Correspondence

Schistosomiasis

N Engl J Med 2002; 347:766-768September 5, 2002

Article

To the Editor:

The enormous increase in travel has led to an increase in the number of cases of schistosomiasis in developed countries where the infection is not endemic. Our knowledge of schistosomiasis derives from many studies in countries where it is endemic, as described in the review by Ross et al. (April 18 issue).1 However, in the new population of nonimmune travelers, the disease has a different clinical pattern. Acute schistosomiasis is practically nonexistent in populations in which the infection is hyperendemic, but it is prominent among returning travelers. In the past three years in our clinic, 23 of 41 patients with schistosomiasis (56 percent) presented at this acute stage. Katayama fever is only one of the manifestations of acute schistosomiasis. The pulmonary manifestations include a prolonged, disturbing, dry cough without fever.2 Chest radiography may reveal not only interstitial pneumonitis, as mentioned by Ross et al., but also multiple nodules.

The diagnosis of acute schistosomiasis is challenging, since it involves the period soon after exposure and before oviposition occurs. Thus, the standard method of diagnosis — the detection of eggs — is ineffective. Until antigen methods become available, serologic tests should be used to detect schistosomiasis in travelers, since most travelers have not previously been exposed.

Currently, there is no clear policy with regard to treatment of the acute stage. Since much of the pathobiology of schistosomiasis is immunologic in nature,3 corticosteroids may be effective. Praziquantel, the basic antischistosomal drug used in countries where the infection is endemic, is effective against adult worms but is ineffective against the parasites during the early stage. Artemether, which acts on the juvenile forms of the schistosome,4 may have a major role in treating the acute stage of infection.

Eli Schwartz, M.D., D.T.M.H.
Judith Rozenman, M.D.
Chaim Sheba Medical Center, Tel Hashomer 52621, Israel
elischwa@post.tau.ac.il

4 References

1. 1

   Ross AGP, Bartley BP, Sleigh AC, et al. Schistosomiasis. N Engl J Med 2002;346:1212-1220
   Full Text | Web of Science | Medline

2. 2

   Schwartz E, Rozenman J, Perelman M. Pulmonary manifestations of early schistosome infection among nonimmune travelers. Am J Med 2000;109:718-722
   CrossRef | Web of Science | Medline

3. 3

   Hiatt RA, Ottesen EA, Sotomayor ZR, Lawley TJ. Serial observations of circulating immune complexes in patients with acute schistosomiasis. J Infect Dis 1980;142:665-670
   CrossRef | Web of Science | Medline

4. 4

   Shuhua X, Binggui S, Chollet J, Utzinger J, Tanner M. Tegumental alterations in juvenile Schistosoma haematobium harboured in hamsters following artemether treatment. Parasitol Int 2001;50:175-183
   CrossRef | Web of Science | Medline

To the Editor:

In their excellent review of schistosomiasis, Ross et al. include little information about spinal disease as a cause of neurologic disability in tropical and subtropical areas. Spinal disease most often consists of a mass lesion in the conus medullaris or cauda equina or of arachnoiditis in young children living in areas where schistosomiasis is endemic.1 Occasional cases occur in travelers and in adults who are seropositive for the human immunodeficiency virus.2 Clinicians' failure to obtain an appropriate history from travelers and lack of awareness of the entity have resulted in serious delays in diagnosis as well as unnecessary laminectomy in some patients.

Although there are no controlled trials, in my experience praziquantel with or without corticosteroids is effective therapy. The clinical response is often rapid and takes place over a period of several days or weeks. It is not clear why praziquantel is effective, since the spinal lesions are granulomatous reactions to deposited ova rather than to adult worms. In experimentally infected animals, praziquantel treatment leads to rapid resolution of periovular visceral granulomas. Praziquantel may have ovicidal or antiinflammatory actions as well.3

Ahmed Bhigjee, M.D.
Wentworth Hospital, Jacobs, Durban 4026, South Africa
bhigjee@nu.ac.za

3 References

1. 1

   Haribhai HC, Bhigjee AI, Bill PLA, et al. Spinal cord schistosomiasis: a clinical, laboratory and radiological study, with a note on therapeutic aspects. Brain 1991;114:709-726
   CrossRef | Web of Science | Medline

2. 2

   Bhigjee AI, Madurai S, Bill PLA, et al. Spectrum of myelopathies in HIV seropositive South African patients. Neurology 2001;57:348-351
   Web of Science | Medline

3. 3

   Bill PLA. Schistosomiasis. In: Shakir RA, Newman PK, Poser CM, eds. Tropical neurology. London: W.B. Saunders, 1996:295-316.
   

To the Editor:

Women who present with acute appendicitis during pregnancy may have schistosomiasis. In this age of traveling and migration, this possibility must be considered, even in areas where this infection is not endemic. We describe a case of schistosomiasis in a pregnant woman.

