outline
Introduction
Pathophysiology
Clinical presentation
Investigations
Differential
Diagnosis
Management
Follow up and
prognosis
References
Introduction
Dfn:- An acute and chronic
inflammatory disorder caused by
human infection with trematode
worms of the genus schistosoma.
Also known as Bilharziasis after
Theodor Bilharz-identified the
parasite in 1852
Epidemiology
Schistosomiasis is the second most important
parasitic infection after malaria in terms of its
social economic impact.
It affects more than 240 million people world wide
with 90% cases in sub-Saharan Africa.
In Uganda S.mansoni is the commonest species
with more than 7 million people infected and 17
million leaving at risk.
S. mansoni was observed and reported in kuluva
hospital in Arua district in north western Uganda
as early as the 1900’s.
Epidemiology cont.…
Prevalent in tropical and subtropical areas,
poor communities without access to safe
water and proper sanitation
Children are more vulnerable due to lack of
hygiene, play habits like swimming/ fishing in
infested waters
Especially school going and pre-school
children.
Species and distribution
Five schistosome species infect humans:
Schistosoma haematobium,S.japonicum,
S.intercalatum, S.mekongi and S.mansoni
SPECIES DISTRIBUTION
Intestinal S. mansoni Africa, the
schistosomiasi Middle East, the
s Caribbean,
Brazil,
Venezuela and
Suriname
S. Japonicum China,
Indonesia,
Philippines
S. Mekongi D.R.C,
Cambodia
S. intercalatum Central Africa
Urogenital S. Haematobium Africa, middle
schistosomiasi East, France
Pathophysiology
Paediatric Schistosomiasis
majorly takes on one or two
forms; Intestinal (S. mansoni or
S. japonicum), Urogenital (S.
haematobium)
Different schistoma species are
prevalent in different geographical
regions
Life cycle
Schistosomes are digenetic, with two hosts,
man(definitive host for sexual reproduction)
and some snail species as the intermediate
host for asexual reproduction.
Humans become infected through
penetration of their skin by cercaria rather
than through oral ingestion.
Thecercaria, motile, forked-tail organisms
emerge from infected snails to penetrate
intact human skin.
Life cycle cont.…
Adultworms migrate to
specific anatomic sites
characteristic of each
schistosome species:
The human schistosomes can
infect other vertebrates and
provide an animal reservoir of
infection (S.japonicum)
Life cycle cont.…
Schistosoma eggs are eliminated within
feces or urine, depending on the species.
Eggs hatch and release miracidia, which
swim and penetrate specific snail intermediate
hosts-two generations of sporocysts and the
production of cercariae in the snail.
The infective cercariae are released(4-12
wks.)later, they penetrate the skin of the
human host , and shed their forked tails,
becoming schistosomulae.
Life Cycle Cont.…
Schistosomulae migrates: via venous
circulation to lungs, heart, and then develops
in the liver, and exits via the portal vein
system when mature.
Sexual stage: Male and female adult worms
copulate and reside in the mesenteric venules
(S. japonicum -superior mesenteric veins
draining the Small intestine, S. mansoni-
inferior mesenteric veins of the large intestine,
S. mansoni- pelvic plexus of the urinary
bladder)
Cont.…
Theeggs are moved progressively
towards the lumen of the
intestines(S. mansoni,S. japonicum,
S. mekongi, S. intercalatum) and of
the bladder and ureters (S.
haematobium), and are eliminated
with feces or urine, respectively.
THE CYCLE CONTINUES!!!!!!!
Granuloma formation
Not
all schistosome eggs are excreted from the
body
50% can embolize to other body areas forming
granulomas, causing ulceration in host
tissues(bladder and intestine)
Mostcommon sites are the liver and the
bladder
Otherless affected sites are the lungs, CNS and
kidneys
They involve the delayed hypersensitivity type
of Type 1 (Th1) and Type 2(Th2) helper cell
responses with local cytokine production
Life cycle
Clinical presentation
Symptoms of schistosomiasis are not
caused by the worms themselves but by
the body’s reaction to the eggs.
Takes two clinical syndromes;
Intestinal (S. mansoni or S.
japonicum)
Urogenital (S. haematobium)
Incubation period 14-84 days
Many infections are asymptomatic.
Clinical Cont.…
Schistosomal dermatitis/
swimmer’s itch A local cutaneous
hypersensitivity reaction with an itchy
maculopapular lesions occurs
following skin penetration by cercariae
Occasionally, systemic
hypersensitivity reaction may occur
weeks after the initial
infection(Katayama fever),
especially by S. mansoni and S.
japonicum
Katayama fever
A.k.a acute schistosomiasis, mostly
in heavily infested individuals, 4-8
weeks after exposure.
