Schistosomiasis
Schistosomiasis (also known as bilharzia,
bilharziosis or snail fever) is a chronic parasitic
disease caused by several species of flatworm of the
genus Schistosoma and can cause liver, intestinal and
urinary damage.
• Schistosomiasis is known in many countries, after
Theodor Bilharz, who first described the cause of
urinary schistosomiasis in 1851.
• It is most commonly found in Asia, Africa, and
South America, especially in areas with water that
is contaminated with freshwater snails, which may
carry the parasite.
Types
There are five species of flatworms that cause
schistosomiasis.
• Schistosoma mansoni and Schistosoma
intercalatum cause intestinal schistosomiasis
• Schistosoma haematobium causes urinary
schistosomiasis
• Schistosoma japonicum and Schistosoma mekongi
cause Asian intestinal schistosomiasis.
Each causes a different clinical presentation of the
disease.
Sucker
Spiny inside of the sucker
Schistosoma mansoni - is cause of
intestinal schistosomiasis
Morphology
• The male is 10 to 12 mm long, and has
gynaecophoric canal or schist in which
may be tubercules or spikes.
• The shorter and flatter male envelopes
the female in schist.
• The female is to 15 mm long. In a short
uterus usually only one egg.
• The eggs are ellipsoidal with a lateral
spine.
• The size of eggs is 0,14 – 0,16 mm х
0,06 – 0,07 mm.
Geographical distribution
• Schistosoma mansoni is found in parts of South
America and the Caribbean, Africa, and the Middle
East;
Schistosoma haematobium
causes urinary schistosomiasis
Morphology
• The male is 10 to 15 mm long, and has
gynaecophoric canal or schist in which
may be tubercules or spikes. There are
many papillars on the helminthes body.
• The female is more longer (to 20 mm)
and thin than male worm. The uterus
contains from 20 to 30 eggs.
• The eggs are large, colorless, fusiform
and have a terminal spine.
• The size of eggs is 0,12 – 0,19 mm х
0,05 – 0,073 mm.
Geographical distribution
• S. haematobium is found in Africa and the Middle East;
Schistosoma japonicum causes
intestinal schistosomiasis
Morphology
• The male is 9,5 to 20 mm long, its schist
is without papillars.
• The female is 15 to 20 mm long. The
uterus contains many eggs.
• The eggs are more spherical form and
have small knob nearly at one of poles.
The size of eggs is 0,075 – 0,106 mm х
0,055 – 0,08 mm.
Geographical distribution
• S. japonicum is found in the Far East
Life cycle
The life cycles of all human
schistosomes are broadly similar:
• parasite eggs are released into the
environment from infected individuals,
hatching on contact with fresh water to
release the free-swimming miracidium.
• Miracidia infect fresh-water snails by
penetrating the snail's foot. After
infection, close to the site of penetration,
the miracidium transforms at first into a
primary (mother) sporocyst and then into
secondary (daughter) sporocysts, which
migrate to the snail's hepatopancreas.
• Once at the hepatopancreas the
secondary sporocyst begin to divide
again and producing thousands of new
parasites, known as cercariae, which are
the larvae capable of infecting mammals.
Life cycle
Life cycle
• During 2 days after penetration • Parasites reach maturity in six to eight
schistosomulum may remain in the weeks, at which time they begin to
skin before locating a post-capillary produce eggs.
venule;
• Many of the eggs pass through the
• Then it travels to the lungs where it walls of the blood vessels, and through
changes to next form and migrates to the intestinal wall, to be passed out of
the liver sinusoids (8-10 days after the body in faeces. S. haematobium
penetration). eggs pass through the ureteral or
bladder wall and into the urine.
• Juvenile S. mansoni and S. japonicum
worms develop an oral sucker after • Up to half the eggs released by the
arriving at the liver, and it begins to worm pairs become trapped in the
feed on red blood cells. mesenteric veins, or will be washed
back into the liver, where they will
• Worm pairs of S. mansoni and S. become lodged. Worm pairs can live in
japonicum relocate to the the body for an average of four and a
mesenteric or rectal veins. S. half years, but may persist up to 20
haematobium schistosomula migrate years.
from the liver to the perivesical
venous plexus of the bladder,
ureters, and kidneys through the
hemorrhoidal plexus.
Developing
schistosome in
liver
Hepatosplenomegaly in
chronic schistosomiasis
Schistosome dermatitis, or "swimmers itch” occurs when skin is
penetrated by a free-swimming, fork-tailed infective cercaria.
Source: WikiMedia.
Eggs of Schistosoma mansoni
in the liver
Cellular reaction around eggs
of Schistosoma mansoni
Egg of S. haematobium
Schistosomaiasis
granuloma
Schistosomaiasis granuloma
Pathology of Schistosomiasis
• Schistosoma haematobium
• Schistosoma mansoni
• Causes urinary schistosomiasis
Causes intestinal schistosomiasis
1. PREPATENT PERIOD 10-12 wks
2. EGG DEPOSITION AND 1. PREPATENT PERIOD 5-7 wks
EXTRUSION: 2. EGG DEPOSITION AND
1. painless haematuria EXTRUSION:
2. Inflammation of bladder and 1. dysentery (blood and mucus in
burning micturition stools),
2. hepatomegaly splenomegaly
3. TISSUE PROLIFERATION AND
REPAIR: 3. TISSUE PROLIFERATION AND
• Fibrosis , papillomata in the REPAIR:Fibrosis ,
bladder and lower ureter leading • Papillomata in intestine,
to obstructive uropathy. • Pperiportal
• Periportal fibrosis fibrosis,hematemesis
• Lung and CNS involvement • Lung and CNS involvement.
