Hepatosplenic Schistosomiasis Research Articles

Splenic artery aneurysm rupture in a pregnant woman with hepatosplenic schistosomiasis: case report and literature review

BackgroundPregnancy is not uncommon in patients with non-cirrhotic portal hypertension. Rupture of a splenic artery aneurysm remains a rare complication, associated with a very poor maternal–fetal prognosis. Our aim is to report a case of ruptured splenic aneurysm and to show the maternal–fetal over-risks during the association of pregnancy and portal hypertension, even in non-cirrhotic patients.Case presentationWe report a case of a 34-year-old woman, pregnant at 24 weeks gestation, with non-cirrhotic portal hypertension due to hepatic schistosomiasis. She was hospitalized for variceal bleeding. Patient had undergone endoscopic variceal band ligation and no bleeding recurrence. An unexplained hypovolemic shock appeared during the hospitalization with the occurrence of an in utero fetal death. The fetus was delivered by vaginal delivery. Abdominal CT scan angiogram showed a splenic artery aneurysm rupture. The patient underwent an emergency laparotomy with ligation of the splenic artery associated with splenectomy. Postoperative course was simple. Management of portal hypertension was continued at discharge (diuretic, beta-blockers, and esophageal varices ligation).ConclusionThe association of pregnancy and portal hypertension remains a serious situation with a high risk of maternal–fetal complications. Splenic artery aneurysm rupture is one of the rare complications of this association with a very poor maternal–fetal prognosis. Open repair is the surgical treatment of choice with a non-negligible morbi-mortality.

Noninvasive diagnosis of liver fibrosis in schistosomiasis japonica: Opportunities and challenges

