Schistosomiasis Screening of Travelers from Italy with Possible Exposure in Corsica, France

Diagnosis and management of complicated urogenital schistosomiasis: a systematic review of the literature

BACKGROUND

Currently, there are no standardized guidelines for the diagnosis or management of the complications of urogenital schistosomiasis (UGS). This systematic review of the literature aims to investigate the state of the art in reference to diagnostic approaches and the clinical management of this condition.

METHODS

A systematic review of literature published between January 1990 and January 2021 was conducted in the MEDLINE database, scoping for articles regarding diagnostic means or therapeutic options for the complications of UGS, namely obstructive uropathy, bladder cancer, abortion, ectopic pregnancy, infertility, kidney failure, urolithiasis and the need for invasive procedures. Relevant data were then extracted from the articles deemed eligible according to the inclusion criteria.

MAIN RESULTS

In total, 3052 articles were identified by the research query, of which 167 articles fulfilling inclusion criteria after title/abstract screening and full-text evaluation were included, 35% on both diagnostic and therapeutic aspects, and 51% on diagnosis and 14% on therapy. Ultrasound was the most frequently tool employed for the diagnosis of UGS complications showing a good performance. Concerning the management of hydronephrosis, the majority of available evidences came from community-based studies where universal treatment with praziquantel was used leading to decrease of prevalence of obstructive uropathy. Concerning studies on surgical procedures, laser endoureterotomy followed by stenting was mostly employed in adult patients leading to a crude cure rate of 60% (43 of 71 patients). In the case of severe hydronephrosis, surgery consisting of ureteral re-implantation showed excellent results with a crude cure rate of 98% (157 cured patients of 160 treated). Concerning bladder cancer, data on 93 patients with a clear diagnosis of UGS-related bladder were available reporting a variable and sometime combined approach based on disease stage. Available data on diagnosis and management of abortion, ectopic pregnancy, infertility, kidney failure, urolithiasis and the need for invasive procedures due to UGS are also presented.

CONCLUSIONS

The review produced a complete picture of the diagnostic and therapeutic options currently available for complicated UGS. These results can be useful both for guiding clinicians towards correct management and for tracing the direction of future research.

Clinical Spectrum of Schistosomiasis: An Update

Schistosomiasis is a helminthic infection and one of the neglected tropical diseases (NTDs). It is caused by blood flukes of the genus Schistosoma. It is an important public health problem, particularly in poverty-stricken areas, especially those within the tropics and subtropics. It is estimated that at least 236 million people worldwide are infected, 90% of them in sub-Saharan Africa, and that this disease causes approximately 300,000 deaths annually. The clinical manifestations are varied and affect practically all organs. There are substantial differences in the clinical presentation, depending on the phase and clinical form of schistosomiasis in which it occurs. Schistosomiasis can remain undiagnosed for a long period of time, with secondary clinical lesion. Here, we review the clinical profile of schistosomiasis. This information may aid in the development of more efficacious treatments and improved disease prognosis.

Schistosoma haematobium infection with pulmonary involvement in a traveller returning from Congo: A case report and systematic review of literature on nodular pulmonary schistosomiasis

BACKGROUND

Schistosomiasis is highly prevalent in sub-Saharan Africa and diagnosis is difficult for travel medicine practitioners, because it can affect different organs with atypical manifestations. S. haematobium is mostly associated with urinary involvement and rarely with pulmonary lesions. This review aims to summarise the pulmonary forms associated with schistosomiasis, especially with S. haematobium.

METHOD

Based on a case report of both pulmonary and urogenital schistosomiasis, we performed a systematic literature review of schistosomiasis occurring in migrants and travellers, with a specific focus on pulmonary schistosomiasis.

RESULTS

Pulmonary schistosomiasis can present two different clinical patterns. On the one hand, there is an acute pattern, which more frequently affects non-immune young travellers within three to eight weeks of their return and, on the other hand, there is a chronic pattern, which has been evolving in recent years and which mostly affects people living in endemic areas or migrating from these countries. Nodular pulmonary lesions are described in both patterns. Genus identification should not focus only on known patterns, and identification of S. haematobium should not be associated exclusively with urinary schistosomiasis.

CONCLUSIONS

Pulmonary schistosomiasis, even when resulting from S. haematobium, is a rare but existing infection that appears to be spreading with increasing travel and global migration. Physicians need to be more aware of non-specific symptoms that may reveal an atypical presentation of a tropical disease, in order to avoid the chronic complications which can result from parasitic diseases.