Bladder lesions in urinary schistosomiasis
Portal hypertension in chronic
schistosomiasis
Clinical features
• Above all, schistosomiasis is a chronic disease. Many infections are
subclinically symptomatic, with mild anemia and malnutrition being
common in endemic areas. Acute schistosomiasis (Katayama's fever)
may occur weeks after the initial infection, especially by S. mansoni and
S. japonicum. Manifestations include:
• Abdominal pain
• Cough
• Diarrhea
• Eosinophilia - extremely high eosinophil granulocyte count.
• Fever
• Fatigue
• Hepatosplenomegaly - the enlargement of both the liver and the
spleen.
Clinical features
There are 4 stages
1. STAGE OF INVASION: CERCARIAL
DERMATITIS
2. STAGE OF MATURATION: ACUTE
SCHISTOSOMIASIS
3. STAGE OF ESTABLISHED INFECTION
4. STAGE OF LATE INFECTION AND
SEQUELAE
STAGE OF INVASION: CERCARIAL
DERMATITIS
• Penetration of the skin by cercariae, leads to
occurrence of dermatitis (cercarial dermatitis
or «swimmer's itch») and can be associated
the death of cercariae in the skin.
• A transient immediate hypersensitivity
reaction that occurs 10 to 15 min after
exposure is followed by a more prolonged,
delayed reaction, which develops after 12 to
24 h and may persist for up to 15 days.
• The lesion is characterized by a small, red,
pruritic, macular rash, which progresses to
papules, possibly accompanied by vesicle
formation and oedema. Pustules may form if
secondary infection occurs, and residual
pigmentation may persist for months.
• The next symptoms develops a few days after
exposure and can be associated with transient
fever, cough and pulmonary infiltrates, as
well as myalgia and abdominal pain.
STAGE OF MATURATION: ACUTE SCHISTOSOMIASIS
• fever,
• rigors,
• sweating,
• headache,
• malaise,
• muscular aches,
• profound weakness,
• an unproductive,
• irritating cough,
• abdominal pain or swelling,
• nausea, vomiting,
• diarrhoea, and loss of weight.
• pyrexia (intermittent or remittent with evening
peaks),
• oedema,
• a generalized soft lymphadenopathy,
• a tender enlarged liver, enlarged and soft spleen,
stuporose, or show visual impairment or
papilloedema.
• Severe central-nervous manifestations
• Eggs become detectable in the faeces about 6 weeks
after exposure.
STAGE OF ESTABLISHED INFECTION
S. haematobium infection: S. mansoni and S.
• hypogastric discomfort, japonicum infections is very
frequently asymptomatic.
• suprapubic pain,
Classical symptoms include:
• dysuria,
• hypogastric pain,
• haematuria, proteinuria and
pyuria. • diarrhoea, and the
• passage of blood or mucus in the
stool.
• the liver may be enlarged and
tender;
• the spleen may also be enlarged,
but is usually soft.
STAGE OF LATE INFECTION AND
SEQUELAE
Urinary schistosomiasis, S. mansoni and S. japonicum
in the bladder: infections, is associated with:
• calcification, • intermittent diarrhoea, with or
• ulceration, without the passage of blood or
mucus;
• papillomas, • the colon may be tender.
• nocturia, • In between the episodes of
• precipitancy, diarrhoea, the stools are normal.
• retention of urine, • bleeding from oesophageal
• dribbling, varices
• severe pain. • haematemesis,
• The ureteric pathology is usually • melaena.
asymptomatic, but may lead to • Blood loss is frequently
ureteric colic. massive, and exsanguination is
• uraemia. the usual cause of death rather
than hepatic coma.
Laboratory diagnosis
• Microscopic exam:
detection the eggs in the
feces or urine.
• Pelvic x-ray.
• Photomicrography of
bladder in S. hematobium
infection, showing clusters
of the parasite eggs with
intense eosinophilia
Laboratory diagnosis
• Tissue biopsy (rectal
biopsy and biopsy of the
bladder) may
demonstrate eggs when
stool or urine
examinations are
negative.
• Serology test –
Antibody detection.
Treatment
• Praziquantel - is safe and highly
effective in curing an infected patient,
it does not prevent re-infection by
cercariae and is thus not an optimum
treatment for people living in endemic
areas. Praziquantel is universally used.
• Antimony has been used in the past to • Niridazole, is active against all
treat the disease. In low doses, this species of parasite.
toxic metalloid bonds to sulfur atoms
in enzymes used by the parasite and • Metrifonate is an inexpensive
kills it without harming the host. organophosphorus compound
that is active only against S.
• Oxamniquine has been used for haematobium and that can be
treating Schistosoma mansoni. given orally(usually 7.5 mg/kg
body weight, once every 2 weeks
on up to three occasions each
year).
Preventation
• Individual protection against infection is
achieved by avoiding contact with all potentially
contaminated fresh water in endemic areas; for
example, by wearing boots and other
waterproof clothing.
• Such water should be boiled before drinking, or
left to stand for at least 2 days before use for
other purposes such as washing. Should contact
with water occur, the skin should be
immediately rubbed vigorously with a towel;
the water should not be allowed to evaporate,
as this aids cercarial penetration.
• Soap and alcohol also kill cercariae, and
cercaricidal barrier creams can be used.
Diagnosis of
Schistosomiasis
• Schistosoma • Schistosoma mansoni
haematobium • Parasitological
• Parasitological: – Examination of stools
– Examination of urine • Immunological
• Immunological – Serological tests
– Serological tests • Indirect:
• Indirect: – Radiological
– Radiological – endoscopy
– Cystoscopy