Schistosomiasis is an infectious disease caused by trematode parasites of the genus Schistosoma. According to the World Health Organization (WHO), it is estimated that about 250 million people in the world are infected with the disease, nearly 800 million people are at risk of infection, and more than 200,000 people die of schistosomiasis every year.1, 2 In China, the endemic species of schistosome that primarily infects humans is Schistosoma japonicum. Schistosomiasis japonica has been a major public health problem affecting human health and economic development in the past decades. The latest national epidemiological data showed that there were still 29,517 advanced cases of schistosomiasis japonica at the end of 2020. Moreover, approximately 842,500 patients had been previously infected with S. japonicum nationwide, of whom 83.3% had chronic schistosomiasis.3 Our previous studies confirmed that past cases have no possibility of re-infection after antiparasitic treatment and that liver fibrosis continues to progress and eventually develops into advanced schistosomiasis.4 Some studies have also shown that although chemotherapy with praziquantel is readily available and has good efficacy, liver fibrosis remains the most serious consequence of S. japonicum chronic infection, with an incidence of nearly 20% in infected patients.5 Hence, nearly one million patients with chronic schistosomiasis are at risk of later developing liver fibrosis. Unlike Schistosoma haematobium which causes urinary tract morbidities, S. japonicum causes gastrointestinal and liver diseases. In the human host, some schistosome eggs excreted by adult parasites that have settled in the mesenteric venous plexuses are transported by mesenteric circulation to the liver, where they are trapped in small portal branches. A granulomatous cell-mediated response to egg antigens occurs around the eggs, resulting in the excessive production and deposition of collagen along the portal vein and tract branches by activated hepatic stellate cells. Repeated embolization of eggs over time, especially in cases of high-burden infection, leads to hepatosplenic schistosomiasis (HSS) or also known as Symmers' fibrosis, a form of hepatopathy that results in periportal fibrosis (PPF) with portal hypertension. HSS represents one of the most common chronic sequelae of this infection.6, 7 Patients with periportal fibrosis retain hepatocellular function, differentiating the disease from cirrhosis and other liver diseases (Table 1).8 Confluent granulomata around trapped helminth ova → portal “pipe-stem” fibrosis around portal vessels; liver parenchyma preserved Liver cell necrosis followed by nodular hepatocellular regeneration and fibrous septa and bands involving the entire liver parenchyma Presinusoidal block; normal occluded hepatic venous pressure Sinusoidal block; increased occluded hepatic venous pressure Liver function preserved Liver function impaired Normal hepatic vein pressure gradient Increased hepatic vein pressure gradient The presence and severity of liver fibrosis determines the prognosis and clinical management. Therefore, the early diagnosis and long-term dynamic monitoring of liver fibrosis are clinically important. According to the consensus on the diagnosis and therapy of liver fibrosis (2019) issued by the Chinese Medical Association, liver biopsy remains the gold standard for the diagnosis of liver fibrosis. The hepatic venous pressure gradient (HVPG) is significantly related to the stage of liver fibrosis and is the gold standard for the diagnosis and risk classification of portal hypertension. Liver biopsy is an invasive examination that causes discomfort to patients. Additionally, cases may result in complications, such as bleeding and sepsis, that are not easily accepted by patients. Moreover, the uneven distribution of fibrosis in the liver often leads to sampling errors, resulting in the underestimation of stages of fibrosis and missed diagnosis of liver cirrhosis. The histological analysis relies on the experience and skills of pathologists and has a subjective tendency, which is easy to produce differences within and among observers. In addition to the aforementioned technical shortcomings, the high cost of tissue biopsies limits widespread application. HVPG measures the pressure difference between the portal vein and the intra-abdominal vena cava by comparing the difference between the wedge pressure of the hepatic vein and the free pressure of the hepatic vein. Compared to the wedge pressure of the hepatic vein, the pressure gradient of the hepatic vein eliminates the influence of intra-abdominal pressure on the measurement results and therefore better reflects the pressure of the portal vein. However, in prehepatic or intrahepatic presinusoidal portal hypertension, the wedge pressure of the hepatic vein cannot reflect the increase in portal vein pressure as the blood flowing to the hepatic vein travels through the unaffected sinuses with a large volume and low resistance. Therefore, the hepatic vein wedge and pressure were normal in these patients. Portal hypertension caused by advanced schistosomiasis does not cause changes in wedge pressure or free pressure of the hepatic vein. Therefore, HVPG may not be effective in diagnosing and monitoring hepatic fibrosis in patients with advanced schistosomiasis. Considering these limitations, most studies have focused on noninvasive methods for detecting liver fibrosis. Serum markers can directly or indirectly reflect liver fibrosis. Studies have explored the diagnostic performance of individual and combinations of serum markers for the assessment of liver fibrosis in S. japonica (Supporting Information: Table 1). Hou et al. selected seven biomarkers to evaluate diagnostic efficacy and found that hyaluronic acid (HA) resulted in a high area under receiver operating characteristic curve (AUROC) of 0.938 (95% confidence interval [CI], 0.886–0.990) for significant fibrosis (F ≥ 2). Using a combination of aspartate aminotransferase and platelet ratio index and HA/100, the AUROC was 0.958 (95% CI, 0.914–1.000) for F ≥ 2.9 Another study constructed a new index using biomarkers to diagnose significant fibrosis. The international normalized ratio × HA/100 yielded a higher AUROC of 0.921 and therefore, the new index was considered a useful tool for identifying significant fibrosis in patients with schistosomiasis.10 However, serum markers have several limitations, including overestimating or underestimating the stage of fibrosis in certain conditions, as well as the inability to discriminate between intermediate stages of fibrosis. Due to the advantages of noninvasiveness and high repeatability, abdominal ultrasound plays an important role in the diagnosis of hepatosplenic schistosomiasis (Supporting Information: Figure 1). However, ultrasound is limited by the need for adequate experience and training, in addition to its low accuracy during the initial stages of the disease. Transient elastography (TE) is an ultrasound-based noninvasive technology for diagnosing liver fibrosis based on the assessment of liver stiffness measurement (LSM). The diagnostic value of LSM using TE for assessing liver fibrosis has been widely investigated in patients with various chronic liver diseases. A study showed that LSM is a reliable parameter for predicting significant to advanced liver fibrosis and cirrhosis in patients with advanced schistosomiasis japonica.5 LSM using TE is a noninvasive, convenient, and economical method for fibrosis risk evaluation; however, it has a few limitations. First, LSM cannot be accurately measured in patients with high body mass index or ascites because the mechanical waves cannot correctly propagate to the tissue. Moreover, TE evaluation does not allow the region of interest (ROI) to be placed in a specific area. Given the nature and distribution of fibrosis in HSS (fibrosis is not diffused by the liver parenchyma), LSM measured by TE will be subject to sampling error. Acoustic radiation force impulse elastography (point shear wave elastography, pSWE; two-dimensional shear wave elastography, 2DSWE) can also be used to diagnose HSS, enabling the detection of fibrosis in an ROI and yielding better diagnostic accuracy than conventional TE.11 A recent study that explored the application of pSWE in the context of schistosomiasis showed that pSWE was able to differentiate between mild and significant PPF at higher velocities (1.40 m/s).12 With the application of artificial intelligence technology in the medical field, an emerging technology called radiomics that is widely used in disease diagnosis can provide the automated quantification of image features from a large number of medical images. A recent prospective multicenter study investigating the diagnostic performance of the newly developed deep learning radiomics of elastography (DLRE) in 2D-SWE images for liver fibrosis staging in patients with HBV infection showed that DLRE was more accurate than 2D-SWE in assessing cirrhosis and advanced fibrosis, and more accurate than biomarkers in assessing all three liver fibrosis stages in patients with CHB.13 However, no studies on the use of radiomics technology have been conducted to evaluate periportal fibrosis caused by schistosomiasis. Although the noninvasive diagnosis of PPF has been extensively explored, there is still a lack of accepted and easy-to-use standards. Future studies should focus on establishing the role of noninvasive techniques in the diagnosis of liver fibrosis in schistosomiasis japonica, identifying fibrosis regression following antiparasitic therapy, and predicting the progression of the disease. Tao Wang and Kun Yang drafted the manuscript. HaiYong Hua, JianFeng Zhang, Wei Li, and Kun Yang critically revised the manuscript for important intellectual content. All the authors have read and approved the final version of the manuscript. This study was funded by the National Natural Science Foundation of China (Grant No.: 82173586) and Jiangsu Provincial Department of Science and Technology (Grant No.: BZ2020003). The authors declare no conflict of interest. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Natural History of Hepatosplenic Schistosomiasis (HSS) Non-Cirrhotic Portal Hypertension (NCPH): Influence of Gastrointestinal Bleeding and Decompensation in Prognosis.

