Symptomatic, radiological, and functional improvement following treatment of urinary schistosomiasis in Egypt

Schistosomiasis and hydration status: Schistosoma haematobium, but not Schistosoma mansoni increases urine specific gravity among rural Tanzanian women

OBJECTIVES

Schistosome infections can damage organs important for water homeostasis, especially the kidneys. Urogenital schistosomiasis (caused by Schistosoma haematobium) increases protein and blood in urine and intestinal schistosomiasis (caused by S. mansoni) affects total body water. However, no data exist on how different schistosome species affect urine specific gravity (USG), a hydration biomarker. Therefore, we assessed the relationship between S. haematobium- and S. mansoni-infected and uninfected women and USG in rural Tanzania.

MATERIALS AND METHODS

Surveys were conducted and stool and urine samples were collected among 211 nonpregnant women aged 18-50. S. haematobium eggs were detected using the urine filtration method. S. mansoni eggs were detected using the Kato Katz method. USG was measured using a refractometer and analyzed as both a continuous and dichotomous variable. Regression (linear/logistic) models were estimated to test the relationship between infection and hydration status.

RESULTS

The prevalence of S. haematobium was 5.9% and S. mansoni was 5.4% with no coinfections. In regression models, S. haematobium-infected women had significantly higher USG (Beta = 0.007 g mL^-1 ; standard error = 0.002; p = 0.001) and odds (Odds ratio: 7.76, 95% CI: 1.21-49.5) of elevated USG (>1.020 g mL^-1 ) than uninfected women, whereas S. mansoni-infected women did not.

DISCUSSION

Schistosoma haematobium, but not S. mansoni, infection is associated with higher USG and risk of inadequate hydration. Future work should determine whether findings are attributable to parasite-induced debris in urine or urinary tract pathologies and signs of renal damage. Human and non-human primate studies using USG in schistosome-endemic areas should account for schistosomiasis.

Case-Control Study of Posttreatment Regression of Urinary Tract Morbidity Among Adults in Schistosoma haematobium-Endemic Communities in Kwale County, Kenya

Previous population-based studies have examined treatment impact on Schistosoma-associated urinary tract disease among children, but much less is known about longer-term treatment benefits for affected adult populations in areas where risk of recurrent infection is high. In communities in Msambweni, along the Kenya coast, we identified, using a portable ultrasound, 77 adults (aged 17-85) with moderate-to-severe obstructive uropathy or bladder disease due to Schistosoma haematobium. Treatment response was assessed by repeat ultrasound 1-2 years after praziquantel (PZQ) therapy and compared with interval changes among age- and sex-matched infected/treated control subjects who did not have urinary tract abnormalities at the time of initial examination. Of the 77 affected adults, 62 (81%) had improvement in bladder and/or kidney scores after treatment, 14 (18%) had no change, and one (1.3%) had progression of disease. Of the 77 controls, 75 (97%) remained disease free by ultrasound, while two (3%) had apparent progression with abnormal findings on follow-up examination. We conclude that PZQ therapy for S. haematobium is effective in significantly reducing urinary tract morbidity from urogenital schistosomiasis among adult age groups, and affected adults stand to benefit from inclusion in mass treatment campaigns.

Origins of the Interdepartmental Committee on Nutrition for National Defense, and a Brief Note Concerning Its Demise

The Interdepartmental Committee on Nutrition for National Defense was established in 1955 after malnutrition was found common among troops of the Republic of Korea and of the Republic of China (Taiwan). The initial purpose was identification of nutrition problems among military personnel (later, and among civilians) of countries of "special interest." Surveys measured status, assisted with the establishment of nutrition resources, and facilitated investigator learning and research. A major initial accomplishment was the preparation of a manual of procedures, which evolved into the 1963 Manual for Nutrition Surveys. The first 3 surveys, conducted in 1956, were of the armies of Iran, Pakistan, and Korea. They identified poor nutrition status in some troops, provided a basis for improving rations, and confirmed the effectiveness of the methodology. These surveys were followed by surveys of 30 additional countries that in nearly all instances included civilians and provided a basis for programs and the institutions for improvement of nutrition. On August 1, 1967, the program was reorganized and the Nutrition Program, CDC, based at NIH, was created. This occurred in response to the 1967 Partnership for Health Amendments "to make a comprehensive survey of the incidence and location of serious hunger and malnutrition, and health problems incident thereto, in the United States and to report these conditions to the Congress." The Ten State Nutrition Survey was done in response. Findings of malnutrition, especially in populations of low-income states were politically unwelcome in some quarters. Consequently the program was redirected, and, according to 2 observers, the survey findings were suppressed.

