1. Case Study: Schistosomiasis
Dr. Jennifer Coetzee
CMID / Ampath

2. Clinical Presentation
8 year old boy
Referred to renal clinic from peripheral hospital
Two year history of painless, macroscopic hematuria
Urine microscopy: eggs of Schistosoma haematobium

3. Objectives Describe the life cycle of the bilharzia parasite
Discuss the pathogenesis of bilharzia as a prototype of a parasitic infection
Briefly describe the principles of the diagnosis and management of this infection

4. Life Cycle of the Schistosome
Life Cycle of the Bilharzia Parasite
Ross A et al. N Engl J Med 2002;346:

5. Pathophysiology and Clinical Disease
Acute disease:
Cercarial dermatitis after penetration of the cercaria
“Swimmers itch” if cercaria from birds involved
After onset of egg laying, may develop acute reaction (Katayama fever) if never exposed before
Symptoms resolve as immune system adapts

6. Chronic Stages Eggs entrapped in host tissues secrete antigens
Incite an inflammatory granulomatous response
Granulomas eventually replaced by dense fibrosis obstruct blood flow
Clinical symptoms vary according to species, total worm burden, patient’s stage of health at time of infection

7. Gastrointestinal Complications
Wall of distal colon damaged as eggs pass through, become lodged
Inflammatory response can cause focal ulcers or polyps
May develop diarrhoea, abdominal pain or colitis
?Predisposing factor for colorectal carcinoma

8. Hepatosplenic Complications
Eggs may incite granulomatous response in liver
May become walled off with dense layers of fibrous tissue
Pipestem fibrosis - obstructs portal veins
Leads to portal hypertension, oesophageal varices, splenomegaly

9. Genitourinary Complications
Eggs lodged in bladder wall - inflammatory infiltrate around the egg
Overlying bladder epithelium hyperplastic, polyps
Polyps erode, ulcerate - cause hematuria
Log standing and severe infections may lead to carcinoma
Fibrosis may lead to ureteric stricturing, hydronephrosis

10. Clinical Findings in Two Patients Infected with Schistosoma Species
Figure 3. Clinical Findings in Two Patients Infected with Schistosoma Species.
Panel A shows loose granuloma formation surrounding a Schistosoma haematobium egg (arrow) in a bladder-biopsy specimen from a 27-year-old man with hematuria and left-sided loin pain who had S. haematobium eggs in his urine (hematoxylin and eosin, x400). The black bar represents 100 {micro}m. In Panel B, a computed tomographic scan of the abdomen of the same patient shows gross bilateral hydronephrosis (arrows) due to ureteric stricturing. The right kidney is atrophic and nonfunctional. In Panel C, an ultrasonogram shows gross hepatic fibrosis (grade 3) (arrows) in a 45-year-old man with severe hepatic schistosomiasis.
Ross A et al. N Engl J Med 2002;346:

11. Other Complications Cardiopulmonary Complications:
Eggs from shunted portosystemic blood lodged in pulmonary arterioles
Granuloma formation, pulmonary hypertension, cor pulmonale
Central nervous system:
Eggs deposited in spinal column transverse myelitis-like syndrome

12. Laboratory Diagnosis Microscopy
Detection of eggs in wet mounts of stool or urine
S. manoni has a lateral spine, S. haematobium has a terminal spine
Rectal or bladder biopsies may be necessary
Also antigen and antibody detection
Antibodies cross react with other helminth infections
Problematic in endemic areas

13. An eight-year-old boy was referred to the nephrology clinic with a two-year history of painless, gross macroscopic hematuria
Kaplan B and Meyers K. N Engl J Med 2000;343:1085

14. Management and Prevention
Anti-schistosomal drugs
Praziquantel
Symptomatic management of complications
Chemoprophylaxis available
Vaccines under development
Snail control!

15. Bibliography
Ross A.G.P., Bartley P.B. et al. Schistosomiasis. New Eng J Med 2002; 346(16):
Coon D.R. Schistosomiasis: Overview of the history, biology, clinicopathology, and laboratory diagosis. Clin Micro Newsletter 27(21):