Hepatosplenic schistosomiasis (HSS) is a peculiar form of non-cirrhotic portal hypertension (NCPH). Although HSS patients present normal hepatic function, some evolve signs of hepatocellular failure and features of decompensated cirrhosis. The natural history of HSS-NCPH is unknown. A retrospective study was conducted that evaluated patients who fulfilled clinical-laboratorial criteria for HSS. A total of 105 patients were included. Eleven patients already presented with decompensated disease and had lower transplant-free survival at 5 years than those without (61% vs. 95%, p = 0.015). Among 94 patients without prior decompensation, the median follow-up was 62 months and 44% of them had varicose bleeding (two or more episodes in 27%). Twenty-one patients presented at least one episode of decompensation (10-year probability 38%). Upon multivariate analysis, varicose bleeding and higher bilirubin levels were associated with decompensation. The 10-year probability of survival was 87%. Development of decompensation and age were predictive of mortality. HSS is characterized by multiple episodes of GI bleeding, a high probability of decompensation and reduced survival at the end of the first decade. Decompensation is more common in patients with varicose esophageal bleeding and is associated with lower survival.

Insights on the Pathophysiology of the Progression to Decompensated Hepato-Splenic Schistosomiasis

Hepato-splenic schistosomiasis is the most important etiology of non-cirrhotic portal hypertension. It represents a particular type of chronic liver disease, which presents unique characteristics that differentiate it from those found in cirrhosis. The relative preservation of liver parenchyma despite portal fibrosis was thought to yield a more benign course of hepato-splenic schistosomiasis in terms of synthetic dysfunction and late decompensations. However, a wide range of immunologic and vascular modifications is responsible for an otherwise progressive liver disease resulting in decompensated condition frequently undistinguished from hepatic cirrhosis. A predominant Th2 immune response type, in which a fibrogenic profile of cytokines and interleukins such as IL-13, provides an immune-inflammatory background that favors fibrosis and its progression. Intra-hepatic vascular changes with portal vein branch derangement and abnormal vascular proliferation also contribute to continued disarray of the liver architecture resulting in decompensated disease frequently undistinguished from hepatic cirrhosis. This article will review immunologic and pathophysiological aspects of hepato-splenic schistosomiasis that might explain disease progression and severity.

Hepatosplenic schistosomiasis: an uncommon cause of liver disease in developed countries.

Schistosomiasis is a parasitic infection caused by trematode species of the genus Schistosoma. It is prevalent in tropical regions of Africa, Asia and South America, being rare in Europe, where it is usually diagnosed in immigrants and tourists from endemic areas. It has different clinical forms of presentation. Hepatosplenic schistosomiasis produces periportal fibrosis, which can progress to presinusoidal portal hypertension, with all its associated complications. We present the case of a 43-year-old female patient from the Philippines who was referred to gastroenterology consultation due to liver enzyme alteration with a predominantly cholestatic pattern. An aetiological study was performed, with negative results. An abdominal ultrasound revealed signs of chronic liver disease, with transient elastography of 9.5 kPa. A percutaneous liver biopsy was performed, with histological findings consistent with infestation by schistosome eggs, receiving treatment with praziquantel and subsequently verifying its eradication with a stool test.

HEPATOSPLENIC SCHISTOSOMIASIS-ASSOCIATED CHRONIC PORTAL VEIN THROMBOSIS: RISK FACTOR FOR HEPATOCELLULAR CARCINOMA?

Hepatosplenic schistosomiasis is an endemic disease prevalent in tropical countries and is associated with a high incidence of portal vein thrombosis. Inflammatory changes caused by both parasitic infection and portal thrombosis can lead to the development of chronic liver disease with potential carcinogenesis. To assess the incidence of portal vein thrombosis and hepatocellular carcinoma in patients with schistosomiasis during long-term follow-up. A retrospective study was conducted involving patients with schistosomiasis followed up at our institution between 1990 and 2021. A total of 126 patients with schistosomiasis were evaluated in the study. The mean follow-up time was 16 years (range 5-31). Of the total, 73 (57.9%) patients presented portal vein thrombosis during follow-up. Six (8.1%) of them were diagnosed with hepatocellular carcinoma, all with portal vein thrombosis diagnosed more than ten years before. The incidence of hepatocellular carcinoma in patients with schistosomiasis and chronic portal vein thrombosis highlights the importance of a systematic long-term follow-up in this group of patients.