Schistosomiasis with a Focus on Africa

Schistosomiasis is a common neglected tropical disease of impoverished people and livestock in many developing countries in tropical Africa, the Middle East, Asia, and Latin America. Substantial progress has been made in controlling schistosomiasis in some African countries, but the disease still prevails in most parts of sub-Saharan Africa with an estimated 800 million people at risk of infection. Current control strategies rely primarily on treatment with praziquantel, as no vaccine is available; however, treatment alone does not prevent reinfection. There has been emphasis on the use of integrated approaches in the control and elimination of the disease in recent years with the development of health infrastructure and health education. However, there is a need to evaluate the present status of African schistosomiasis, primarily caused by Schistosoma mansoni and S. haematobium, and the factors affecting the disease as the basis for developing more effective control and elimination strategies in the future. This review provides an historical perspective of schistosomiasis in Africa and discusses the current status of control efforts in those countries where the disease is endemic.

Urological management and surgical procedures in migrants from Sub-Saharan Africa with urogenital schistosomiasis

INTRODUCTION AND OBJECTIVES

An increasing number of urogenital schistosomiasis (UGS) is being diagnosed in Europe following the unprecedented migratory flux from Sub-Saharan Africa (SSA). This phenomenon represent a challenge for urologists working in a non-endemic area. The aim of this study is to describe the urological management and the surgical procedures of patients with UGS in a tertiary referral centre.

PATIENTS

All subjects from SAA diagnosed with UGS from January 2011 to November 2018 were enrolled retrospectively. Detailed data of patients with UGS undergoing to urological procedures were collected and analysed.

RESULTS

Thirty patients were diagnosed with UGS, among them 12 (42.8%) were submitted to surgery. The most common surgical procedure was trans urethral resection of bladder (TURB) for suspected lesions persisted after praziquantel treatment performed in 7cases (58%). Other surgical procedure were TURB and concomitant ureteroscopy with laser fragmentation for suspected bladder neoplasm with renal stone, endoscopic lithotripsy and percutaneous nephrolithotomy for bladder and renal stones, laparoscopic nephrectomy for end-stage kidney disease, placement of bilateral nephrostomy for hydroureteronephrosis, explorative testicular surgery for a suspected testicular torsion in one case each. Four patients (33%) were lost at the follow up.

CONCLUSION

An increasing number of migrants from SSA diagnosed with UGS has been observed. Some patients required a surgical intervention for suspected neoplastic lesions or end-stage organ damage. It was particularly difficult to perform a regular follow-up in several patients. Further multicentric studies are needed to reach a proper standard in diagnosis, treatment and follow-up of subjects with UGS.

Schistosomiasis, strongyloidiasis and Chagas disease: the leading imported neglected tropical diseases in Italy

BACKGROUND

In recent years, an increasing number of individuals affected by neglected tropical diseases (NTDs) have been observed in Italy, due to migration, international travels and climate changes. Reliable data on the current NTD epidemiology in Italy and the health system preparedness on this issue are not available.

METHODS

We report the results of a survey on selected NTDs (schistosomiasis, strongyloidiasis, echinococcosis, Chagas disease, leishmaniasis, cysticercosis, filariasis and scabies) in nine Italian sentinel centres, in order to investigate their occurrence throughout the country and identify which ones are a priority for public health interventions, development of protocols for case management, and training activities. To explore the preparedness of the centres, we investigate the availability of specific diagnostic tools and drugs, needed for the management of the most common NTDs. We also reviewed and summarized the available national policies, recommendations and guidelines on NTDs in Italy.

RESULTS

Overall, 4123 NTDs cases were diagnosed in nine Italian centres within a 7-year period (2011-2017). Schistosomiasis and strongyloidiasis were the most common NTDs, accounting for about one-third each of all the diagnosed cases, followed by Chagas disease. The number of cases showed a significant trend to increase over time, mainly due to foreign-born subjects. Serology for Schistosoma spp. and Strongyloides stercoralis was available in seven and five centres, respectively. Agar plate stool culture for S. stercoralis was available in three sites. Ivermectin and praziquantel were always available in six centres. Six national policies, recommendations and guidelines documents were available, but for the most part, they are not fully implemented yet.

