Cystoscopic picture of Schistosoma haematobium in Egyptian children correlated to intensity of infection and morbidity

Epidemiological and Diagnostic Aspects of Bladder Bilharziomas in the Urology Department of Idrissa Pouye General Hospital (HOGIP)

Objective

The aim of our study is to assess the diagnostic aspects of bladder bilharzioma in the Urology Department of Idrissa Pouye General Hospital (Senegal).

Materials and Methods

It is a descriptive study from January 2013 to December 2018. The patients included in the study were those who had anatomopathological examination of bladder biopsy that showed a schistosomiasis pseudotumor of the bladder. The variables studied were sociodemographic, clinical symptoms, imaging findings, histology, and treatment. The data have been saved and analyzed by the 2013 Excel software.

Results

Thirteen patients were included in our study. The average age was 27 ± 12.1 years. Sex ratio was 1.6. The majority of the patients were from the northern part of Senegal. Hematuria was the main symptom for all the patients. Cystoscopy was performed for all the patients and showed 5 granulomas and 8 fibrocalcic polyps. A transurethral resection of the bladder was performed, and treatment with praziquantel (40 mg/kg of bodyweight) has been carried out. One patient presented precancerous lesions such as metaplasia and dysplasia of the bladder mucosa. After a median follow-up of 40 months (6–57 months), ten patients had a favorable clinical and endoscopic outcome.

Conclusion

Granulomas and fibrocalcic polyps of the bladder mucosa are, respectively, confused with squamous cell carcinoma and bladder lithiasis in endemic areas of schistosomiasis. Good cystoscopy interpretation can provide the diagnosis of bladder bilharzioma and start the treatment.

Dynamics of paediatric urogenital schistosome infection, morbidity and treatment: a longitudinal study among preschool children in Zimbabwe

Background

Recent research has shown that in schistosome-endemic areas preschool-aged children (PSAC), that is, ≤5 years, are at risk of infection. However, there exists a knowledge gap on the dynamics of infection and morbidity in this age group. In this study, we determined the incidence and dynamics of the first urogenital schistosome infections, morbidity and treatment in PSAC.

Methods

Children (6 months to 5 years) were recruited and followed up for 12 months. Baseline demographics, anthropometric and parasitology data were collected from 1502 children. Urinary morbidity was assessed by haematuria and growth-related morbidity was assessed using standard WHO anthropometric indices. Children negative for Schistosoma haematobium infection were followed up quarterly to determine infection and morbidity incidence.

Results

At baseline, the prevalence of S haematobium infection and microhaematuria was 8.5% and 8.6%, respectively. Based on different anthropometric indices, 2.2%-8.2% of children were malnourished, 10.1% underweight and 18.0% stunted. The fraction of morbidity attributable to schistosome infection was 92% for microhaematuria, 38% for stunting and malnutrition at 9%-34%, depending on indices used. S haematobium-positive children were at greater odds of presenting with microhaematuria (adjusted OR (AOR)=25.6; 95% CI 14.5 to 45.1) and stunting (AOR=1.7; 95% CI 1.1 to 2.7). Annual incidence of S haematobium infection and microhaematuria was 17.4% and 20.4%, respectively. Microhaematuria occurred within 3 months of first infection and resolved in a significant number of children, 12 weeks post-praziquantel treatment, from 42.3% to 10.3%; P<0.001.

Conclusion

We demonstrated for the first time the incidence of schistosome infection in PSAC, along with microhaematuria, which appears within 3 months of first infection and resolves after praziquantel treatment. A proportion of stunting and malnutrition is attributable to S haematobium infection. The study adds scientific evidence to the calls for inclusion of PSAC in schistosome control programmes.

Eosinophil granule proteins ECP and EPX as markers for a potential early-stage inflammatory lesion in female genital schistosomiasis (FGS)

BACKGROUND

Genital granulomas induced by Schistosoma haematobium eggs can manifest as different lesion types visible by colposcopy; rubbery papules (RP), homogenous sandy patches (HSP) and grainy sandy patches (GSP). Pronounced tissue eosinophilia is a candidate marker for active S. haematobium pathology, as viable schistosome egg granulomas often are eosinophil rich. Here it was investigated whether eosinophil granule proteins ECP (eosinophil cationic protein) and EPX (eosinophil protein-X) in urine and genital lavage can be used as markers for active FGS lesions.

