SCHISTOSOMIASIS

Presenter Hizkiel Abera(MD,ImR1)

Moderator Dr. Sisay ( MD+, Assistant Professor of Internal Medicine)

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Outline
• Introduction
• Etiology and Life cycle
• Epidemiology
• Pathogenesis
• Clinical features
• DDx
• Diagnosis
• Treatment and follow-up
• Complication
• Prevention
• Reference's 2
Introduction
Schistosomiasis is a disease caused by infection with parasitic blood
flukes.

Schistosoma infection is contracted through contact with freshwater

bodies harboring infected intermediate-host snails.

Cause considerable intestinal, hepatic, and genitourinary morbidity.

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 Etiology & Life cycle

• The life cycle of schistosomiasis is complex and requires both

intermediate and definitive hosts. Cercariae released from snails in
fresh water penetrate human skin and migrate to the liver, where they
mature into adults.

• The adult worms migrate to the mesenteric venules of the intestine (S.
japonicum and S. mekongi), the colon (S. mansoni), or the vesical
venous plexus (S. haematobium).

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Etiology & Life cycle
• The female worms deposit eggs in the portal or perivesical systems,
which migrate to the lumen of the intestine (S. mansoni and S.
japonicum) or bladder (S. haematobium) and are excreted via stool or
urine, respectively.

• The eggs hatch and release miracidia, which penetrate snail

intermediate hosts; subsequently cercariae are produced.

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 Etiology & Life cycle

• Human schistosomiasis is caused by six

species of the parasitic genus Schistosoma:
S. mansoni, S. japonicum, S. mekongi,
S.intercalatum, and the recently described
S. guineensis and S. haematobium

• When excreted eggs from stool or urine

reach water, they hatch and release a free-
swimming larval stage (miracidium), which,
after penetrating a host snail releases
• Cercariae, the infective larval stage
released from the snail.

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 Epidemiology
• It is estimated that 229 million people
are infected globally and at least 229
million people required preventive
treatment in 2018.
• More than 70% of infected people live
in sub-Saharan Africa.
• S. mansoni occurs in most of sub-
Saharan Africa,
• In Ethiopia, about 5.01 million people
are infected with schistosomiasis and
37.5 million people are at an increased
risk of infection
• It is a poverty-related disease, and
infection is prevalent in areas where
adequate water supplies and sanitary
facilities are lacking. 7
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 Pathogenesis

• Cercarial invasion may be associated with dermatitis arising from

dermal and subdermal inflammatory reactions in response to dying
cercariae that trigger innate immune responses.

• All evidence suggests that schistosome eggs, and not adult worms,
induce the organ-specific morbidity caused by schistosome infections

• Clinical disease is caused by the host immune response to migrating

eggs.

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Pathogenesis…
• Migration of eggs through tissues can be associated with entrapment,
inflammation, and subsequent fibrosis.

• Eggs are carried via the splanchnic venous system and may embolize
to the liver, lungs, spleen, brain, or spinal cord; less common sites of
embolization include the skin and peritoneal surfaces 

• In the bowel, inflammation can result in ulceration, blood loss, and

scarring 

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Pathogenesis…
• In the liver, periportal fibrosis (known as Symmers' pipestem fibrosis)
can lead to portal hypertension and subsequent esophageal varices.

• In the bladder, the eggs provoke granulomatous inflammation,

ulcerations, and development of pseudopolyps in the vesical and
ureteral walls, which may mimic malignancy.

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 Clinical features

• In general, disease manifestations of schistosomiasis occur in three stages—

acute, active, and chronic—according to the duration and intensity of
infection.

• Cercarial Dermatitis (“Swimmer’s Itch”)

• Cercarial penetration of the skin may result in a maculopapular rash called

cercarial dermatitis or “swimmer’s itch.”

• it is rare among people living in endemic areas. Check uptodate!!

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 Clinical features…
• Acute Schistosomiasis (Katayama Fever)-is a systemic
hypersensitivity reaction to schistosome antigens and circulating
immune complexes that occurs three to eight weeks after infection

• usually seen in patients who have contracted the infection for the first
time.

