Severe Form Of Schistosomiasis Research Articles

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.

Plasma levels of innate immune mediators are associated with liver fibrosis in low parasite burden Schistosoma mansoni-infected individuals.

In the murine model, it was demonstrated that pro-inflammatory cytokines and chemokines are essential to the formation and modulation of Schistosoma-induced granulomatous inflammation. However, the relationship of these immune mediators and disease severity is hard to be established in naturally infected individuals. The current study evaluates the association between plasma concentrations of MIF, sTNF-R1, CCL3, CCL7 and CCL24 and schistosomiasis morbidity in Schistosoma mansoni-infected patients with a low parasite burden. For this propose, 97 S.mansoni-infected individuals were subjected to abdominal ultrasound analysis and clinical examination. Among them, 88 had plasma concentration of immune mediators estimated by ELISA assay. Multivariate linear regression models were used to evaluate the relationship between the plasma concentration of immune mediators and the variables investigated. Although most individuals presented low parasite burden, over 30% of them showed signs of fibrosis defined by ultrasound measurements and 2 patients had a severe form of schistosomiasis. No association between parasite burden and the plasma levels of chemokine/cytokines or disease severity was observed. There was a positive association between plasma concentration of CCL4, sTNF-R1, CCL3 and MIF with gall bladder thickness and/or with portal vein thickness that are liver fibrosis markers. In contrast, no association was found between CCL7 plasma concentrations with any of the schistosomiasis morbidity parameters evaluated. The data showed that CCL24, sTNFR1, MIF and CCL3 can be detected in plasma of S.mansoni-infected individuals and their concentration would be used as prognostic makers of Schistosoma-induced liver fibrosis, even in individuals with low parasite burden.

Clinical-epidemiological and laboratory profiles of severe Schistosomiasis mansoni infections at a university hospital

OBJECTIVE:Schistosomiasis remains a public health problem. This was a descriptive and retrospective study of 42 patients with a severe form of schistosomiasis who were admitted to the outpatient clinic of the Faculdade de Medicina da Universidade de São Paulo, São Paulo, in São Paulo, Brazil.METHODS:A data collection questionnaire was designed from the patient charts, and the following variables were evaluated: age, sex, place of birth, occupation, signs and symptoms of schistosomiasis, data from laboratory and imaging examinations, data regarding treatment outcomes, and the existence of comorbidities. Statistical analysis was carried out using Statistical Package for the Social Sciences 15.0 and Microsoft Excel 2003 software. The significance levels of the tests were fixed, accepting 5% type 1 error (α=0.05). Since this was a retrospective observational study, not all data were available for analysis.RESULTS:The mean age of the patients was 48.24 years; 57.1% were male. Statistically significant associations were observed between splenomegaly and thrombocytopenia (p=0.004) and between splenomegaly and leukopenia (p=0.046); however, only 4.5% of the patients had esophageal hemorrhage. Some patients received a specific treatment; of those, 42% took praziquantel, and 35.4% took oxamniquine. Nonspecific drug therapy was given as follows: 65% received propranolol, 90% omeprazole, and 43.6% aluminum hydroxide. The other treatments were as follows: 92.9% of patients underwent endoscopic treatment, 85% received sclerotherapy, and 62.5% used elastic bandages.CONCLUSION:This preliminary study presents a multidisciplinary outpatient follow-up associated with endoscopic and drug treatments that may be effective at preventing bleeding.

Morbidity of schistosomiasis mansoni in a low endemic setting in Ouro Preto, Minas Gerais, Brazil.

Despite the advances of disease control programs, severe forms of schistosomiasis are prevalent. The prevalence of the disease in areas frequented by tourists urges for permanent prevention and control. The aim of this study was to describe the morbidity of schistosomiasis in the district of Antônio Pereira, Ouro Preto, Minas Gerais, Brazil. The proportion of positives was defined by Kato-Katz coproscopy and urinary POC-CCA rapid test. Hepatosplenic form was diagnosed using abdominal ultrasound. Out of 180 participants,97 were examined by Kato-Katz, with 4 (4.1%) being positive. Thirty-four (22.1%) out of 154 were positive by POC-CCA. Five (2.8%) of 177 examined by ultrasound had hepatosplenic form. One of them had undergone splenectomy. One (0.6%)participant had myeloradiculopathy. Severe forms of schistosomiasis are still prevalent in low endemic areas and should be thoroughly investigated.

