THE CLINICAL THE CLINICAL PICTURE, DIAGNOSIS PICTURE, DIAGNOSIS AND TREATMENT OF AND TREATMENT OF SCHISTOSOMIASISSCHISTOSOMIASIS

PROF. S. M. BHATTPROF. S. M. BHATT

DEPARTMENT OF DEPARTMENT OF MEDICINEMEDICINE

UNIVERSITY OF NAIROBIUNIVERSITY OF NAIROBI

NAIROBI KENYANAIROBI KENYA

EPIDEMIOLOGY OF EPIDEMIOLOGY OF URINARY URINARY

SCHISTOSOMIASISSCHISTOSOMIASIS S. Haematobium- the fluke responsible S. Haematobium- the fluke responsible

for urinary tract manifestations is for urinary tract manifestations is endemic in Africa, S.W. Asia and Middle endemic in Africa, S.W. Asia and Middle East countries East countries

The Bulinus snail acts as intermediate The Bulinus snail acts as intermediate hosthost

The spread of disease to non endemic The spread of disease to non endemic areas by travelers / migrant worker areas by travelers / migrant worker

Associated with dams, irrigation schemes Associated with dams, irrigation schemes rivers because snails breed in fresh waterrivers because snails breed in fresh water

CONTINUATION OF CONTINUATION OF EPIDEMIOLOGYEPIDEMIOLOGY

The linear rise (with increasing age) in The linear rise (with increasing age) in both prevalence and intensity of both prevalence and intensity of infection. Pick infection levels found infection. Pick infection levels found among children aged 12 to 15 years. among children aged 12 to 15 years.

Infection with S. Haematobium has the Infection with S. Haematobium has the highest prevalence of associated highest prevalence of associated disease.disease.

Is a cause of death in 1 to 2 per 1000 Is a cause of death in 1 to 2 per 1000 individuals per year, and is estimated to individuals per year, and is estimated to contribute, through renal disease, to 1 contribute, through renal disease, to 1 to 3 % of deaths. to 3 % of deaths.

THE CLINICAL THE CLINICAL SYNDROMES OF URINARY SYNDROMES OF URINARY

SCHISTOSOMIASISSCHISTOSOMIASIS Cercarial dermatitis [swimmers itch Cercarial dermatitis [swimmers itch

or kabure itch] or kabure itch] Katayama syndrome [appear 3-6 Katayama syndrome [appear 3-6

weeks after the penetration of weeks after the penetration of cercarie. Presenting with fever, cercarie. Presenting with fever, cough, headache, sweating, cough, headache, sweating, abdominal pains, tender hepato- abdominal pains, tender hepato- splenomegaly, high eosinophilia splenomegaly, high eosinophilia

The commonest presentation is The commonest presentation is terminal haematuria [sometimes terminal haematuria [sometimes uniform or microscopic]uniform or microscopic]

Haematuria initially painless Haematuria initially painless

CONTINUATION OF CONTINUATION OF CLINICAL SYNDROMECLINICAL SYNDROME

Burning micturation and hypogastric Burning micturation and hypogastric painpain

Ureteric colic [due to the passage of Ureteric colic [due to the passage of coagulated blood from a source of coagulated blood from a source of bleeding situated high up in the bleeding situated high up in the ureter] ureter]

Pain and burning sensation in the Pain and burning sensation in the epigastrium- due to involvement of the epigastrium- due to involvement of the submucosa of the stomach submucosa of the stomach

High urinary blood and protein levels High urinary blood and protein levels are related to intensity of infection and are related to intensity of infection and lower urinary tract pathologylower urinary tract pathology

COMPLICATIONS OF S. COMPLICATIONS OF S. HAEMATOBIUMHAEMATOBIUM

Pyelonephritis, glomerulonephritis Pyelonephritis, glomerulonephritis nephrotic syndrome nephrotic syndrome

Long standing urinary schistosomiasis Long standing urinary schistosomiasis lead to reduced bladder capacity lead to reduced bladder capacity

Ureters liable to stenosis especially Ureters liable to stenosis especially around their orifices causing partial around their orifices causing partial obstruction to urine flow obstruction to urine flow

Secondary bacterial infection may occur Secondary bacterial infection may occur Hydroureter, hydronephrosis, Hydroureter, hydronephrosis,

pyelonephrosis, bladder / ureter pyelonephrosis, bladder / ureter calcificationcalcification

CONTINUATON OF CONTINUATON OF COMPLICATIONSCOMPLICATIONS

Carcinoma of bladder [squamous cell Carcinoma of bladder [squamous cell type]type]

Other system involvementOther system involvement- Pulmonary hypertension, fibrosis, cor-Pulmonary hypertension, fibrosis, cor-

pulmonale pulmonale - Myelitis / spinal tumour / space Myelitis / spinal tumour / space

occupying lesion due to granuloma occupying lesion due to granuloma - Infertility in women from granulomata Infertility in women from granulomata

blocking the fallopian tubes blocking the fallopian tubes - Salmonella septicaemia [organisms Salmonella septicaemia [organisms

incorporated into adult worms]incorporated into adult worms]

COMPLICATIONS OF COMPLICATIONS OF SCHISTOSOMIASIS SCHISTOSOMIASIS

MANSONIMANSONI Portal hypertensionPortal hypertension Oesophageal varicesOesophageal varices Splenomegaly Splenomegaly Ascites Ascites Granulomatous lesions in the brain, Granulomatous lesions in the brain,

spinal cord and lungsspinal cord and lungs

DIAGNOSIS OF URINARY DIAGNOSIS OF URINARY SCHISTOSOMIASISSCHISTOSOMIASIS

Urine sedimentation [passed around Urine sedimentation [passed around mid-day], examine for ova S. mid-day], examine for ova S. HaematobiumHaematobium