Isa febrile illness due to oviposition
and early infection
Characterized by a serum- like
syndrome with acute onset of
fever, cough, chills, sweating,
abdominal pain, lymphadenopathy,
hepatomegaly and eosinophilia.
chronic Intestinal
presentation
Colicky abdominal pain
Bloody diarrhea
Hematemesis
Hepatomegaly
Portal hypertension
Ascites
Non- organ specific
symptoms
Anemia
Chronic pain
Diarrhea
Exercise intolerance
Chronic under nutrition(growth
stunting)
Chronic Urogenital
presentation
Urinary frequency, dysuria,
terminal hematuria
Referred suprapubic pain
Complications
Female genital schistosmiasis-
granulomatous inflammatory response,
contact bleeding, pain and infertility-
starts at 10 years
Male schistosomiasis-
hematospermia, pain, lumpy semen.
Liver disease- due to granuloma
formation and periportal fibrosis.
Eggs in lungs causes pulmonary HTN
and cor pulmonale.
CNS seizures due to CNS migration of
eggs.
NOTE
Advanced stages of
urogenital schistosomiasis
are associated with chronic
renal failure, secondary
infections and squamous
carcinoma of the bladder
Investigations
Urinalysis-around 10 mls of urine collected
at midday(time of maximum egg
deposition)
Stoolanalysis (blood, melena, eggs
depending on worm burden)
CBC (eosinophilia, thrombocytopenia,
anemia)
Prolonged PT
Normal or slightly elevated serum bilirubin
and transaminases
Lab cont.…
The unique schistosome antigens
circulating anodic antigen (CAA)
and circulating cathodic antigen
(CCA) may also be detected in the
urine or plasma.
PCR assays- 99.9% specific, 94.4%
sensitive for the diagnosis of
schistosomiasis.
Imaging.
CT ( R/O pulmonary disease and
brain involvement)
Ultrasonography
MRI (granulomas in brain,
lungs, liver, spinal cord—ring
enhancing lesions)
Imaging cont…
IV pyelography
(hydronephrosis, calcifications
and filing defects)
Endoscopy, sigmoidoscopy,
bronchoscopy, colonoscopy
Histology of liver biopsy
Differential diagnosis
Peptic ulcer disease
Pancreatitis
Visceral leishmaniasis
Myeloproliferative
syndromes
Tropical splenomegaly
Management(pharmacolo
gical)
Praziquantel 20mg/kg BD on day 1
for S.haematobium, S intercalatum,and S
mansoni
20mg/kg orally TDS on day 1 for S
japonicum and S mekongi.
Children<5 years may need 60mg/kg/day
to achieve clearance
Mgt cont.…
Monitorpatients for seizures or
neurologic sequelae
Corticosteroids
to control post
treatment inflammation
Give second dose of drug 4-6weeks
after 1st dose because immature
forms are less susceptible
Surgical management
Surgery (resection of bladder and
colonic polyps)
Correction of obstructive uropathy
Partial colectomy for intestinal polyps
Resection of cerebral cortical
granulomas after failure of
chemotherapy
Surgical mgt cont.…
Placement of a distal spleno-
renal shunt for reversal of Portal
Hypertension
Consult with other specialist…
Follow up and prognosis.
Prognosis is generally good
Acute schistosomiasis is associated with a
mortality rate of up to 25% in some series
Repeat stool and urinalysis for 1 year post
treatment for decreased egg excretion
Monitor antigen levels
Prevention.
Currently no vaccine against schistosomiasis
Prevention can be achieved by reducing the
parasite load in the population by single dose
anti parasitic.
Focal application of molluscicidals
Animal vaccination
Creating awareness about the risks and
access to clean water and proper sanitation
are the best prevention measures to
overcome the burden.
Reduce exposure to contaminated water
references
Kleigman.R.M, ST Geme III.J.W, Blum.N,2019.
Nelson Textbook of Paediatric 20th Edition, Pg.
1745-1747
World Health Organization. (2023, February,1st).
Schistosomiasis. Retrieved from
https://www.who.int/news-room/fact-sheets/detail/
schistosomiasis#:~:text=Schistosomiasis%20is%
20an%20acute%20and%20chronic%20parasitic%
20disease%20caused%20by,will%20reduce%20an
d%20prevent%20morbidity
.
Center for Disease Control. (2020,October, 28th).
Parasites- Schistosomiasis. Retrieved from
https://www.cdc.gov/parasites/schistosomiasis/he
alth_professionals/index.html#:~:text=If%20the%
20pre%2Dtreatment%20stool,to%20help%20confi
rm%20successful%20cure
