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Schistosomes and other flukes
Rahajeng N. Tunjungputri, MD, MSc
Department of Parasitology Faculty of Medicine Diponegoro University - 2012
Case
A 22-year-old student from Sulawesi presented at the hospital with acute haematemesis
Physical examination revealed marked hepatosplenomegaly
Oesophageal and gastric varices were identified at upper gastrointestinal endoscopy portal hypertension
Trematodes
Schistosomes
S. mansoni
S. japonicum
S. hematobium
Liver flukes
Clonorchis sinensis
Opistorchis sp.
Fasciola hepatica
Intestinal flukes
Fasciolopsis buski, Metagonimus yokogawai, Heterophyes heterophyes
Human schistosomiasis/ bilharziasis
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
Water resource development projects and population movements have spread the disease to non-endemic areas
Global distribution
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
Snail habitat
Schistosomes morphology
Male
9,5 mm x 19,5 mm
Canalis gynecophorus
Female : 16 mm x 26 mm
Thin-shaped
S. mansoni
Habitat
Mesenteric and portal veins
V. mesenterica inferior
S. mansoni
S. mansoni male adult: tegument
S. japonicum
Habitat Mesenteric and portal veins V. mesenterica superior
S. haematobium
Habitat
V. vesicalis
Video
Life cycle
Cercariae penetration
Intensity of infection
Severity of disease
In snails: sporocyst I sporocyst II cercaria
Transmission
Clinical manifestation
Period Affected organ Manifestation
Immediate 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 Schistosomiasis Katayama fever
Systemic Gastrointestinal Lungs Liver, spleen
A history of contact with contaminated water 2-6 weeks before (in travellers) Mediated by the immune complex 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 tests
Chronic shistosomiasis
Especially in people with longstanding infection in poor areas Gastrointestinal and Liver Disease Genitourinary Disease Neurologic and Other Manifestations
Pathogenesis
Egg production commences four to six weeks after infection and continues for the life of the worm — usually three to five years.
Eggs in blood vessels
Tissue Pass the mucosa
Shed in feces (S.m, S.j) and
urine (S.h)
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
Adult in mesenteric
veins
Eggs in venulae/ tissue
Inflammation
Portal hypertension, variceal bleeding
Hepatomegaly Varices Variceal bleeding Splenomegaly
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
Schistosomal dermatitis
http://img.medscape.com/pi/emed/ckb/pediatrics_general/996090-999469-98.jpg
Schistosomal dermatitis
http://upload.wikimedia.org/wikipedia/commons/5/5a/Cercarial_dermatitis_lower_legs.jpg
GU disease
27-year-old man with hematuria and left-sided loin pain who had S. haematobium eggs in his urine
Liver disease
ultrasonogram showing gross hepatic fibrosis (arrows) in a 45-year-old man with severe hepatic schistosomiasis
Diagnosis: Schistosomiasis
Eggs in stool
Multiple samples
Others:
PCR
Serology - ELISA
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
Other liver flukes
Clonorchis sinensis
flattened
10-25 mm long by 3-5 mm wide
ovary
two branches testes
habitat: bile ducts
Opistorchis spp.
Testes: 2, lobular shape
Eggs often indistinguishable from C. sinensis
Habitat: bile ducts
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
Infection:
ingesting the metacercariae in raw or inadequately cooked fish
Fasciola hepatica
large and broadly-flat
up to 30 mm x 15 mm
The anterior end is cone-shaped
Habitat: bile duct
ingesting uncooked aquatic vegetation
Clinical syndromes of F. hepatica infection
• In 6-12 weeks after infection: Marked eosinophilia, abdominal pain, intermittent high fever, weight loss, urticaria
• Tender hepatomegaly, jaundice, anemia
Acute/ Migratory phase
• eosinophilia
• inflammation and intermittent obstruction of bile ducts, cholecystitis, ascending cholangitis
Chronic phase
Diagnosis: other liver flukes
Finding eggs in stool
Multiple samples
Treatment
Schistosomiasis: Praziquantel repeated dose after 4-6 weeks in Katayama fever
Niridazol for schistosomiasis due to toxicity
Case: Examination of stool specimens
Serology
Enzyme immunoassay high levels of serum antibodies to S. mansoni were subsequently detected
Therapy
Endoscopy sclerotherapy
Pharmacotherapy
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.