Miracidal hatching testMiracidal hatching test Rectal mucosal biopsyRectal mucosal biopsy Cystoscopy- demonstrate fibrosis, polyps Cystoscopy- demonstrate fibrosis, polyps

haemorrhagic spots, and later “ sandy haemorrhagic spots, and later “ sandy patches” [dead eggs and calcified areas] patches” [dead eggs and calcified areas]

Bladder wall biopsy will confirm Bladder wall biopsy will confirm carcinoma carcinoma

Straight x-ray abdomen show bladder Straight x-ray abdomen show bladder calcification [foetal head calcification]calcification [foetal head calcification]

FURTHER FURTHER INVESTIGATIONSINVESTIGATIONS

I.V.U.I.V.U. Chest x-rayChest x-ray Barium studiesBarium studies MyelographyMyelography Immunodiagnostic tests [skin test, Immunodiagnostic tests [skin test,

complement fixation test, gel complement fixation test, gel diffusion] provide supportive diffusion] provide supportive evidenceevidence

Haemogram [eosinophilia in early Haemogram [eosinophilia in early stages of the disease but constant stages of the disease but constant finding in the bone marrow]finding in the bone marrow]

LABORATORY DIAGNOSIS LABORATORY DIAGNOSIS FOR S. MANSONIFOR S. MANSONI

Stool examination directly Stool examination directly Concentration method using formalin-Concentration method using formalin-

ether or Kato-testether or Kato-test Rectal snipRectal snip Serology – ELISA test (using soluble Serology – ELISA test (using soluble

egg antigen) egg antigen)

TREATMENT OF URINARY TREATMENT OF URINARY SCHISTOSOMIASIS SCHISTOSOMIASIS

Drug of choice [currently Drug of choice [currently recommended by W.H.O.] recommended by W.H.O.] Praziquantel – dose 40 mg/kg, once Praziquantel – dose 40 mg/kg, once after meal [expensive]after meal [expensive]

Side effects – slight abdominal Side effects – slight abdominal discomfort, nausea, headache, slight discomfort, nausea, headache, slight drowsiness drowsiness

Metrifonate [organophosphate group]Metrifonate [organophosphate group]-dose 10mg/kg orally once at night, 3 -dose 10mg/kg orally once at night, 3 courses at 2 weeks intervalcourses at 2 weeks interval

CONTINUATION OF CONTINUATION OF TREATMENTTREATMENT

Side effect of Metrifonate due to Side effect of Metrifonate due to depressed acetylcholine levels in blooddepressed acetylcholine levels in blood

Thus cholinergic symptoms- fatigue, Thus cholinergic symptoms- fatigue, muscle weakness/tremor, sweating, muscle weakness/tremor, sweating, abdominal colic, diarrhoea , vomiting abdominal colic, diarrhoea , vomiting

Due to recent widespread resistance Due to recent widespread resistance to Metrifonate W.H.O. does not to Metrifonate W.H.O. does not recommend its userecommend its use

Antischistosomal drugs are mutogenic Antischistosomal drugs are mutogenic thus carcinogenic; not used in thus carcinogenic; not used in pregnancy pregnancy

CONTROL MEASURES CONTROL MEASURES FOR SCHISTOSOMIASISFOR SCHISTOSOMIASIS

REDUCED EXPOSURE TO INFECTED REDUCED EXPOSURE TO INFECTED WATER WATER

NON-SPECIFIC MEASURES INCLUDE:-NON-SPECIFIC MEASURES INCLUDE:-

- Provision of clean drinking water, - Provision of clean drinking water,

uncontaminated water for washing and uncontaminated water for washing and

recreation recreation

- Reduce water contact by fences, bridges - Reduce water contact by fences, bridges

CONTINUATION OF CONTINUATION OF CONTROL MEASURESCONTROL MEASURES

SPECIFIC MEASURES INCLUDE REDUCED SPECIFIC MEASURES INCLUDE REDUCED INFECTION IN WATER: INFECTION IN WATER:

Control of snails Control of snails

[I] reduction of snail breeding [I] reduction of snail breeding

[II] chemical control using [II] chemical control using molluscides molluscides

[III] biological methods [fish, [III] biological methods [fish, competitor competitor

snailssnails]]

CONTINUATION OF CONTINUATION OF CONTROL MEASURESCONTROL MEASURES

REDUCE CONTAMINATION OF WATER REDUCE CONTAMINATION OF WATER

- NON-SPECIFIC MEASURES - NON-SPECIFIC MEASURES INCLUDE:- Building and use of INCLUDE:- Building and use of latrines so as to avoid defecating or latrines so as to avoid defecating or urinating in and around open water. urinating in and around open water.

-SPECIFIC MEASURES INCLUDE:- -SPECIFIC MEASURES INCLUDE:- Mass treatment of the Mass treatment of the community, education of the community, education of the community, individual diagnosis and community, individual diagnosis and treatment. treatment.

CONTINUATION OF CONTINUATION OF CONTROL MEASURESCONTROL MEASURES

Artemether may be used in both Artemether may be used in both control and treatment of control and treatment of schistosomiasis in areas where there schistosomiasis in areas where there is no regular malaria transmissionis no regular malaria transmission

Combination of both Praziquantel and Combination of both Praziquantel and Artemether may be usedArtemether may be used

Praziquantel affects adult worms while Praziquantel affects adult worms while Artemether kill SchistosomulaArtemether kill Schistosomula

Vaccine development in progress Vaccine development in progress