Ultrasound for detecting Schistosoma haematobium urinary tract complications: comparison with radiographic procedures

Chronic infection with Schistosoma haematobium primarily causes urinary tract complications. These lesions are often silent or ignored and not detected until irreversible changes have occurred. However, early chemotherapy can prevent progression and usually reverse all but the more severe abnormalities. Recently, abdominal ultrasound has been shown to be an inexpensive, portable and safe means of detecting schistosomal morbidity. A prospective study was performed on 40 patients comparing abdominal radiography, excretory urography (IVP), cystoscopy and ultrasound to detect urinary tract morbidity due to S. haematobium infection. Ultrasound was as sensitive as an IVP in detecting bladder masses, hydronephrosis and renal stones. It detected hydroureter less frequently (sensitivity 62.5%) than an IVP but visualized this lesion and hydronephrosis in some patients with nonfunctioning kidneys. Ultrasound demonstrated bladder stones as well as an x-ray but it detected bladder wall calcification with less sensitivity (65%) and was much less sensitive (12.5%) for detecting ureteral stones.

A review of the literature on the use of ultrasonography in schistosomiasis with special reference to its use in field studies

This review presents an outline of the pathology resulting from Schistosoma haematobium infections, and the ways in which the lesions can be investigated. The use of ultrasonography is covered in detail. Ultrasonography can provide direct information about lesions in internal organs, and thus provide information about patterns of morbidity and about the regression of pathological changes after treatment. The method has the advantages that it is non-invasive, and is also relatively inexpensive and can be used under field conditions. Ultrasonography has already been used in a number of epidemiological studies in areas where S. haematobium is endemic. The method has proved to be feasible and useful. However, the methodology used for ultrasound studies has varied considerably, so that it is difficult to make valid comparisons between results obtained in different places or at different times. A standardized methodology for making observations and recording the results is needed if the full potential benefit of using ultrasound in the monitoring of schistosomiasis control projects is to be realised. The correlation of results obtained using ultrasound with the results of clinical, parasitological and other observations has been investigated in a number of studies, but many questions remain to be answered.

Reversibility of urinary tract abnormalities due to Schistosoma haematobium infection

In view of the controversial results regarding reversibility of urinary tract lesions due to Schistosoma haematobium infection, 103 patients in the People's Republic of Congo were followed up one year after treatment with Praziquantel (40 mg/kg body wt) by means of ultrasonography. The study group consisted mainly of children. Before therapy a total of 113 lesions were detected in the lower urinary tract. These consisted of bladder wall enlargements (N = 53), enlargements of the bladder wall in combination with singular (N = 16) or multiple polyps (N = 30), vesical calcifications (N = 10), and cases with cystitis cystica (N = 4). One year after therapy, a drastic reduction of ova output was observed, and only eight pathological abnormalities of the lower urinary tract were still detectable. Vesical calcifications persisted in four out of ten cases. Urinary tract obstructions of different degrees (N = 42) showed a comparably marked reversibility. It was concluded that, in children, the resolution of bladder lesions induced by urinary schistosomiasis resulted in reversibility of urinary tract obstructions one year after treatment with Praziquantel.

Ultrasonographical aspects of urinary schistosomiasis: assessment of morphological lesions in the upper and lower urinary tract

Ultrasonographic evaluation of 213 patients with urinary schistosomiasis in different age groups was performed in an endemic area of the Democratic Republic of Congo. The results were compared with 94 age matched controls without urinary schistosomiasis. In patients the bladder showed thickening of the wall, polypoid lesions of the mucosa and bladder wall, calcifications and urinary retention. Urinary tract obstruction, predominantly unilateral, was demonstrated. The lesions increased in severity with the intensity of infection, parallel to an increase in ova excretion. Children aged between 8 and 19 years were most severely affected. Pathological lesions of the upper urinary tract were rare in patients over 25 years of age. The combination of morphological abnormalities was interpreted as being specific for urinary schistosomiasis as they did not occur in the control group. It is suggested that real time ultrasonography may be used to identify morphological lesions in urinary schistosomiasis.