MicroRNA-181b promotes schistosomiasis-induced hepatic fibrosis by targeting Smad7

Schistosomiasis is a common parasitic disease. Hepatosplenic schistosomiasis, caused by Schistosoma japonicum and Schistosoma mansoni, involves pathological changes, including worm egg-induced hepatic granuloma and fibrosis, which can markedly affect the liver’s physiological functions. Although the drug praziquantel (PZQ) is used to treat schistosomiasis, drugs against schistosomiasis-induced liver fibrosis are rare in the clinical setting. Therefore, developing effective strategies to prevent and treat schistosomiasis-induced liver fibrosis is crucial. Previous studies have shown that miRNAs are involved in various liver diseases. In this study, we found a gradual increase in miR-181b expression in the murine liver as S. japonicum infection progressed, while the expression of Smad7 decreased. Down-regulating miR-181b significantly alleviated S. japonicum-induced hepatic granuloma and liver fibrosis. In vitro experiments showed that treatment with TGF-β1 upregulated miR-181b levels in the hepatic stellate cell (HSC) line LX2 in a concentration- and time-dependent manner. Downregulation of miR-181b significantly decreased collagen type I alpha 1 chain (COL1A1) expression in TGF-β1-stimulated LX2 cells. These findings indicate that miR-181b promotes HSC activation by down-regulating Smad7 expression, activating the TGF-β1/Smad signaling pathway, and leading to excess collagen expression and deposition. Our findings suggest that miR-181b might be a potentially novel therapeutic target for schistosomiasis-induced liver fibrosis.

[Progress of researches on schistosomiasis-associated pulmonary arterial hypertension].

Schistosomiasis-associated pulmonary arterial hypertension (Sch-PAH) is categorized as WHO Group I PAH because its clinical manifestations, laboratory and hemodynamic features share with PAH of other etiologies, such as idiopathic, heritable, HIV and autoimmune disorders. Sch-PAH is usually a life-threatening complication of hepatosplenic schistosomiasis characterized by changes in the vascular wall, remodeling and vasoconstriction with lesions primarily located in the precapillary segments of the pulmonary vasculature, which may result in a marked and sustained increase in pulmonary vascular resistance, right ventricular failure and ultimately death. Although egg deposition into lung and subsequent inflammatory cascades are key factors in the pathogenesis of Sch-PAH, the exact pathogenesis, course of disease and treatment of Sch-PAH remain largely uncertain. This review mainly discusses the pathophysiological and immunological mechanisms of Sch-PAH, so as to provide insights into the clinical diagnosis and treatment of Sch-PAH.

A Comparative Cross-Sectional Study of Coagulation Profiles and Platelet Parameters of Schistosoma mansoni-Infected Adults at Haik Primary Hospital, Northeast Ethiopia.

Introduction Schistosoma mansoni is an intravascular parasite that interacts with all components of the host blood. Nearly, 10% of S. mansoni-infected patients progress to severe hepatosplenic Schistosomiasis is characterized by periportal fibrosis, obstruction of intrahepatic veins, presinusoidal portal hypertension, and splenomegaly. Thus, this study aimed to compare the basic coagulation profiles and platelet parameters of S. mansoni-infected adults and noninfected individuals as controls at Haik Primary Hospital, Northeast Ethiopia. Methods A comparative cross-sectional study was conducted at Haik Primary Hospital from April to June 2021. The diagnosis and intensity of S. mansoni infection was determined using the Kato–Katz technique. The coagulation profiles and platelet parameters were analyzed using coagulation and hematology analyzers. Data were analyzed using SPSS version 26.0. The Kolmogorov–Smirnov and Shapiro–Wilk tests were done to check the distribution of continuous variables. The Mann–Whitney U test was used to compare the coagulation profiles and platelet parameters. Spearman's rank-order correlation was done to assess the correlation between the intensity of infection and coagulation profiles and platelet parameters. In all comparison, a P value <0.05 was considered statistically significant. Result In this study, a total of 180 study participants (90 S. mansoni-infected adults and 90 controls) were included. Of the total S. mansoni-infected adults, 55.6%, 28.9%, 33, and 15.6% had light, moderate, and heavy intensity of infections, respectively. All S. mansoni-infected study participants had prolonged prothrombin time (PT) and international normalized ratio (INR). Moreover, about 80% of S. mansoni-infected adults had prolonged activated partial thromboplastin time (APTT). Thrombocytopenia was found in 26.7% of the S. mansoni-infected adults. The Mann–Whitney U test showed a statistically significant difference in coagulation profiles between S. mansoni-infected adults and healthy controls (P-value ≤0.001). The Kruskal–Wallis H-test showed a significant difference in PT, APTT, and INR between the intensity of infection and healthy controls (P-value <0.05). Conclusion This study showed a prolonged coagulation time in S. mansoni-infected individuals. Thus, screening of schistosomiasis patients for hemostatic abnormalities and treating the underlying disorder is crucial.