CONCLUSIONS

This survey showed how some NTDs, such as schistosomiasis and strongyloidiasis, are becoming more common in Italy, due to multiple components. A list of seven key actions was proposed, in order to improve diagnosis, management and control of NTDs in Italy.

Schistosomiasis: Still a Cause of Significant Morbidity and Mortality

Tropical diseases remain severe threats to global health with acute or chronic debility. Public health issues are regularly monitored and reported by the WHO. Conditions with high prevalence and virulence such as Schistosomiasis or Malaria still need active treatment. Advances over the decades in the treatment and management of Schistosomiasis have reduced morbidity and mortality in patients. However, poverty, adverse environments, lack of education and awareness, with parasites and vectors that can thrive if uncontrolled, remain issues for the successful global eradication of Schistosomiasis. From the disease's discovery in 1850, the author relates historical details to its current status. Several countries previously affected, including Japan and Tunisia, have eliminated the disease while others seek the same goal. Africa remains the most severely affected continent with vulnerable women and children, although the infection persists in South America and the Far East of Asia as well. Realistic improvements for continuing health conditions are vogue and emphasized for those at risk or afflicted by the infection, illustrating success models of concerted efforts of extirpation. Constant proximity to infected water, with a parasite host, are hurdles in reducing exposure. Effective medication for acute treatment is available, and prophylaxis by vaccination is promising. Where endemic Schistosomiasis is prevalent, significant morbidity and mortality have far-reaching complications in multiple human organ systems, including irreversible pulmonary hypertension, renal, genitourinary, central nervous system conditions, and neoplasia. Two hundred and thirty million people are estimated to have contracted Schistosomiasis globally, with up to 700 million still at risk of infection, and 200,000 deaths occur annually. The disease may be more prevalent than thought after newer tests have shown increased sensitivity to pathological antigens. The author discusses infectivity risks, investigations, prognosis, treatment, and management, as well as morbidity and mortality.

Persistence of schistosomal transmission linked to the Cavu river in southern Corsica since 2013

Seven cases of urogenital schistosomiasis occurred in Corsica in 2015 and 2016. The episodes were related to exposure to the same river and involved the same parasite strain as an outbreak with 106 cases in summer 2013. The connection calls for further investigations on the presence of an animal reservoir and the survival of infested snails during winter. However, recontamination of the river from previously infected bathers remains the most likely hypothesis.

The diagnosis and treatment of urogenital schistosomiasis in Italy in a retrospective cohort of immigrants from Sub-Saharan Africa

OBJECTIVES

To evaluate ultrasound and praziquantel to, respectively, assess and reduce urogenital schistosomiasis (UGS)-associated morbidity in migrants from Sub-Saharan Africa (SSA).

METHODS

Migrants from SSA with UGS attending three Italian centres for tropical diseases during 2011-2016 were retrospectively enrolled. Data on clinical symptoms, routine laboratory, parasitological tests, and ultrasound reported as per the WHO-Niamey protocol were collected at baseline and at available follow-up visits after treatment with praziquantel 40 mg/kg/day for 3 days.

RESULTS

One hundred and seventy patients with UGS were enrolled and treated with praziquantel. Baseline ultrasonography showed urinary tract abnormalities in 115/169 patients (68%); the mean global Schistosoma haematobium score was 2.29 (SD 2.84, IQR 0-2), the mean urinary bladder intermediate score 1.75 (SD 1.73, IQR 0-2), and the mean upper urinary tract intermediate score 0.54 (SD 2.37, IQR 1-10). Abnormalities were more common among the 111 (65%) who were symptomatic (p < 0.02; OR 2.53; 95% CI 1.19-5.35). Symptoms started in 94/111 (85%) before arriving (median 63 months, IQR 12-119). At follow-up, we observed a significant reduction in the prevalence of UGS-related symptoms, blood, urine, and ultrasound abnormalities.

CONCLUSIONS

Our study results support the use of ultrasound and praziquantel for assessing and reducing UGS-associated morbidity in migrants. Health-seeking behaviour, diagnostic, and treatment delays contribute to the advanced pathology and qualified treatment success. To ensure earlier treatment, based on our findings, clinical experience, and available literature, we propose an algorithm for the diagnosis and clinical management of UGS. Multicentre studies are needed to improve the management of subjects with UGS in non-endemic countries.