• The symptoms may appear suddenly and include fever, myalgia,

general malaise and fatigue, headache, nonproductive cough, and
intestinal symptoms such as abdominal tenderness or pain.

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Clinical features…
• An elevated eosinophil count (>1000/microL) is almost universally
present within a few days after onset of symptoms

•  Patients with cough and/or dyspnea may have patchy infiltrates on

chest radiograph

• Severe cerebral or spinal cord manifestations may occur.

• Katayama fever is rare in people chronically exposed to infection in

areas endemic for S. mansoni or S. haematobium.
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• Chronic infection - Symptoms of chronic infection often begin
insidiously.

• Major organs with potential involvement include the intestinal tract,

liver, spleen, genitourinary tract, lungs, and central nervous system.

• Intestinal schistosomiasis-chronic or intermittent abdominal pain,

poor appetite, and diarrhea are the most common symptoms.

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Clinical features… A) Pseudopolyps of Schistosoma
hematobium in bladder
B) Pseudopolyps of Schistosoma spp in
Intestinal schistosomiasis rectocolon.

•  Intestinal polyps and dysplasia

can arise due to granulomatous
inflammation surrounding eggs
deposited in the bowel wall

• chronic colonic ulceration may

lead to intestinal bleeding and
iron deficiency anemia 
 

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 Clinical features…
Hepatosplenic Schistosomiasis,
• Portal hypertension with splenomegaly, portocaval shunting, and
gastrointestinal varices.

• Hematemesis is the most severe complication of hepatosplenic

schistosomiasis, and death may result from massive loss of blood.

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Clinical features…

• On physical examination, the liver is firm and nodular.

• Ascites, attributable both to portal hypertension and to

hypoalbuminemia.

• The spleen is enlarged, often massively, and is firm or hard.

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Clinical features…
• Pulmonary schistosomiasis -caused by  portal hypertension which can
lead to development of portosystemic collateral vessels, allowing a
path for embolization of schistosome eggs into the pulmonary
circulation.

• Dyspnea is the primary clinical manifestation.

•  Pulmonary hypertension and cor pulmonale

• These manifestations represent end-stage disease and are generally

irreversible. 19
Clinical features…
• Urogenital Schistosomiasis (S. haematobium),
• A characteristic sign in the active stage is painless, terminal hematuria.

• Dysuria and suprapubic discomfort or pain.

• As the infection progresses, nocturia, urine retention, dribbling, and

incontinence.

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Clinical features…
• The genital organs, most commonly in the cervix and vagina in
women and the seminal vessels in men.

• dyspareunia, abnormal vaginal discharge, contact bleeding, and lower

back pain in women and

• Perineal pain, painful ejaculation, and hematospermia in men.

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Clinical features…
• Neuroschistosomiasis,
• Brain involvement- epileptic seizures, encephalopathy with
headache, visual impairment, motor deficit, and ataxia.

• Spinal cord involvement-lower limb pain, lower motor dysfunction,

bladder paralysis, and bowel dysfunction

• Neuroschistosomiasis is a medical emergency!!

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Differential Diagnoses
• Fever and rash with eosinophilia can be due to other helminthic
parasitic disease or drug reactions. hematuria may also indicate other
disorders like,
Renal tuberculosis
Urogenital tract cancer
Acute nephritis

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Differential…
• Intestinal and liver symptoms may indicate the following disorders
Peptic ulcer disease
Pancreatitis
Visceral leishmaniasis
Myeloproliferative syndromes
tropical splenomegaly

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 Diagnosis
• Eosinophilia is a common finding.

• Anemia may be observed in patients with blood loss 

• Thrombocytopenia may be observed in patients with portal

hypertension

• Liver enzymes are rarely elevated

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 Diagnosis
• Hematuria and/or leukocyturia are common in the setting of S.
haematobium infection

• Detection of schistosome eggs in stool or urine is indicative of active

infection and is the standard diagnostic method.

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Human schistosomiasis eggs:
(A) S. mansoni.
(B) S. hematobium.
(C) S. intercalatum.
(D) S. japonicum.
(E) S. mekongi

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 Diagnosis
• Antigen detection-Soluble schistosome antigen titers correlate well
with infection intensity and with clinical severity of disease.