Sarcopenia, body composition and factors associated with variceal gastrointestinal bleeding and splenectomy in hepatosplenic schistosomiasis mansoni.

Sarcopenia is a common complication of cirrhosis and an important predictor of morbimortality. We aimed to determine the prevalence of sarcopenia and its associated factors in hepatosplenic schistosomiasis (HSS) as well as to evaluate whether muscle mass and function are associated with variceal upper gastrointestinal bleeding (VUGIB) and previous splenectomy in subjects without other liver diseases. We conducted a cross-sectional study including adults with HSS who underwent clinical, biochemical, anthropometric, muscle strength and physical performance evaluations and were submitted to bioelectrical impedance analysis and abdominal ultrasound. Sarcopenia was diagnosed according to the 2019 European consensus criteria. A total of 66 patients with HSS (62.1% male; mean age 48.8±8.6y) were included. Overall, six subjects (9.1%) were diagnosed with probable sarcopenia and none had confirmed sarcopenia. Fat-free body mass index (BMI) was independently associated with VUGIB (odds ratio 0.701 [95% confidence interval 0.51 to 0.96]; p=0.025). Compared with patients who did not undergo surgery, individuals who underwent esophagogastric devascularization combined with splenectomy (EGDS) had higher serum lipid levels, fat percentage and frequency of metabolic syndrome, with lower skeletal muscle mass index and hand grip strength. HSS mansoni seems not to cause sarcopenia. However, a lower fat-free BMI was associated with previous VUGIB and the subgroup of patients who underwent EGDS presented higher lipid levels, fat percentage and frequency of metabolic syndrome and lower muscle mass and function.

Splenectomy Combined with Endoscopic Variceal Ligation (EVL) versus EVL Alone for Secondary Prophylaxis of Variceal Bleeding in Hepatosplenic Schistosomiasis: A Retrospective Case-Control Study.

BackgroundHepatosplenic schistosomiasis (HSS) is one of the most common causes of portal hypertension in developing countries. Variceal bleeding is the most common cause of mortality during HSS. The objective of this study was to evaluate the efficacy of splenectomy associated with endoscopic variceal ligation (EVL) compared with EVL alone in preventing variceal bleeding in patients with HSS.MethodsThis was a single-center, retrospective, case–control study. Between January 2015 and December 2019, a total of 59 patients with HSS who had at least one variceal bleeding episode and received EVL with or without splenectomy were identified and stratified. In this case–control design, 22 patients had splenectomy + EVL (case group) and 37 patients had EVL alone (control group). The main endpoints were the rate of variceal rebleeding and the mortality rate between the two groups.ResultsThe mean age of our patients was 39.92 ± 13.4 (19–75) years with a sex ratio of 1.8. The recurrence rate of variceal bleeding was significantly lower in the case group (splenectomy + EVL) than in the control group (EVL alone) (4.45% vs 27.2%, p = 0.041). There was no significant difference between the two groups in terms of mortality (4.54 vs 2.7%, p = 1.00).ConclusionSplenectomy combined with EVL was effective than EVL alone in preventing variceal rebleeding in patients with HSS.

Carvedilol versus propranolol in the prevention of variceal rebleeding in hepatosplenic schistosomiasis: Efficacy and safety

Background and AimBeta blockers combined with endoscopic variceal band ligation (EVL) is the most effective means for the prevention of variceal rebleeding. No data are available on the efficacy of carvedilol in the secondary prophylaxis of variceal bleeding in hepatosplenic schistosomiasis. The aim of this study was to evaluate the efficacy and safety of carvedilol compared to propranolol as secondary prophylaxis of variceal bleeding in hepatosplenic schistosomiasis.MethodsThis was a prospective, randomized study over a period of 14 months from February 2019 to March 2020. All patients with portal hypertension due to schistosomiasis with at least one episode of variceal bleeding were included and randomized to the propranolol and carvedilol groups. EVL protocol was continued in both groups.ResultsSixty‐one patients were eligible and randomized to propranolol (n = 30) and carvedilol (n = 31) groups. There was no significant difference in hemorrhagic recurrence between the carvedilol (n = 1) and propranolol (n = 3) groups (3.33 vs 10%; P = 0.30). At 4 months, there was a significant reduction in mean arterial pressure (−4.13 mm Hg; 95% CI: −6.27 to −1.99; P < 0.05) and heart rate (−12.13 bpm; 95% CI: −13.92 to −10.35; P < 0.05) in the carvedilol group. There was no significant difference between the groups on the mean difference in arterial pressure. One patient in the carvedilol group had breathing difficulty. There were no adverse events in the propranolol group.ConclusionThere was no significant difference in the efficacy between carvedilol and propranolol. Carvedilol may be an alternative to propranolol for secondary prophylaxis of variceal rebleeding in hepatosplenic schistosomiasis.