Epidemia de microcefalia e vírus Zika: a construção do conhecimento em epidemiologia

Em agosto de 2015, neuropediatras de hospitais públicos do Recife, Pernambuco, Brasil, observaram um aumento do número de casos de microcefalia desproporcional associado a anomalias cerebrais. Esse fato gerou comoção social, mobilização da comunidade acadêmica e levou o Ministério da Saúde a decretar emergência de saúde pública nacional, seguida pela declaração de emergência de saúde pública de interesse internacional da Organização Mundial da Saúde. A hipótese formulada para o fenômeno foi a infecção congênita pelo vírus Zika (ZIKV), com base na correlação espaço-temporal e nas características clínico-epidemiológicas das duas epidemias. Evidências se acumularam e no âmbito do raciocínio epidemiológico preencheram critérios que deram sustentação à hipótese. Sua plausibilidade está ancorada no neurotropismo do ZIKV demonstrado em animais, atingindo neurônios progenitores do cérebro em desenvolvimento, e em seres humanos devido às complicações neurológicas observadas em adultos após a infecção. O isolamento do RNA e antígenos virais no líquido amniótico de mães infectadas e em cérebros de neonatos e fetos com microcefalia contribuíram para demonstrar a consistência da hipótese. O critério de temporalidade foi contemplado ao se identificar desfechos desfavoráveis em uma coorte de gestantes com exantema e positivas para o ZIKV. Finalmente, o primeiro estudo caso-controle conduzido demonstrou existir uma forte associação entre microcefalia e infecção congênita pelo ZIKV. O conhecimento construído no âmbito do paradigma epidemiológico recebeu a chancela da comunidade científica, construindo o consenso de uma relação causal entre o ZIKV e a epidemia de microcefalia.

Post-transplant liver graft schistosomiasis in a migrant from Sub-Saharan Africa

We report a case of post-transplant liver graft infection with Schistosoma spp in a migrant from sub-Saharan Africa transplanted for HBV-related cirrhosis and with undiagnosed schistosomiasis pre-transplantation. The occurrence of tropical diseases in non-endemic areas warrants screening protocols for organ donors and recipients with a history of exposure in endemic areas.

Accuracy of parasitological and immunological tests for the screening of human schistosomiasis in immigrants and refugees from African countries: An approach with Latent Class Analysis

Background

Schistosomiasis is a neglected infection affecting millions of people, mostly living in sub-Saharan Africa. Morbidity and mortality due to chronic infection are relevant, although schistosomiasis is often clinically silent. Different diagnostic tests have been implemented in order to improve screening and diagnosis, that traditionally rely on parasitological tests with low sensitivity. Aim of this study was to evaluate the accuracy of different tests for the screening of schistosomiasis in African migrants, in a non endemic setting.

Methodology/Principal findings

A retrospective study was conducted on 373 patients screened at the Centre for Tropical Diseases (CTD) in Negrar, Verona, Italy. Biological samples were tested with: stool/urine microscopy, Circulating Cathodic Antigen (CCA) dipstick test, ELISA, Western blot, immune-chromatographic test (ICT). Test accuracy and predictive values of the immunological tests were assessed primarily on the basis of the results of microscopy (primary reference standard): ICT and WB resulted the test with highest sensitivity (94% and 92%, respectively), with a high NPV (98%). CCA showed the highest specificity (93%), but low sensitivity (48%). The analysis was conducted also using a composite reference standard, CRS (patients classified as infected in case of positive microscopy and/or at least 2 concordant positive immunological tests) and Latent Class Analysis (LCA). The latter two models demonstrated excellent agreement (Cohen’s kappa: 0.92) for the classification of the results. In fact, they both confirmed ICT as the test with the highest sensitivity (96%) and NPV (97%), moreover PPV was reasonably good (78% and 72% according to CRS and LCA, respectively). ELISA resulted the most specific immunological test (over 99%). The ICT appears to be a suitable screening test, even when used alone.

Conclusions

The rapid test ICT was the most sensitive test, with the potential of being used as a single screening test for African migrants.

