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ESSENTIALS OF DIAGNOSIS

  • History of freshwater exposure in an endemic area.

  • Acute schistosomiasis: fever, headache, myalgias, cough, urticaria, diarrhea, and eosinophilia.

  • Intestinal schistosomiasis: abdominal pain, diarrhea, and hepatomegaly, progressing to anorexia, weight loss, and features of portal hypertension.

  • Urinary schistosomiasis: hematuria and dysuria, progressing to hydronephrosis and urinary infections.

  • Diagnosis: characteristic eggs in feces or urine; biopsy of rectal or bladder mucosa; positive serology.

GENERAL CONSIDERATIONS

Schistosomiasis, which affects more than 200 million persons worldwide, leads to severe consequences in 20 million persons and about 100,000 deaths annually. The disease is caused by six species of trematode blood flukes. Five species cause intestinal schistosomiasis, with infection of mesenteric venules: Schistosoma mansoni, which is present in Africa, the Arabian peninsula, South America, and the Caribbean; Schistosoma japonicum, which is endemic in China and Southeast Asia; Schistosoma mekongi, which is endemic near the Mekong River in Southeast Asia; and Schistosoma intercalatum and Schistosoma guineensis, which occur in parts of Africa. Schistosoma haematobium causes urinary schistosomiasis, with infection of venules of the urinary tract, and is endemic in Africa and the Middle East. Transmission of schistosomiasis is focal, with greatest prevalence in poor rural areas. Control efforts have diminished transmission significantly in many areas, but high-level transmission remains common in sub-Saharan Africa and some other areas. Prevalence of infection and illness typically peaks at about 15–20 years of age.

Humans are infected with schistosomes after contact with freshwater containing cercariae released by infected snails (eFigure 35–15). Infection is initiated by penetration of skin or mucous membranes. After penetration, schistosomulae migrate to the portal circulation, where they rapidly mature. After about 6 weeks, adult worms mate, and migrate to terminal mesenteric or bladder venules, where females deposit their eggs. Some eggs reach the lumen of the bowel or bladder and are passed with feces or urine, while others are retained in the bowel or bladder wall or transported in the circulation to other tissues, in particular the liver. Disease in endemic areas is primarily due to a host response to eggs, with granuloma formation and inflammation, eventually leading to fibrosis. Chronic infection can result in scarring of mesenteric or vesicular blood vessels, leading to portal hypertension and alterations in the urinary tract. In previously uninfected individuals, such as travelers with freshwater contact in endemic regions, acute schistosomiasis may occur, with a febrile illness 2–8 weeks after infection.

eFigure 35–15.

Life cycle of Schistosoma. Eggs are eliminated with feces or urine image. Under optimal conditions the eggs hatch and release miracidia image, which swim and penetrate specific snail intermediate hosts image. The stages in the snail include two generations of sporocysts image and the production of cercariae image. Upon release from the snail, the infective cercariae swim, penetrate the skin of the human host image, and shed their forked tail, becoming schistosomulae image. The schistosomulae migrate through several tissues and stages to their residence ...

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