Are seizures associated with neuroschistosomiasis mansoni? An exploratory survey in an endemic area of Brazil

Deposition of Schistosoma mansoni eggs in the brain of patients with hepatosplenic schistosomiasis (HS-SM) is frequent and usually asymptomatic. However, it is questioned whether it could cause seizures. Thus, we investigated the occurrence of seizures in these patients and also searched for parameters associated with this disorder. In a cross-sectional survey, we compared 128 patients with HS-SM with 102 patients with portal hypertension due to compensated chronic hepatic disease of other etiologies. A standardized questionnaire, emphasizing epilepsy-related parameters, was applied to all participants. Eight (6.3%) patients with HS-SM had a history of seizures, whereas this condition was reported by three (2.9%) individuals from the comparison group (p=0.354). None of the variables were associated with the occurrence of seizures, either in univariate or in multivariate analysis. The frequency of seizures was similar in both study groups. However, it was higher than that described in population-based studies. Thus, we hypothesize that HS-SM individuals may have a higher frequency of seizure. The lack of difference between the two study groups may be explained by the inclusion of cases of HS-MS overlapping other chronic liver diseases in the comparison group, because this finding is relatively common in schistosome-endemic areas.

Carvedilol as secondary prophylaxis for variceal bleeding in hepatosplenic schistosomiasis

Upper variceal bleeding (UVB) is a possible complication of portal hypertension secondary to hepatosplenic schistosomiasis (HSS). Propranolol is a non-selective beta-blocker used as secondary prophylaxis for UVB, but no previous studies have addressed carvedilol effects in rebleeding prevention. A retrospective exploratory study of 57 patients with chronic HSS and index UVB treated with endoscopic variceal ligation and propranolol or carvedilol was conducted. The primary outcome was UVB-free time in the first 12 mo after the initial bleeding episode. Propranolol was used for secondary UVB prophylaxis in 43 (75.4%) participants (median dose 80 [interquartile range - IQR 60-80] mg/d) and carvedilol in 14 (24.6%) participants (median dose 12.5 [IQR 7.9-25.0] mg/d). During a 12-mo follow-up, rebleeding was observed in 13 (22.8%) patients, 9 (20.9%) of those treated with propranolol and 4 (28.6%) treated with carvedilol (p=0.715). Mean time from the beginning of drug prophylaxis to rebleeding was 6±3 mo and there was no difference between that for propranolol vs carvedilol subgroups. Portal vein thrombosis did not influence the bleeding recurrence in either subgroup. Carvedilol may be equally effective as propranolol in preventing secondary UVB in HSS at 12-mo follow-up.

Noninvasive predictors of esophageal varices in patients with hepatosplenic schistosomiasis mansoni

Background: No previous study have evaluated transient elastography for predicting esophageal varices in hepatosplenic schistosomiasis.Aim: To investigate noninvasive methods of predicting esophageal varices in patients with hepatosplenic schistosomiasis mansoni.Methods: Cross-sectional multicentric study included 51 patients with hepatosplenic schistosomiasis. Patients underwent ultrasonography-dopplerfluxometry, upper endoscopy, complete blood cell count and transient elastography (Fibroscan®) for liver and spleen stiffness measurement (LSM and SSM). Noninvasive scores previously established for cirrhotic population were studied: platelet count to spleen diameter ratio (PSR), LSM-spleen diameter to platelet ratio score (LSPS) and varices risk score (VRS). We proposed a version of LSPS and VRS by replacing LSM with SSM and named them SSPS and modified-VRS, respectively.Results: Esophageal varices were detected in 42 (82.4%) subjects. Individuals with varices presented higher SSM (73.5 vs 36.3 Kpa, p = 0.001), splenic vein diameter (10.8 vs 8.0 mm, p = 0.017), SSPS (18.7 vs 6.7, p = 0.003) and modified-VRS (4.0 vs 1.4, p = 0.013), besides lower PSR (332 vs 542, p = 0.038), than those without varices. SSPS was independently associated with varices presence (OR=1.19, 95%CI 1.03–1.37, p = 0.020) after multivariate analysis. In a model excluding noninvasive scores, SSM was independently associated with varices diagnosis (OR=1.09, 95%CI 1.03–1.16, p = 0.004). AUROC was 0.856 (95%CI 0.752–0.961, p = 0.001) for SSM and 0.816 (95%CI 0.699–0.932, p = 0.003) for SSPS (p = 0.551).Conclusions: Spleen-related variables were predictors of esophageal varices: SSM, splenic vein diameter, SSPS, modified-VRS and PSR. Multivariate models indicated that SSM and SSPS are useful tools for predicting varices in non-cirrhotic portal hypertension by hepatosplenic schistosomiasis and may be used in clinical practice.