METHODS

Uro-genital samples from 118 Malagasy women were analysed for ECP and EPX by standard sandwich avidin/biotin amplified ELISA.

PRINCIPAL FINDINGS

The women with RP lesions had significantly higher levels of ECP and EPX in both lavage and urine. Furthermore, women with RP lesions were significantly younger than those with GSP. This could indicate that RP lesions might be more recently established and thus represent an earlier inflammatory lesion stage.

CONCLUSION

ECP in genital lavage might be a future tool aiding the identification of FGS pathology at a stage where reversibility remains a possibility following praziquantel treatment.

[Tumorlike form of bladder schistosomiasis in children]

Two tumorlike forms of urinary schistosomiasis are reported. Diagnosis was suspected as the patients exerted haematuria while they originated from a geographic area where schistosomiasis is endemic. Terminal urine samples were positive for Schistosoma haematobium. Cystoscopy revealed an hemorrhagic granulomatous polyp in one case and villous polyps in the other case, associated with suggestive lesions of schistosomiasis. Schistosoma haematobium infection in children is uncommon in Europe and rarely considered in the diagnosis of haematuria.

Ultrasonography of urinary tract lesions caused by bilharziasis in Yemeni patients

OBJECTIVE

To evaluate abnormalities detected by ultrasonography in Yemeni patients with active Schistosoma haematobium infection.

PATIENTS AND METHODS

As part of a co-operation between a private hospital and the Schistosomiasis Control Project in Yemen, laboratory and ultrasonographic examinations were undertaken in 158 patients (eight female, 150 male, mean age 17 years) with active S. haematobium infection. Upper urinary tract dilatation, lower ureteric changes and bladder wall abnormalities (thickness, hyper-echogenicity and polypoid lesions) were recorded. Laboratory findings and ultrasonographic changes were evaluated and categorized according to the age of the patients.

RESULTS

Twenty-eight patients (18%) showed no morphological lesion on ultrasonography. Bladder abnormalities (thickness, hyper-echogenicity and polypoid lesions) were found in 130 patients (82%) and upper tract lesions in 86 (54%). There were no upper tract lesions seen without an associated bladder abnormality. There were polyps within the lower ureteric lumen in four patients; in these patients there was a higher incidence of severe infection. One patient had a urinary bladder tumour.

CONCLUSION

Urinary bilharziasis has typical ultrasonographic features, but may occur with no morphological lesion detectable on ultrasonography. Upper tract lesions seem to develop only with lower tract abnormalities.

Ultrasonographic urinary tract abnormalities in Schistosoma haematobium infection

OBJECTIVE

Evaluation of ultrasonographic abnormalities with active Schistosoma haematobium infection in Yemeni patients.

METHODS

As part of a cooperation between a private hospital and Schistosomiasis Control Project in Yemen, laboratory and ultrasonographic examinations were performed in 158 patients (8 females, 150 males, mean age: 17 years) with active Schistosoma haematobium infection. Upper urinary tract dilation, lower ureter changes and bladder wall abnormalities (thickness, hyperechogenicity and polypoid lesions) were registered. Laboratory findings and ultrasonographic changes were evaluated and assorted according to age groups of the patients.

RESULTS

Twenty-eight patients (18%) showed no ultrasonographic morphological lesion. Bladder abnormalities (thickness, hyperechogenicity and polypoid lesions) were found in 130 patients (82%) and upper tract lesions in 86 patients (54%). No upper tract lesions were seen without bladder abnormality. Polyps within the lower ureteric lumen occurred in four patients. In patients with polypoid lesions, higher incidence of severe infection was found. One patient had urinary bladder mass.

CONCLUSION

Urinary schistosomiasis has typical sonographic features, however, it may occur also without ultrasonographic morphological lesion. Upper tract lesions seem to develop only with lower tract abnormalities.