Long-term ureterostomy with suprapubic intravesical drainage used to bypass severe schistosomal obstructive uropathy--preliminary report

Severe obstructive uropathy due to infection with S. hematobium often requires reconstructive surgery. Recent reports, have emphasized that many lesions will disappear after specific chemotherapy given the necessary time. Time for effective chemotherapy may be impossible to allow in severe obstruction. The necessary surgical procedures range from ureteric dilatation to ureteric resection with ileal loop replacement. We suggest that temporary long-term bypass of the diseased ureter using silastic tubes may offer an alternative to resection in many cases while the effect of specific chemotherapy is awaited. One case is described in which ureterostomy with suprapubic intravesical drainage adequately bypassed the diseased and obstructed lower two thirds of the left ureter. In the following six months specific chemotherapy had encouraging effects on the bypassed area.

Efficacy of medical treatment of schistosomal obstructive uropathy as determined by 131I-Hippuran renography

Ten male patients with obstructive uropathy secondary to Schistosoma haematobium and with associated bacteriuria were evaluated with serial urograms, renograms and renal function tests (endogenous creatinine clearance, maximal urinary concentration and total hydrogen ion excretion) before and after medical treatment. The mean duration of follow-up was 4.2 months. Significant improvement was observed in the renograms and the renal function tests while the degree of obstructive uropathy as determined by urography remained essentially unchanged. Thus the renogram can be a more sensitive test for evaluating the efficacy of treatment in patients with schistosomal obstructive uropathy.

Schistosomiasis as a worldwide problem: pathology

Low-grade schistosome infection is often well tolerated, except for the danger of ectopic lesions; the risk of life-threatening pathology increases with rising worm burdens. At present, quantitative stool or urine egg counts do not reliably measure individual infection intensity, especially in adult patients, and more precise methods are needed on which to base therapeutic decisions. Timely schistosomicidal treatment will prevent or improve bilharzial lesions, often dramatically, but can not reverse established liver pipe stem fibrosis. Pathological studies in Ibadan and Cairo have shown that in schistosomiasis haematobia the frequency of obstructive uropathy increases in relation to the egg load in urinary tissues. Obstruction, in turn, predisposes to bacterial superinfection and is a significant cause of renal failure and death in highly endemic populations. Urinary bilharzial lesions are most active in the young and tend to become inactive in older patients. Urinary tissue egg burdens first rise, plateau, and ultimately decrease with age, most sharply after the fifth decade. The relationship between tissue egg burden and 24-hr urinary egg output varies according to stage of activity, while the severity of disease depends on egg burden regardless of stage. Therefore, during the inactive stage, severe pathology can coexist with a minimal urinary egg output. Both clinical and autopsy statistics show a correlation between the frequency and the intensity of bilharzial infection. Most of the severe pathology occurs in population groups with an autopsy frequency above a threshold of 30%. The clinical and epidemiological implications of these findings are discussed.

Obstructive renal failure in bilharziasis

The management is considered of 10 patients who presented in advanced uraemia due to ureteric strictures consequent upon schistosomal infestation, 4 of whom recovered.

In view of the length of ureter involved in the disease process it is highly probable that definitive by-pass of the obstruction will require a replacement procedure, such as an ileal loop.

It seems likely that improved survival rates will be obtained where energetic measures are pursued aimed at the support of the patient and early relief of the obstruction, even if this can only be performed under local anaesthesia owing to the condition of the patient.

Urinary schistosomiasis treated with sodium antimony tartrate--a quantitative evaluation

Seventeen Egyptian male farm-workers aged 8 to 27 years infected with Schistosoma haematobium were given twice-weekly intravenous injections of sodium antimony tartrate in a dose of 0.5 g. (30 mg.) per 15 kg. body weight for 12 injections. Bell's egg-count technique was used to evaluate results on 24-hour urine collections before and at 1, 4, 8, and 12 weeks after treatment. Patients were considered to be cured only when there were no eggs in the urine when examined by the filtration-staining, miracidial-hatching, and 24-hour urinesediment examination methods.At the final follow-up 14 out of 17 patients were found not to be passing eggs in the urine-an 82% cure rate. The mean reduction in egg output in the remaining three patients was 99%. These results are superior to any reported for other antimony drugs.