Spinal Cord Schistosomiasis. MRI Findings Arthur B Dublin, MD, MBA, FACR University of California Davis, Medical Center ASNR 2016 Annual Meeting Poster #:eP-205 Abstract Control Number 2138

I HAVE NO FINANCIAL CONFLICTS OF INTEREST TO REPORT

PURPOSE To present the MRI findings of this disorder To outline the life cycle of this parasite, and its diagnosis and treatment

SCHISTOSOMIASIS Also called Bilharzia after Theodor Bilharz ( ), a German pathologist who described the parasite in Egypt in 1851 Mansoni and Japonicum ova tend to lodge and develop into adults in veins of the liver and small bowel Haematobium ova tend to lodge and develop into adults in veins of bladder wall, which can lead to bladder stones and cancer. (very common in Egypt)

SCHISTOSOMIASIS LIFE CYCLE Courtesy of the Centers for Disease Control and Prevention (CDC)

SCHISTOSOMIASIS Involvement of the spinal cord by Schistosomiasis is very rare The possible routes for spinal involvement are the retrograde venous embolization of ova, or less likely in situ deposition of ova by adult worms showing anomalous migration into the spinal vessels

MATERIALS AND METHODS A USA aid worker traveled to Egypt and had an episode of falling from a canoe into a tributary of the Nile. Presented upon return to the USA (2007) with lower extremity pain and rapidly progressive paraplegia Pre- and post-contrast MRI of the spine was undertaken

Cord edema (arrows), multiple cord leptomeningeal and intramedullary nodules of enhancement (arrows) T2 SAGITTAL T2 AXIAL POST GAD T1 SAGITTAL 2007 MRI STUDY

MRI FINDINGS This case is typical of the disease with cord edema and nodular enhancement of the surface and substance of the spinal cord. In a recent publication (Saleem, at al. AJNR 2005; 26: ) the ova were S. mansoni in three cases, S. Hematobium in one case, and no identifiable ova in 4 cases. –This report showed T1 images of the spinal cord to be hypo- to iso-intense –T2 images were usually hyper-intense cord findings –All nodules showed contrast enhancement

RESULTS CSF analysis in our patient showed elevated white count and protein, but no parasites/ova Blood serum Antibody test for Schistosomiasis from the CDC was positive Treatment was nonsurgical with steroids and anti-Schistosomiasis drugs Praziquantel. Unfortunately, paraplegia persisted in this patient

T2 SAGITTAL T1 POST GAD SAGITTAL RESOLUTION OF CONTRAST ENHANCING NODULES AND CORD EDEMA WITH SOME ATROPHY OF THE THORACIC CORD AFTER MEDICAL TREATMENT MRI 2014 POST TREATMENT

CONCLUSION The MRI findings of Schistosomiasis have been demonstrated and are in agreement with published reports An individual with progressive paraplegia with contrast enhancing spinal cord nodules, and no intracranial tumor, and most importantly, a history of travel to endemic areas, should be considered to posses this disease until proven otherwise. The recovery of ova may be difficult from the CSF, and therefore blood serology testing for Schistosomiasis antibodies is crucial Unless cord swelling is tremendous, decompressive surgery is not recommended, but steroid and anti-schistosomiasis drugs should be initiated

SO, WHEN TRAVELING IN EGYPT TAKE A CAMEL RATHER THAN A CANOE THANK YOU FOR YOU ATTENTION!