Schistosoma mansoni associated glomerulopathy with IgA mesangial deposits: case report

Renal involvement is a severe form of schistosomiasis and occurs in 10% to 15% of patients with the hepatosplenic form of the disease. Nephrotic syndrome is the most common clinical presentation. It is a complication caused by immune complexes (IC), it is rare to appear in the Brazilian context with a immunoglobulin A (IgA) deposits. When installed the renal injury by Schistosoma mansoni, classically presents as membranoproliferative glomerulonephritis (mesangiocapillary) with lobular accentuation. To report a case of schistosomiasis nephropathy that appeared 7 years after treatment of hepatosplenic schistosomiasis with histologic pattern of mesangial proliferative glomerulonephritis with IgA deposits in mesangium. Clinically developed with progressive decrease of proteinuria with angiotensin receptor blocker (ARB). It was reported a case of a 36 years old patient, brown, with classical sintoms of nephrotic syndrome (proteinuria > 3.5 g/24h, hypoalbuminemia and hypercholesterolemia), however with hepatosplenic schistosomiasis history 7 years ago and portal hypertension. Patient underwent renal biopsy which showed IgA deposits in mesangial, being more intense than immunoglobulin G (IgG), accompanied by C1q and C3, with 4/13 glomeruli sclerotic, standard light mesangial glomerulonephritis renal injury with IgA deposits. Patient began taking ARB with progressive improvement in proteinuria. Patients with glomerulonephritis by schistosoma don't show improvement of disease progression with antiparasitic treatment. However the anti-proteinuric treatment can slow the progression of end stage kidney disease.

Abnormal liver function in different patients with Schistosoma japonicum.

Schistosomiasis japonica, caused by Schistosoma japonicum, is still a serious public health problem in China. It is important for schistosomiasis control to prevent from infection and advanced patients. Recent years, however, the form of the prevalence of schistosomiasis japonica in China was changed these days. Paying attention to the quality of life of these patients already infected with S. japonicum becomes a new objective to schistosomiasis control program. Although most of the chronic infections with S. japonicum will finally appear as liver fibrosis symptoms, it is still unknown liver function abnormalities in patients with severe forms of schistosomiasis, and there is also no evidence whether S. japonicum infection will directly cause damage to liver cells. Thus, this study investigated 494 patients diagnosed with S. japonicum (87.7%) and 69 healthy subjects from a endemic areas belonging to Jiangxi Province of China and aimed to evaluate the liver function abnormalities in patients with severe forms of schistosomiasis and possible associations with coinfection with HBV. The results showed that the hepatic metabolism situation significantly changed in patients infected with S. japonicum; meanwhile, the abnormal rates of ALT and AST in patients with schistosomiasis were significantly higher than that in the control group, which confirmed that patients infected with S. japonicum not only had damaged liver function but also the hepatic cells were directly influenced. And the coinfection of CHB and schistosomiasis japonica can be a risk factor for more serious outcomes in patients from endemic areas. These results give us the advice that in the further treatment of patients infected with S. japonicum, especially these coinfections, we should better give the routine liver-protection treatment in advance.

Comment on: the relationship between splenomegaly and hematologic findings in patients with hepatosplenic schistosomiasis