Relationship between schistosomiasis and bladder cancer

Carcinoma of the urinary bladder is the most common malignancy in the Middle East and parts of Africa where schistosomiasis is a widespread problem. Much evidence supports the association between schistosomiasis and bladder cancer: this includes the geographical correlation between the two conditions, the distinctive patterns of gender and age at diagnosis, the clinicopathological identity of schistosome-associated bladder cancer, and extensive evidence in experimentally infected animals. Multiple factors have been suggested as causative agents in schistosome-associated bladder carcinogenesis. Of these, N-nitroso compounds appear to be of particular importance since they were found at high levels in the urine of patients with schistosomiasis-associated bladder cancer. Various strains of bacteria that can mediate nitrosation reactions leading to the formation of N-nitrosamines have been identified in the urine of subjects with schistosomiasis at higher intensities of infection than in normal subjects. In experimental schistosomiasis, the activities of carcinogen-metabolizing enzymes are increased soon after infection but are reduced again during the later chronic stages of the disease. Not only could this prolong the period of exposure to activated N-nitrosamines, but also inflammatory cells, stimulated as a result of the infection, may induce the endogenous synthesis of N-nitrosamines as well as generating oxygen radicals. Higher than normal levels of host cell DNA damage are therefore anticipated, and they have indeed been observed in the case of alkylation damage, together with an inefficiency in the capacity of relevant enzymes to repair this damaged DNA. In experimental schistosomiasis, it was also found that endogenous levels of host cell DNA damage were related to the intensity of infection. All of these factors could contribute to an increased risk of bladder cancer in patients with schistosomiasis, and in particular, the gene changes observed may have potential for use as biomarkers in the early detection of bladder cancer that may assist in alleviating the problem.

The diagnostic potential of three indirect tests for urinary schistosomiasis in Nigeria

Schistosomiasis is one of the major parasitic infections of man in the tropical and subtropical areas of the world. Diagnosis of the disease is usually based on microscopic detection of eggs in excreta which is both laborious and time consuming. In Nigeria, the Government's emphasis on the control of the disease dictates the need for a simple, fast, reliable and affordable diagnostic test for the identification of infected communities and detection of infected persons. Three indirect diagnostic tests for urinary schistosomiasis: interview technique, visual examination for macrohaematuria and the use of a chemical reagent strip were employed in screening 1056 individuals of the Kainji Lake area of Nigeria for urinary schistosomiasis, using haematuria as the disease indicator. The sensitivity of the three tests were determined using the filtration (egg counting) technique as the reference test. The sensitivity of the reagent strip test was 69.0% and 44 and 38% for the interview technique and visual examination respectively. The reagent strip test was particularly useful for screening children (5-19 years old). The implication of these findings are discussed.

Abdominal ultrasonography for assessing morbidity from schistosomiasis. 2. Hospital studies

Abdominal ultrasound, which uses a pulse echo device to record reflected waves of a sound beam in 2 dimensions, has revolutionized the evaluation of schistosomal morbidity. It is relatively inexpensive, rapid, simple to perform and portable, causes no biological hazards to the subject and, because of its speed, is ideal for diagnosis and directing interventions, e.g., biopsies. Ultrasound complements or replaces intravenous pyelography, cystoscopy, endoscopy, liver biopsy, angiography and other invasive techniques for studying morbidity due to schistosomiasis. The sensitivity and specificity of ultrasound, in comparison to these other procedures, for detecting schistosomal lesions has been between 80% and 100%, with the exception of detection of hydroureter, ureteral calculi and calcified bladder. Ultrasound is the best method for measuring liver and spleen size and configuration; detecting and grading periportal fibrosis, portal hypertension, hydronephrosis and urinary bladder wall lesions; and for demonstrating renal and bladder 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.

Schistosomiasis in childhood

Schistosomiasis is a parasitic disease of the tropics which is estimated to affect up to 300 million people worldwide. In endemic areas the childhood age group has the highest prevalence and intensity of infection. There are several distinct species of schistosomes. The principal organ system involved in Schistosoma haematobium infection is the urinary tract since parasite eggs penetrate the bladder and are excreted in the urine. Hematuria, proteinuria, leukocyturia and symptoms like dysuria or nocturia are the most common clinical presentations. Heavily infected patients show obstructive uropathy of different severity which may lead to renal failure. Intestinal schistosomiasis is caused by Schistosoma mansoni infection. Initial symptoms can be diarrhea and blood-tinged stool. Chronic infection is characterized by fibrotic involvement of the liver and consecutive portal hypertension. The diagnosis of schistosomiasis depends on the demonstration of schistosome eggs in human excreta or biopsy material. Imported cases of schistosomiasis to Europe show an increasing tendency due to expanding international travel. Furthermore imported cases are usually not diagnosed until years after the patients have left an endemic area. The treatment of choice is a single dose of praziquantel 40 m/kg bodyweight resulting in cure rates of around 90% and considerable reversibility of pathological abnormalities due to schistosome infections.

