Schistosomiasis a common diagnosis in tanzania
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Schistosomiasis: A Common Diagnosis in Tanzania . Anna Person, MD PGY-3. 43 year old male presents to Kilimanjaro Christian Medical Centre in Moshi, Tanzania…. One week of melena Progressive abdominal distension One day of hemetemesis No hx of fever, cough, diarrhea

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43 year old male presents to kilimanjaro christian medical centre in moshi tanzania l.jpg
43 year old male presents to Kilimanjaro Christian Medical Centre in Moshi, Tanzania…

  • One week of melena

  • Progressive abdominal distension

  • One day of hemetemesis

  • No hx of fever, cough, diarrhea

  • Works as a farmer in the rice paddies

  • No past medical history

  • No medications

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Exam Centre in Moshi, Tanzania…

  • BP 86/50, HR 121, Temp 36.5 C, RR 21

  • Thin male in mild distress

  • HEENT- pale conjunctiva

  • CV- regular rate and rhythm, no murmurs

  • Pulm- clear to ascultation bilaterally

  • Ab- distended, dullness to percussion, palpable, enlarged liver and spleen

  • Ext- no edema

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Studies Centre in Moshi, Tanzania…

  • Hb- 5, Hct- 15

  • Abdominal US- markedly enlarged spleen, somewhat enlarged liver, heterogenous in appearance

  • Endoscopy (available at KCMC)- bleeding esophageal varices identified

Schistosomiasis l.jpg
Schistosomiasis Centre in Moshi, Tanzania…

  • Trematode infecting over 200 million worldwide1

  • Transmitted through skin while wading in freshwater

  • S. hematobium (Africa and Middle East) kidney and bladder

  • S. mansoni (Africa, ME, Carribean, S. America), japonicum (Asia), mekongi (Asia) liver

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Life Cycle of Schistosomes Centre in Moshi, Tanzania…

Life cycle l.jpg
Life Cycle Centre in Moshi, Tanzania…

  • Females produce eggs which release larvae into water

  • Larvae seek out snails and become sporocyts and then cercarial larvae

  • Cercarial larvae leave the snail and penetrate intact skin of humans

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Transmission Centre in Moshi, Tanzania…


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Transmission, cont. Centre in Moshi, Tanzania…

  • Once in humans they become schistosomulae

  • These migrate into the arterial circulation

  • Then they reach the liver and mature into adults (within 4 weeks)

  • Worms can live up to 30 years2

Acute schistosomiasis katayama fever l.jpg
Acute Schistosomiasis (Katayama fever) Centre in Moshi, Tanzania…

  • Usually occurs 14-84 days from initial contact

  • Fever, headache, myalgias, bloody diarrhea, abdominal pain, hives

  • Respiratory symptoms can occur in up to 70% of those infected with S. mansoni3

  • A clinical diagnosis antibody titers can take 3 months to be positive5

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Acute schistosomiasis: case report Centre in Moshi, Tanzania…4

  • 16 patients between ’94-’95

  • All had been in sub-Saharan Africa

  • Dominant symptoms were fever, lethargy

  • Symptoms began on average 36 days after exposure

  • 14/16 had eosinophilia, 12/16 had negative stool microscopy

  • All were treated with praziquantel, 8 required further courses of tx

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Chronic Schistosomiasis Centre in Moshi, Tanzania…

  • Long-term sequelae caused by granuloma formation (immune response to antigens from schistosome)6

  • Small subset with high burden of organisms (S. mansoni and S. japonicum) develop periportal fibrosis causes portal hypertension, esophageal varices, etc

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Chronic Schistosomiasis, cont. Centre in Moshi, Tanzania…

  • S. hematobium infections hematuria, fibrosis of bladder and ureters, effects on kidneys (protenuria)

  • Causes many types of bladder cancer 75% are squamous, 20% are transitional cell, 5% are adenocarcinoma, more common in men than women7

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Genitourinary Schistosomiasis: a study at KCMC Centre in Moshi, Tanzania…

  • Retrospective analysis of pathologic specimens from 1999-2005 at KCMC in Moshi, Tanzania8

  • Schistosomiasis diagnosed histo-pathologically in 423 specimens

  • 125 of these specimens were found in female genitourinary tract (cervix in 71 cases)

Burden of genitourinary schistosomiasis l.jpg
Burden of genitourinary schistosomiasis Centre in Moshi, Tanzania…

  • Main symptoms reported were bleeding (48%), ulcer (17%), tumor (20%), lower abdominal pain (11%), and infertility (7%).

  • Authors conclude that genitourinary schisto is underrecognized cause of disease burden in women in Moshi, Tanzania

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Diagnosis Centre in Moshi, Tanzania…

  • Sometimes a clinical diagnosis if other tests not available

  • Peripheral eosinophilia can be suggestive

  • Microscopic examination of feces and urine for eggs sensitivity unknown

  • Serologic tests for antischistosomal antibodies, ELISA tests reported to be >90% sensitive and >95% specific

  • PCR not widespread

Treatment l.jpg
Treatment Centre in Moshi, Tanzania…

  • Praziquantel.

  • 20mg/kg po bid for 1 day (two total doses) for S. hematobium, intercalatum, and mansoni

  • 20mg/kg po tid for 1 day (three total doses) for S. japonicum and S. mekongi9

  • Steroids often used w/ praziquantel in acute schisto

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Reducing Morbidity Centre in Moshi, Tanzania…

  • Burkina Faso, Mali and Niger annual mass-treatments of schoolchildren w/ praziquantel. In Burkina Faso, prevalence went from 90% to <5% after one year.10

  • WHO has adopted a Resolution 54.19, which aims to treat 75% of all school-age children at risk for morbidity due to schistosomiasis by 201011.

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References Centre in Moshi, Tanzania…

  • 1,3 Ross, A et al: Current Concepts: Schistosomiasis. N Engl J Med 346:1212, 2002

  • 2 Arnon, R. Life span of parasite in schistosomiasis patients. Isr J Med Sci 1990; 26:404.

  • 4,5 Doherty, JF et al. Lesson of the Week: Katayama fever: an acute manifestation of schistosomiasis. BMJ 1996;313(7064):1071.

  • 6 Boros DL, et al. Delayed hypersensitivity-type granuloma formation and dermal reaction induced and elicited by a soluble factor isolated from Schistosoma mansoni eggs. J Exp Med 1970;132:488-507.

  • 7 Ghoneim MA, Radical cystectomy for carcinoma of the bladder: critical evaluation of the results in 1,026 cases. J Urol. 1997 Aug;158(2):393-9.

  • 8 Swai, B et al. Female genital schistosomiasis as an evidence of a neglected cause for reproductive ill-health: a retrospective histopathological study from Tanzania. BMC Infectious Disease 2006, 6:134.

  • 9 Gilbert et al. The Sanford Guide to Antimicrobial Therapy: 36th Edition, 2006.

  • 10 Garba, A et al. Implementation of national schistosomiasis control programmes in West Africa. Trends in Parasitology. 2006 July; Volume 22, Issue 7, 322-326.

  • 11 Weekly Epidemiological Record, No.16; 2006, 81, 145-164.