Schistosomiasis

by Sri Sundari Purbohadi

 Schitosoma japonicum inhabits in the portal

Introduction

venous system Skin contact with water contaminated by cercaria The basic pathologic lesion is the egg granuloma in the liver and colon Acute schitosomiasis:fever,enlargement and tenderness of the liver,eosinophilia,and dysentery Chronic schitosomiasis : fibro-obstructive lesion around the portal vessels Late stage: giant spleen, ascites, hypertension of portal venous system

Etiology
Mature worms: Dioecious
Female :long and thin. Male:short and thick

Eggs: miracidia in it

Life cycle
adult worm passing eggs
egg into fresh water

cercariae
miracidia

penetrate into the body of the snail (intermediate host) oncomelania

Life Cycle of Schistosoma spp.

78

2530

Epidemiology
Source of infection: humans and mammals

(especially cattle) infected by schistosome Route of transmission: three major factors are responsible for the occurrence of schistosomiasis Susceptibility : everyone is susceptive. Especially peasant and fisherman

Three Major Factors

The method of disposal of human

excreta The presence of the snail intermediate host The contact with cercaria-infected water

Pathogenesis
It belong to a kind of allergic

reaction(rapid & delayed) Formation of granuloma produced by eggs (Hoeplli sign) Concomitant immunity Ectopic lesion (lung & brain)

 Miracidia produces

enzymes and secretions while in the egg.

Ag/Ab reaction to

miracidial secretions through egg, resulting in egg granuloma the Hoeppli phenomenon!

Ag/Ab

How many eggs make it to the lumen?

2/3 of those that enter tissue do not leave. Many eggs do not enter tissue Swept away in blood stream Liver and spleen are first organs Then Lungs Other organs Eggs look like Psuedotubercles 100, 000 eggs/gram!

Pathology
Colon: acute -mucosa congestion,

edema and egg granuloma chronic-fibro obstructive lesion Liver: acute -enlargement of the liver and egg granuloma on it chronic-portal liver cirrhosis Other organs: lung and brain, etc Systemic symptoms:

Clinical Manifestations

Acute
When the cercarias contact the skin and begin their

penetration a transient burning pruritus (like swimmers itch) may develop. Over the next 3 days, a punctate hemorrhagic component followed by crusting develops. After several weeks, the eruption resolves, leaving postinflammatory hyperpigmentation. In humans, this cercarial dermatitis is known as schistosomal dermatitis, is less severe than that produced by nonhuman schistosomes, and may be more severe in individuals who have been sensitized by previous exposure. The cercarias of swimmers itch likely belong to ducks or another host.

 An acute syndrome that begins suddenly occurs in infected

individuals can be related to either migration of the worm or the initial release of eggs by the mature worm. The acute syndrome, known as Katayama fever, occurs 2-6 weeks after penetration by cercarias and may last 1-2 months. Manifestations include spiking afternoon fevers, chills, bronchitis, pneumonitis, headache, lymphadenopathy, hepatosplenomegaly, joint pain, diarrhea, urticaria, eosinophilia, leukocytosis and an elevated erythrocyte sedimentation rate.

Acute Schistosomiasis

The history of contact with schistosome-

infected water. Schistosome dermatitis Incubation period: 23-73 days, average 1 month

Acute Schistosomiasis
Clinical manifestations come out after 4 to 8

weeks of infection, similar to the time from egg to adult worm (40 days) Fever: intermittent, maintain weeks to months Allergic reaction:urticaria, angioneuroedema, enlargement of lymph nodes and eosinophilia Digestive syndromes: abdominal pain, diarrhea with pus and blood, constipation or diarrhea Hepatosplenomegaly

Chronic Schistosomiasis
Asymptomatic: most person are

asymptomatic Symptomatic: the most common syndrome is abdominal pain with intermittent diarrhea. hepatosplenomegaly

Chronic schistosomiasis is due to a granulomatous response to egg deposition in target tissues like the bladder
Localized in the venous plexus of the hosts bladder,

S haematobium releases its eggs, resulting in a

characteristic urogenital syndrome in which hematuria, obstructive uropathy, and bladder cancer figure prominently. The other schistosomes that cause disease in humans are found in the venous plexus of the bowel: S japonicum in the superior mesenteric plexus and S mansoni in the inferior mesenteric plexus

Terminal stage of schistosomiasis

Liver cirrhosis is the prominent syndrome

of this stage According to the manifestations , it can be divided into three types: The type of giant spleen The type of ascites The type of dwarf

Ectopic Lesion
Schistosomiasis in lungs:

found in acute schistosomiasis, by egg deposition. Symptoms are light and signs are not clear Schistosomiasis in brain: Acute type: encephalomeningitis Chronic type: focal epilepsy

Laboratory Findings

Blood Routine Test

Acute stage :eosinophilia is characteristic

change.WBC raise to 10-30G/L Chronic stage:eosinophil slightly or moderate rise Terminal stage: WBC and platelets are lower

Liver Function Test

Acute stage: serum globulin rise, ALT

slightly rise Chronic stage: most patients have a normal liver function, especially asymptomatic Terminal stage: serum ALB descend caused by liver cirrhosis

Stool Test
The discovery of eggs in stool is the evidence of

diagnosis by direct smear or other methods

Imaging test
B-ultrasound: the degree of liver cirrhosis CT: the image of liver and brain X-ray: chest; esophagus; and gastrointestinal

tract

Biopsy by Rectal Endoscope Immunological Test

Intracutaneous test Circumoval precipition test ELISA and IHA etc.

Monoclonal antibody technique

Complications

Complications of Liver Cirrhosis

Varicosity of esophagus-fundus-stomach

Hemorrhage of upper gastrointestinal tract

Hepatic encephalopathy (HE) Spontaneous bacteria peritonitis (SBP)

Complications of intestinal tract

Appendicitis

Intestinal obstruction and cancroid change

Diagnosis
Epidemiologic date: occupation, history of

travel to endemic area, contact with infected water Clinical date: Acute stage; chronic stage; terminal stage Laboratory findings: Blood Rt; characteristic eggs in feces; biopsy; positive immunological test

Differential Diagnosis
Acute schistosomiasis: typhoid fever; amebic

liver abscess; tubercular peritonitis; miliary tuberculosis; bacillary dysentery; malaria;etc. etiology test and X-ray of chest are diagnostic. Chronic schistosomiasis:anicteric viral hepatitis;amebic dysentery; chronic bacillary dysentery; Terminal schistosomiasis: portal liver cirrhosis and necrosis liver cirrhosis

Prognosis
Factors affect the prognosis:

The continuance of infection The last of pathogenesis The age of the patients The complications

Treatment

Pathogenic Treatment
Praziquantel is the best choice of drug for the

therapy of schistosomiasis Dose: chronic schistosomiasis 10mg/kg, tid. Po, for 2 days, total 60mg/kg Acute schistosomiasis 10mg/kg,tid. po,for 4 days, total 120mg/kg Vice reaction: slight and short.

Heteropathy
Acute schistosomiasis: rest, nutrition, and

supportive theraphy. Cortical hormone can be used in minidose for severe toxic symptoms. Terminal schistosomiasis: treated as liver cirrhosis, and treat for complications

Prevention
Control of the source of infection:

Treat the patients and domestic animal at the same time. Cut off the route of transmission: Snail control Sanitary disposal of human excreta Protect of susceptive people:avoid the contact with schistosome-infected water