The aim of the authors of the paper 'Relationship between splenomegaly and hematologic findings in patients with hepatosplenic schistosomiasis' published in this edition of the Revista Brasileira de Hematologia e Hemoterapia was to evaluate hematological and hemostatic abnormalities in patients with the severe form of schistosomiasis and its possible association with splenomegaly and portal hypertension(1). For this purpose a prospective study was performed of 55 compensated hepatosplenic schistosomiasis patients previously treated with praziquantel. All patients were outpatients of the Gastrointestinal Service of the Hospital das Clinicas of the Universidade Federal de Pernambuco (UFPE), Recife, Brazil, during the period 2010-2012. Thirty healthy individuals were selected as a control group. An abdominal ultrasound was performed in all patients and the Niamey protocols were used to measure the longitudinal diameter of the spleen and to classify the pattern of fibrosis. Moreover, routine liver tests were performed including albumin, aminotransferases (AST, ALT), alkaline phosphatase (ALP) and gamma glutamyl-transferase (γ-GT). A complete blood count and hemostatic tests such as prothrombin time/international normalization ratio (PT/INR), partial thromboplastin time (PTT), fibrinogen and D-dimer were carried out. The authors observed that patients showed predominance of advanced pattern fibrosis. Furthermore, the routine liver and hemostatic tests had increased values compared to the control group with the exception of the level of fibrinogen. There were also high frequencies of upper gastrointestinal bleeding in patients (34%) and thrombocytopenia (83%); 36.5% had anemia and 47% presented leukopenia. An inverse correlation was found between the longitudinal diameter of the spleen and the platelet count. The development of gastro-esophageal varices is a common complication of portal hypertension and bleeding from varices is a frequent cause of mortality and morbidity(2,3). As the platelet count is a commonly available parameter and measurement of the spleen bipolar diameter has a high reproducibility in abdominal ultrasound studies(4,5), their use might be of help in the clinical management of patients with Schistosoma mansoni infection and suspected esophageal varices in endemic areas. According to some authors(6,7), increases in the ALT and AST levels occur with liver cell damage, but in S. mansoni infections this type of injury is not commonly observed. On the other hand, the most important cause of increases in γ-GT is the chronic stimulation of the microsomal fraction of hepatocytes and the presence of cholestasis(8). According to Martins & Borges, chronic stimulation of the microsomal fraction of hepatocytes occurs only in patients with the hepatosplenic form of schistosomiasis. Some authors(8,9) proposed that changes in the biliary tree, due to fibrosis of the portal space, may be the anatomical substrate for the increases in the ALP and γ-GT levels in patients with the hepatosplenic form of schistosomiasis. In the literature, there is a tendency to explain hematologic changes related to portal hypertension as being due to hypersplenism just through observing hematological laboratory values(10,11). It is noteworthy that pancytopenia in portal hypertension due to schistosomiasis is caused by intra-splenic blood stasis related to difficult venous drainage to the liver. Symmers fibrosis in hepatosplenic schistosomiasis does not interfere in the function of these organs. Therefore, there is doubt regarding the term hypersplenism which is perhaps confused with the term storage. In the case of splenomegaly schistosomiasis, cytopenia may be caused by the increase in splenic storage and not by a mononuclear phagocytic system disorder(11,12). Apart from these considerations, there is the difficulty of explaining why the very low platelet and leukocyte counts found in patients with portal hypertension and schistosomiasis are not accompanied by clinical symptoms(11,13). On the other hand, coagulation disorders are frequently observed in patients with schistosomiasis even though the pathophysiology for this has not yet been established. In patients with advanced hepatosplenic schistosomiasis, high levels of the pro-inflammatory cytokines, interleukin-1 alpha (IL-1α) and tumor necrosis factor alpha (TNF-α) and lipopolysaccharide (LPS) have been detected in the sera(14). It is therefore assumed that a tissue factor procoagulant expressed by endothelial cells because of stimulation by these agents may participate in the activation of the extrinsic coagulation cascade(14). Accordingly, it may be possible that host immune responses to schistosome eggs participate in not only granuloma formation and tissue fibrosis, but also in the development of hemostatic abnormalities in schistosomiasis mansoni(14).

Surgical treatment of portal hypertension in schistosomiasis mansoni

Portal hypertension is defined by an hepatic venous pressure gradient greater than 5mmHg. It is usually caused by an increase in resistance in the portal-hepatic vascular bed due to obstruction to flow. The severe forms of schistosomiasis usually evolve with portal hypertension, esophageal, intraabdominal, retroperitoneal and abdominal wall varices. Massive bleeding due to esophageal or gastric variceal rupture is the major complication of portal hypertension in schistosomiasis. In regard to treatment, clinical (propranolol, somatostain, octreotide), endoscopic (sclerotherapy, clips and ligature of varices), vascular (TIPS - transjugular intrahepatic portosystemic shunt) and surgical (portosystemic shunts and portovariceal disconnection) approaches have been tried to decrease portal hypertension and prevent bleeding. In the present review the author discusses the subject emphasizing the surgical procedures.