Hepatic schistosomiasis, upper gastrointestinal bleeding, and health related quality of life measurements from the Albert Nile Basin

BackgroundHealth related quality of life measurements are vital elements of public health surveillance that uncover unmet health needs and predict the success of health interventions. We described health related quality of life measurements using the EuroQoL 5-dimension (EQ-VAS/EQ-5D) instrument and associated factors among patients with upper gastrointestinal bleeding (UGIB) and hepatic schistosomiasis at a rural health facility in the Albert Nile Basin, Uganda.Methods and materialsThis was a cross-sectional study at Pakwach Health Centre IV. Participants included adult inpatients and outpatients with a history of UGIB and ultrasound evidence of hepatic schistosomiasis. We evaluated and recorded each participant’s medical history, physical examination, laboratory tests results, ultrasound results, and endoscopy findings. We also recorded health related quality of life measurements using the EuroQoL 5-dimension instrument and derived disability weights from EQ-VAS and EQ-5D measurements. These were our dependent variables. Descriptive and inferential statistics were generated summarizing our findings.ResultsWe found 103 participants had a history of upper gastrointestinal bleeding and hepatosplenic schistosomiasis. Sixty percent were between the ages of 30–49 years, 59% were females, 74% were farmers, 92% had splenomegaly, 88% had varices at endoscopy, 22% were medical emergencies with acute variceal upper gastrointestinal bleeding, and 62% had anemia. Measures of the different dimensions of health from 101 participants with patient reported outcomes revealed 77 (76%) participants experienced problems in self-care, 89 (88%) participants reported anxiety or depression, and 89 (88%) participants experienced pain or discomfort. The median EQ-VAS derived disability weights and median EQ-5D index-derived disability weights were 0.3 and 0.34, respectively. Acute upper gastrointestinal bleeding, praziquantel drug treatment, and age by decade predicted higher EQ-VAS derived disability weights (p value < 0.05). Under weight (Body mass index ≤ 18.5), acute upper gastrointestinal bleeding, ascites, age by decade, female gender, and praziquantel drug treatment predicted higher EQ-5D index- derived disability weights (p value < 0.05).ConclusionAdult patients with upper gastrointestinal bleeding and hepatic schistosomiasis from this primary health facility experience poor health and considerable health loss. Several factors predicted increased health loss. These factors probably represent key areas of health intervention towards mitigating increased health loss in this population.

Schistosome-Associated Pulmonary Arterial Hypertension: A Review Emphasizing Pathogenesis.

Schistosomiasis, especially due to Schistosoma mansoni, is a well-recognized cause of pulmonary arterial hypertension (PAH). The high prevalence of this helminthiasis makes schistosome-related PAH (Sch-PAH) one of the most common causes of this disorder worldwide. The pathogenic mechanisms underlying Sch-PAH remain largely unknown. Available evidence suggests that schistosome eggs reach the lung via portocaval shunts formed as a consequence of portal hypertension due to hepatosplenic schistosomiasis. Once deposited into the lungs, the eggs elicit an immune response resulting in periovular granuloma formation. Immune mediators drive transforming growth factor-β (TGF-β) release, which gives rise to pulmonary vascular inflammation with subsequent remodeling and development of angiomatoid and plexiform lesions. These mechanisms elicited by the eggs seem to become autonomous and the vascular lesions progress independently of the antigen. Portopulmonary hypertension, which pathogenesis is still uncertain, may also play a role in the genesis of Sch-PAH. Recently, there have been substantial advances in the diagnosis and treatment of PAH, but it remains a difficult condition to recognize and manage, and patients still die prematurely from right-heart failure. Echocardiography is used for screening, and the formal diagnosis requires right-heart catheterization. The experience in treating Sch-PAH is largely limited to the phosphodiesterase type 5 inhibitors, with evidence suggesting that these vasodilators improve symptoms and may also improve survival. Considering the great deal of uncertainty about Sch-PAH pathogenesis, course, and treatment, the aim of this review is to summarize current knowledge on this condition emphasizing its pathogenesis.