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.

Proteinuria, hematuria, and leukocyturia in children with mixed urinary and intestinal schistosomiasis

Quantitative parasitological assessment and quantitative analysis of proteinuria, hematuria, and leukocyturia were carried out in 182 Sudanese schoolboys with mixed urinary and intestinal schistosomiasis. Pathological proteinuria was found in 73% of patients (median = 380, 95% confidence limits = 200 to 500 mg/liter). The median protein/creatinine ratio was 0.54. SDS polyacrylamide gel electrophoresis showed an excretion of albumin, transferrin, and IgG consistent with a postrenal pattern of proteinuria. Pathological erythrocyturia occurred in 84% of patients (median = 255, 95% CL = 95 to 629 cells/microliter) and leukocyturia in 77% of patients (median = 148, 95% CL = 93 to 246 cells/microliter). Phase contrast microscopy revealed intact erythrocytes, suggestive of postrenal hemorrhage. Proteinuria, erythrocyturia, and leukocyturia correlated significantly with the ova excretion in the urine, but not with egg excretion in the stool. Oxamniquine reduced ova excretion in the stool but did not influence pathological urine findings. In patients treated effectively with Praziquantel or Metrifonate, pathological PU, EU, and LU decreased markedly 1 month post treatment. PU in severely proteinuric patients reached physiological values 5 months post therapy. We suggest that the proteinuria, erythrocyturia, and leukocyturia in mixed schistosomiasis were of postrenal origin.

Isotope renography and urinary schistosomiasis: a study in a Gambian community

A transportable apparatus for isotope renography, which allowed deconvolution analysis, was used to study the prevalence and prognosis of abnormalities associated with urinary schistosomiasis. Before carrying out studies in a heavily infected community, observations were made in a non-endemic area to allow derivation of criteria for abnormality. Comparison of the findings in the two areas showed that changes suggesting urinary tract obstruction were more common in the endemic area in subjects between nine and 45 years but not in older subjects. Measurements of effective renal plasma flow showed renal function was impaired in the endemic area in subjects older than 17 years but not in younger subjects. In the endemic area the results of renography were unrelated to the urinary egg count of the subjects examined, but there was an improvement in the abnormal renograms in a group of subjects aged between nine and 20 years who were re-examined a year after treatment with metrifonate. Follow-up data about 316 subjects was obtained two years after renography. Nine subjects had died, including four of the five subjects with abnormalities suggesting both obstruction and over-all loss of renal function. These findings, which are comparable to the results of similar studies using radiological techniques, suggest urinary schistosomiasis may be a significant cause of mortality in adults in intensely infected communities.

Urography and cystoscopy in bladder mucosal abnormality

A prospective study was carried out on 60 patients. The diagnostic usefulness of intravenous urography (IVU) compared with that of cystoscopy in assessing the state of the bladder mucosa was evaluated. Collectively, radiology was as good as cystoscopy in suggesting the final diagnosis of the location and severity of a mucosal lesion. The after-micturition film (AMF) from IVU was the single most informative film which produced correct results in 59 of 60 patients. The full bladder film was the least useful examination and in 45 cases suggested an incorrect or misleading diagnosis.

Relation between intensity of Schistosoma haematobium infection and clinical haematuria and proteinuria

In an endemic area on Lake Volta, Ghana, urinary blood and protein levels as determined by chemical reagent strips in persons infected with Schistosoma haematobium, particularly in children aged between 5 and 14, correlated positively with urinary egg counts. Geometric mean S haematobium egg counts were 10 or more times higher in urine specimens with at least 10 mg/dl of protein and detectable haematuria than in those without detectable blood or protein. Chemical reagent strips were both specific and sensitive for detection of urinary blood associated with S haematobium infection. This simple technique could be useful for screening entire populations in which urinary schistosomiasis is endemic so that heavily infected persons needing specific treatment can be identified.