Serum hyaluronic acid as a comprehensive marker to assess severity of liver disease in schistosomiasis

Schistosomiasis mansoni is a non-cirrhotic fibrogenic disease model. The mild form shows normal liver function with slight or no liver fibrosis whereas in the periportal fibrosis form the manifestations of portal hypertension prevail over hepatocellular failure. We assessed serum hyaluronic acid as a marker of the course of the disease. We studied 24 patients presenting with pure chronic forms of schistosomiasis and seven with cirrhosis. In order to measure serum hyaluronic acid we developed a sandwich fluorescent ELISA-like assay. α2-Macroglobulin, prothrombin index, γ-glutamyltransferase, platelets and ultrasound parameters were also assessed. The 20 μg/l (ROC plot) hyaluronic acid level differentiated patients with the mild form (with no portal hypertension) from those with the severe form of schistosomiasis with 78% diagnostic efficacy. The 80 μg/l cut-off value differentiated patients with the severe form of schistosomiasis from the cirrhotic group with similar diagnostic efficacy. α2-Macroglobulin provided no distinction between the groups studied. The hyaluronic acid serum concentration correlated positively with the splenic vein diameter ( P=0.004) and marginally with α2-macroglobulin ( P=0.059). Serum hyaluronic acid is a good marker for the initial phase of hepatic fibrosis and it was able to assess severity of liver disease in schistosomiasis.

Phenotype and cytokine profile of Schistosoma mansoni specific T cell lines and clones derived from schistosomiasis patients with distinct clinical forms.

It is essential to distinguish the role of T lymphocytes on the physiopathology associated to more severe forms of schistosomiasis and on the immunomodulation that evolves in the majority of infected people. In this study, we generated Schistosoma mansoni-specific T cell lines and clones from patients with the acute and chronic (intestinal and hepatosplenic forms) phases of disease, from former ones, and from uninfected individuals sensitized to parasite soluble antigens. T cell lines derived from nontreated acute infected donors were capable of producing IL-4 and IL-5, while cells from treated patients secreted IFN-gamma. Lines from intestinal chronic and antigen-sensitized donors preferentially produced IFN-gamma, while those from hepatosplenic patients secreted all three cytokines. The cytokine analysis of CD4+ T cell clones revealed a Th2/Th0 pattern (clones producing IL-4 and IL-5 and clones producing all three cytokines) for those derived from infected patients, while cells from antigen-sensitized donors exhibited an opposite Th1/Th0 pattern (clones producing IFN-gamma and clones producing all three cytokines). The possible role of these T cell populations on human schistosomiasis mansoni is discussed.

Hepatosplenic forms of schistosomiasis mansoni in the interior of Northeastern Brazil

Field studies on the morbidity of schistosomiasis mansoni were carried out in some rural endemic areas of Northeastern Brazil during the first semester of 1991. These cross-sectional studies were limited to the assessment of the gradient of clinical forms of the disease. The entire population present in a house-to-house survey was examined. Results have shown a reduction in the prevalence rates of the more severe form of schistosomiasis, the hepatosplenic form, when compared with previous similar studies made in the same areas during the 1960s and 1970s. Changes in prevalence rates of the severe clinical forms from the younger to the older age groups were observed.

Anthropometric measures in relation to Schistosomiasis mansoni and socioeconomic variables.

A cross-sectional study of anthropometric measures and their association with socioeconomic variables, infection by Schistosoma mansoni, intensity of infection and splenomegaly was carried out in an endemic area for schistosomiasis in Brazil (Comercinho), using multiple logistic regression methods. Eighty-seven per cent of all 1.5-14.4 year-old children in the area participated in the study. Children below the 5th percentile (USA Ten State Survey) for height-for-age, weight-for-age and arm muscle area-for-age were compared to those greater than the 5th percentile. There was no association between low anthropometric measures and schistosomiasis or socioeconomic variables in children under five years of age. For the 4.4-14.4 year-old children, poor condition of the heads of family and poorer housing were independently associated with low height and arm muscle area. Heavy excretion of S. mansoni eggs (greater than or equal to 500 epg) was related to low height, and splenomegaly was the variable which showed the strongest association with low height, weight and arm muscle area (odds ratios adjusted for socioeconomic variables were 6.4, 3.5 and 3.7 respectively). This indicates that there is a biological component for low anthropometric measures in the severe form of schistosomiasis and this reinforces the need for public health measures to prevent the development of splenomegalies in endemic areas.