P-35 NONINVASIVE PREDICTORS OF ESOPHAGEAL VARICES IN PATIENTS WITH HEPATOSPLENIC SCHISTOSOMIASIS MANSONI: MULTICENTER STUDY

No previous study have evaluated transient elastography (TE) for predicting esophageal varices (EV) in hepatosplenic schistosomiasis (HSS). To investigate noninvasive methods of predicting EV in patients with HSS mansoni. Cross-sectional multicentric study included 51 patients with HSS. Patients underwent ultrasonography-dopplerfluxometry, upper endoscopy, complete blood cell count and TE (Fibroscan®) for liver and spleen stiffness measurement (LSM and SSM). Noninvasive scores previously established for cirrhotic population were studied: platelet count to spleen diameter ratio (PSR), LSM-spleen diameter to platelet ratio score (LSPS) and varices risk score (VRS). We proposed a version of LSPS and VRS by replacing LSM with SSM and named them SSPS and modified-VRS, respectively. EV was detected in 42 (82.4%) subjects. Individuals with EV presented higher SSM (73.5 vs 36.3 Kpa, p=0.001), splenic vein diameter (10.8 vs 8.0 mm, p=0.017), SSPS (18.7 vs 6.7, p=0.003) and modified-VRS (4.0 vs 1.4, p=0.013), besides lower PSR (332 vs 542, p=0.038), than those without EV. SSPS was independently associated with EV presence (OR=1.19, 95%CI 1.03-1.37, p=0.020) after multivariate analysis. In a model excluding noninvasive scores, SSM was independently associated with EV diagnosis (OR=1.09, 95%CI 1.03-1.16, p=0.004). AUROC was 0.856 (95%CI 0.752-0.961, p=0.001) for SSM and 0.816 (95%CI 0.699-0.932, p=0.003) for SSPS (p=0.551). Spleen-related variables were predictors of EV: SSM, splenic vein diameter, SSPS, modified-VRS and PSR. Multivariate models indicated that SSM and SSPS are useful tools for predicting EV in non-cirrhotic portal hypertension by HSS and may be used in clinical practice.

Quality of Life Assessment Among Patients Living With Hepatosplenic Schistosomiasis and Schistosomal Myeloradiculopathy.

Schistosomiasis is a major public health problem in tropical areas of the world. Health-related quality of life (HRQOL) measurement is being widely used to evaluate the impact of a disease or treatment in several aspects of daily life. However, few studies evaluated the impact of severe forms of schistosomiasis on HRQOL of affected individuals and compared them to healthy controls with a similar socio-demographic background. Our aims were to evaluate the HRQOL in patients with hepatosplenic schistosomiasis (HS) and schistosomal myeloradiculopathy (SMR) and healthy volunteers (HV) and determine if clinical complications of the disease are associated with HRQOL scores. We interviewed and evaluated the HRQOL in 49 patients with HS, 22 patients with SMR, and 26 HV from an outpatient clinic of the Federal University of Minas Gerais University Hospital using the WHOQOL-BREF questionnaire. SMR and HS patients had a significantly lower overall quality of life score when comparing with the HV control group (p = 0.003 and p = 0.005, respectively). Multivariate ordinal regression model adjusted for sex, age, and educational level indicated that HS and SMR patients have three and five times more chances of having a lower quality of life than healthy volunteers (Odds Ratio 3.13 and 5.04, respectively). There was no association between complications of HS disease and quality of life scores. In contrast, worse quality of life was observed in SMR patients that presented back or leg pain, leg paresthesia, and bladder dysfunction. In conclusion, HS and SMR significantly impact the overall quality of life of the affected individuals, reinforcing the importance of efforts to control and eradicate this debilitating disease and suggesting that multidisciplinary clinical management of schistosomiasis patients would be more appropriate and could potentially improve patient's quality of life.

Diagnosis and clinical management of hepatosplenic schistosomiasis: A scoping review of the literature.

BackgroundHepatosplenic schistosomiasis (HSS) is a disease caused by chronic infection with Schistosma spp. parasites residing in the mesenteric plexus; portal hypertension causing gastrointestinal bleeding is the most dangerous complication of this condition. HSS requires complex clinical management, but no specific guidelines exist. We aimed to provide a comprehensive picture of consolidated findings and knowledge gaps on the diagnosis and treatment of HSS.Methodology/principal findingsWe reviewed relevant original publications including patients with HSS with no coinfections, published in the past 40 years, identified through MEDLINE and EMBASE databases. Treatment with praziquantel and HSS-associated pulmonary hypertension were not investigated. Of the included 60 publications, 13 focused on diagnostic aspects, 45 on therapeutic aspects, and 2 on both aspects. Results were summarized using effect direction plots. The most common diagnostic approaches to stratify patients based on the risk of variceal bleeding included the use of ultrasonography and platelet counts; on the contrary, evaluation and use of noninvasive tools to guide the choice of therapeutic interventions are lacking. Publications on therapeutic aspects included treatment with beta-blockers, local management of esophageal varices, surgical procedures, and transjugular intrahepatic portosystemic shunt. Overall, treatment approaches and measured outcomes were heterogeneous, and data on interventions for primary prevention of gastrointestinal bleeding and on the long-term follow-up after interventions were lacking.ConclusionsMost interventions have been developed on the basis of individual groups’ experiences and almost never rigorously compared; furthermore, there is a lack of data regarding which parameters can guide the choice of intervention. These results highlight a dramatic need for the implementation of rigorous prospective studies with long-term follow-up in different settings to fill such fundamental gaps, still present for a disease affecting millions of patients worldwide.