ul><ul><ul><li>Helicobact...
Travel History <ul><li>Born Monrovia, Liberia </li></ul><ul><li>Lofa county 1-16 yo  </li></ul><ul><li>Bong county 17-18 y...
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 an...
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><...
Differential Diagnosis <ul><li>Immunocompetent native Liberian male h/o latent MTb with 2 year history of chronic abdomina...
Differential Diagnosis <ul><li>Infectious </li></ul><ul><ul><li>Giardiasis </li></ul></ul><ul><ul><li>Strongyloidiasis </l...
 
 
 
 
Human Schistosomiasis <ul><li>Trematode parasitic infection </li></ul><ul><li>Species affecting humans </li></ul><ul><ul><...
Schistosomiasis –  Geographic distribution
Schistosomiasis –  Global disease burden <ul><li>Infects more than 200 million people </li></ul>WHO World Health Report 2002
Schistosomiasis - Liberia <ul><li>S. mansoni  half as prevalent as  S. haematobium </li></ul><ul><li>S. mansoni  with prev...
Schistosomiasis mansoni – Clinical spectrum <ul><li>Acute </li></ul><ul><ul><li>Cercarial dermatitis </li></ul></ul><ul><u...
Intestinal  Schistosomiasis mansoni <ul><li>Parasitologic, clinical and anamnestic data over 2 years in Burundi </li></ul>...
Intestinal schistosomiasis – Clinical features Prevalence (%) of morbidity attributable to  S. mansoni  in two areas of Bu...
Management <ul><li>Intestinal  Schistosomiasis mansoni </li></ul><ul><ul><li>Praziquantel 40 mg/kg po </li></ul></ul><ul><...
Discussion <ul><li>Schistosomiasis has a high global prevalence and a large burden of disease in sub-Saharan Africa </li><...
 
Schistosomiasis –  Transmission cycle NEJM 2002;346:1212-1220
Schistosomiasis mansoni  – Global disease burden WHO World Health Report 2002
Schistosomiasis mansoni –  Hepatosplenic <ul><li>Assessed utility of abdominal palpation </li></ul><ul><li>Two rural commu...
Schistosomiasis mansoni  - Hepatosplenic <ul><li>Two distinct syndromes of early inflammation and late fibrotic disease </...
Schistosomiasis mansoni  - Treatment <ul><li>Furoxan – an oxadiazole & possible alternative to praziquantel </li></ul>Lanc...
Intestinal schistosomiasis – Clinical features <ul><li>Individuals with higher infection intensity at greater risk of morb...
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Intestinal Schistosomiasis

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Case presentation of liberian immigrant with intestinal schistosomiasis

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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

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