• they can also be used to assess treatment efficacy, since loss of excreted
antigens indicates cure. Antigen tests become negative 5 to 10 days
following successful therapy

• The diagnosis of neuroschistosomiasis requires laboratory detection of

infection at an extraneural site together with clinical and radiographic
evidence of neurologic involvement.
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 B) Sagittal contrast-enhanced T1-weighted
MRI confirms linear (arrow) and nodular
Diagnosis enhancement pattern in different imaging
plane.
(C) Axial T2-weighted MR image shows
hyperintense mass (arrow) with surrounding
vasogenic edema involving right parietal lobe

• Computed tomography (CT) and

magnetic resonance imaging
(MRI) of the brain generally
demonstrate nonspecific
contrast-enhancing infiltrates
suggestive of tumors

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Diagnosis
• Chest radiography demonstrates fine miliary nodules.

• Echocardiography is useful screening tool for pulmonary

hypertension in patients with hepatosplenic schistosomiasis. 

• Ultrasonography: periportal fibrosis (also known as Symmers'

pipestem fibrosis) 

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Diagnosis
• Ultrasonography of the kidneys and bladder may demonstrate
bladder wall irregularities due to granulomas. Hydronephrosis, bladder
polyps, and tumors can also be detected.

• Cystoscopy- pseudopolyps in the vesical and ureteral walls.

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 Treatment
•  Treatment of schistosomiasis serves three purposes:
reversing acute or early chronic disease,
preventing complications associated with chronic infection, and
preventing neuroschistosomiasis

• Treatment is not beneficial for reversing late-stage fibrosis of the

hepatic or urinary tract or reversing secondary complications such
as esophageal varices or cor pulmonale!!

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 Treatment
• As a general principle, all patients with acute schistosomiasis should
be treated with praziquantel.

• Adverse effects of praziquantel occur in approximately one-third of

patients.

• They include dizziness, headache, vomiting, abdominal pain, diarrhea,

and pruritus.

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 Treatment
• For S. mansoni,, S.intercalatum, and the recently described S.
guineensis and S. haematobium Praziquantel dose of 40mg/kg/day in
two divided dose for 1 day.

• For S. japonicum, S. mekongi Praziquantel 60mg/kg/day in three

divided dose for 1 day.

• In patients who are not cured by initial treatment, the same dose can be
repeated at weekly intervals for 2 weeks.

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 Treatment
• Since praziquantel does not affect the young migrating stages of the
schistosomes, it may be necessary to repeat the dose 6–12 weeks later,
especially if eosinophilia or symptoms persist despite treatment.

• Follow-up after treatment includes monitoring of clinical

manifestations, eosinophil count (in patients with eosinophilia), and
microscopy evaluation for eggs in stool or urine. 

• Presence of viable eggs 6 to 12 weeks after initial therapy warrants

repeat treatment with praziquantel.
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 Treatment
• Neuroschistosomiasis: Prompt corticosteroid treatment (prednisone 1
to 2 mg/kg) is essential to prevent irreversible tissue damage that
occurs as a result of the intense inflammatory response.

•  Corticosteroid therapy should be continued for two weeks to six

months.

• Anticonvulsants are sometimes needed.

•   Praziquantel should be administered a few days after initiation of

corticosteroid treatment 36
 Complications
• Infertility
• Iron deficiency anemia and malnutrition
• Intestinal dysplasia
• Squamous cell carcinoma of bladder
• Immune complex glomerulopathy(Proteinuria and Nephrotic
syndrome)
• Renal failure
• Transverse myelitis

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 Prevention 
• Schistosomiasis control strategies for endemic areas include water
sanitation programs and mass treatment.

• Praziquantel treatment of infected people, often during mass drug-

administration programs, is a cornerstone of the management and
control of schistosomiasis.

• Minimizing contact with fresh water containing infectious cercarial

larvae is an important control measure.

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References
• UpToDate 2018

• Harrison’s principle of internal medicine 21st edition,2022

• Medscape v147.0

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THANK U!!
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