Schistosomiasis is probably the most important of the neglected tropical diseases (NTD) caused by helminthes (worms). It is acquired bathing in freshwater in endemic areas. The life cycle is complex and involves freshwater snails. Schistosomiasis, caused by Schistosoma mansoni, S. haematobium and less frequently by other species, affects more than 200 million people, mostly in Africa, and may chronically cause irreversible damage of the liver (S. mansoni) or of the kidneys and the urinary tract, including cancer of the bladder (S. haematobium). As in chronic infections eggs of both species are often missed by microscopy of faeces and urine, with this retrospective study we evaluate the accuracy of different, alternative diagnostic tests, for the screening of schistosomiasis in African migrants and asylum seekers, of whom many thousands reach the Italian coast every year proceding from the most endemic areas. The most interesting finding of our study is that a rapid diagnostic test for antibody detection in blood, easy to use as a point-of-care tool, resulted the most sensitive of the five tests evaluated, and thus is very promising as a screening tool even when used without any additional test.

Spectrum and burden of neglected tropical diseases observed in an infectious and tropical diseases unit in Florence, Italy (2000-2015)

Neglected tropical diseases (NTDs) are a diverse group of acute and chronic conditions with distinct characteristics that thrive mainly among the poorest populations, almost exclusively in tropical countries. To evaluate the relevance and impact of NTDs in a temperate area, the number and features of patients diagnosed with NTDs at the Infectious and Tropical Diseases Unit (ITDU), Azienda Ospedaliero-Universitaria Careggi, Florence, Italy between 2000 and 2015 were retrospectively reviewed. Overall 289 NTD cases were diagnosed in 283 subjects accounting for 2.4% of all patients accessing the center: 96 dengue, 62 schistosomiasis, 36 strongyloidiasis, 22 cystic echinococcosis, 19 Chagas disease, 14 leishmaniasis, 11 chikungunya, 10 cysticercosis, 6 soil-transmitted helminthiasis, 6 lymphatic filariasis, 3 trachoma, 2 onchocerciasis, and 2 leprosy. There was one fatal case of disseminated strongyloidiasis. According to the type of exposure, 145 (50.2%) NTDs were diagnosed in immigrants, 121 (41.9%) in travelers, 18 (6.3%) were autochthonous infections, while in 5 cases (1.7%), the type of exposure was unknown. The number of patients seen at the ITDU with a diagnosis of NTD increased over time (from 29 in 2000-2005 to 81 in 2006-2010, to 173 in 2011-2015). Late diagnosis and mismanagement before coming to the center were common features in several cases. Considering the increasing incidence and possible misdiagnosis of NTDs in non-endemic countries, to raise awareness about NTDs among health care providers seems to be of primary concern.

Serological approaches for the diagnosis of schistosomiasis - A review

Schistosomiasis is a common disease in endemic areas of Sub-Saharan Africa, South America and Asia. It is rare in Europe, mainly imported from endemic countries due to travelling or human migration. Available methods for the diagnosis of schistosomiasis comprise microscopic, molecular and serological approaches, with the latter detecting antigens or antibodies associated with Schistosoma spp. infection. The serological approach is a valuable screening tool in low-endemicity settings and for travel medicine, though the interpretation of any diagnostic results requires knowledge of test characteristics and a patient's history. Specific antibody detection by most currently used assays is only possible in a relatively late stage of infection and does not allow for the differentiation of acute from previous infections for therapeutic control or the discrimination between persisting infection and re-infection. Throughout the last decades, new target antigens have been identified, and assays with improved performance and suitability for use in the field have been developed. For numerous assays, large-scale studies are still required to reliably characterise assay characteristics alone and in association with other available methods for the diagnosis of schistosomiasis. Apart from S. mansoni, S. haematobium and S. japonicum, for which most available tests were developed, other species of Schistosoma that occur less frequently need to be taken into account. This narrative review describes and critically discusses the results of published studies on the evaluation of serological assays that detect antibodies against different Schistosoma species of humans. It provides insights into the diagnostic performance and an overview of available assays and their suitability for large-scale use or individual diagnosis, and thus sets the scene for serological diagnosis of schistosomiasis and the interpretation of results.

Evidence for a permanent presence of schistosomiasis in Corsica, France, 2015

We present a case of acute schistosomiasis acquired in Corsica after bathing in the Cavu River during the summer of 2015. The diagnosis was made following epidemiological, laboratory and serological assessments. After a previous outbreak of urogenital schistosomiasis during the summer of 2013, when more than 120 infections were diagnosed, this further case indicates transmission was still effective in 2015, thus suggesting a permanent presence of schistosomiasis in Corsica.