A 27-year-old pregnant woman from Somalia was admitted at 22 weeks of gestation because of nausea and a 48-hour history of abdominal pain in the right lower quadrant. The white-cell count was 10,000 per cubic millimeter, without eosinophilia. Acute appendicitis was suspected and was confirmed by laparoscopy and histologic examination. In addition, many schistosomal eggs were seen in the appendiceal wall (Figure 1Figure 1Schistosomal Ova and Marked Eosinophilic Infiltration in the Appendiceal Wall (×200).). The organism was subsequently identified as Schistosoma haematobium. No parasites were found in the stool, urine, or placenta. The postoperative course was uneventful. Three oral doses of praziquantel (20 mg per kilogram of body weight, given 4 hours apart) were administered, and the patient was discharged after 72 hours. She eventually delivered a healthy, full-term female infant.

Parasitic infections during pregnancy are rare, except in some areas where such infections are hyperendemic; in such areas up to 20 percent of pregnant women may be infested with schistosomes.1 From a pathological point of view, the finding of mucosal and submucosal eggs cannot be considered the cause of appendicitis, because in areas where schistosomiasis is endemic, the parasite is found incidentally at autopsy in 65 percent of appendixes.2,3 Massive deposition of ova in the appendiceal wall may, however, induce edema, leading to luminal obstruction and ischemia and eventually to necrosis and bacterial infection.3,4

Nermin Halkic, M.D.
Daliah Gintzburger, M.D.
University Hospital, 1011 Lausanne, Switzerland
nhalkic@hospvd.ch

4 References

1. 1

   Adebamowo CA, Akang EE, Ladipo JK, Ajao OG. Schistosomiasis of the appendix. Br J Surg 1991;78:1219-1221
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2. 2

   Al-Kraida A, Giangreco A, Shaikh MU, Al-Shehri A. Appendicitis and schistosomiasis. Br J Surg 1988;75:58-59
   CrossRef | Web of Science | Medline

3. 3

   Halkic N, Abdelmoumene A, Gintzburger D, Mosimann F. Schistosomal appendicitis in pregnancy. Swiss Surg 2002;8:121-122
   CrossRef | Medline

4. 4

   Moore GR, Smith CV. Schistosomiasis associated with rupture of the appendix in pregnancy. Obstet Gynecol 1989;74:446-448
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Schwartz and Rozenman correctly highlight the problem of acute schistosomiasis in returning travelers. Conventional parasitologic diagnostic tests are often not helpful in cases of acute schistosomiasis, so the diagnosis relies on clinical skill and in-depth knowledge. Clearly, the burden of disease resides in the developing world, and some unusual presentations may be anticipated in travelers who are returning from areas where schistosomiasis is endemic. The suggestion that artemether may be useful in the treatment of the acute stage of schistosomal infection has merit, but this approach will require systematic clinical study along lines similar to those described recently by Shuhua et al.1

Bhigjee highlights the potential harm that may come to patients as a consequence of clinicians' lack of awareness of the possibility of spinal disease in patients with schistosomiasis. Clinical improvement with praziquantel, with or without corticosteroids, has been reported infrequently but consistently. Further clinical studies will clearly be useful.

Halkic and Gintzburger describe a patient who had an unusual combination of appendicitis and intestinal schistosomiasis during pregnancy and who ultimately had a successful outcome. Although it is tempting to try to find a causal link between two common diagnoses, we urge caution in the attempt to do so. This case does, however, reemphasize the need to be aware of potential complications arising from tropical infectious diseases in immigrants from areas where such diseases are endemic or travelers returning from exotic overseas destinations.

Paul B. Bartley, M.B., B.S.
Donald P. McManus, Ph.D., D.Sc.
Queensland Institute of Medical Research, Brisbane, Queensland 4029, Australia
donm@qimr.edu.au

1 References

1. 1

   Shuhua X, Tanner M, N'Goran EK, et al. Recent investigations of artemether, a novel agent for the prevention of schistosomiasis japonica, mansoni and haematobia. Acta Trop 2002;82:175-181
   CrossRef | Web of Science | Medline

Citing Articles (5)

Citing Articles

1. 1

   Eyal Leshem, Yasmin Maor, Eyal Meltzer, Marc Assous, Eli Schwartz. (2008) Acute Schistosomiasis Outbreak: Clinical Features and Economic Impact. Clinical Infectious Diseases 47:12, 1499-1506
   CrossRef

2. 2

   Xiao Wang, Huali Jin, Xiaogang Du, Chun Cai, Yang Yu, Gan Zhao, Baowei Su, Shan Huang, Yanxin Hu, Dongmei Luo, Ruiping She, Xinsong Luo, Xianfang Zeng, Xinyuan Yi, Bin Wang. (2008) The protective efficacy aganist Schistosoma japonicum infection by immunization with DNA vaccine and levamisole as adjuvant in mice. Vaccine 26:15, 1832-1845
   CrossRef

3. 3

   Edsel Maurice T. Salvana, Charles H. King. (2008) Schistosomiasis in travelers and immigrants. Current Infectious Disease Reports 10:1, 42-49
   CrossRef

4. 4

   FRANCESCO RIVASI, SILVIO PAMPIGLIONE. (2006) Appendicitis associated with presence of Schistosoma haematobium eggs: an unusual pathology for Europe. Report of three cases. APMIS 114:1, 72-76
   CrossRef

5. 5

   Eli Schwartz, Phyllis Kozarsky, Marianna Wilson, Martin Cetron. (2005) Schistosome Infection among River Rafters on Omo River, Ethiopia. Journal of Travel Medicine 12:1, 3-8
   CrossRef