Pulmonary shunts in severe hepatosplenic schistosomiasis: Diagnosis by contrast echocardiography and their relationship with abdominal ultrasound findings

Background

Schistosomiasis is endemic to several parts of the world. Among the species that affect humans, Schistosoma mansoni is one of the most common causes of illness. In regions where schistosomiasis mansoni is endemic, reinfection is responsible for the emergence of hepatosplenic schistosomiasis (HSS) with portal hypertension in about 10% of infected individuals. Regardless of its etiology, portal hypertension may bring about the formation of arteriovenous fistulas and pulmonary vascular dilation, thus constituting a pulmonary shunt and its presence has been associated with the occurrence of neurological complications. The objective of this study was to identify pulmonary shunt using TTCE in patients with HSS and esophageal varices, and to compare the abdominal ultrasound and endoscopy findings among patients with and without pulmonary shunt.

Methodology/Principal findings

In this case series, a total of 461 patients with schistosomiasis mansoni were prospectively evaluated using abdominal ultrasound and endoscopy and 71 presented with HSS with esophageal varices. Fifty seven patients remained in the final analysis. The mean age of the patients was 55 ± 14 years, and 65% were female. Pulmonary shunts were observed in 19 (33.3%) patients. On comparing the groups with and without pulmonary shunt, no significant differences were observed in relation to the abdominal ultrasound and endoscopic findings. When comparing the two subgroups with pulmonary shunts (grade 1 vs grades 2 and 3), it was observed that the subgroup with shunt grades 2 and 3 presented with a significantly higher frequency of an enlarged splenic vein diameter (>0.9 cm), and an advanced pattern of periportal hepatic fibrosis (P = 0.041 and P = 0.005, respectively). None of the patients with pulmonary shunts had severe neurological complications.

Conclusions/Significance

Our findings suggest that in HSS with esophageal varices the pulmonary shunts may be present in higher grades and that in this condition it was associated with ultrasound findings compatible with advanced HSS.

Among the species of Schistosoma that infect humans Schistosoma mansoni is one of the most common causes of illness. In the areas where schistosomiasis mansoni is endemic, around 10% of infected individuals develop hepatosplenic schistosomiasis (HSS) with portal hypertension. Portal hypertension may promotes an imbalance in the hepatic production of vasoactive substances, which may act on the lungs promoting the formation of arteriovenous fistulas and pulmonary vascular dilation, a condition that is called a pulmonary shunt. When the pulmonary shunt is of higher grades, small thrombus or septic emboli that would normally be filtered through the pulmonary capillaries reach the left heart and the systemic circulation, which can lead to neurological complications. We found pulmonary shunts in patients with HSS and esophageal varices and we also found that patients with higher grades of pulmonary shunts presented with a significantly higher frequency of advanced periportal fibrosis and an enlarged splenic vein diameter. No neurological complications were observed. Our findings suggest that pulmonary shunts may be present in patients with HSS and esophageal varices. The abdominal ultrasound findings compatible with advanced HSS could be used as screening to investigate pulmonary shunt.

Caput Medusae due to portal hypertension in schistosomiasis mansoni

A 62-year-old Brazilian man who lived in endemic areas of tropical diseases had an episode of hematemesis associated with portal hypertension. He used to swim in natural ponds during childhood and developed the hepatosplenic form of schistossomiasis with moderate ascites, in addition to the characteristic features of abdominal Caput Medusae. The aim of the report is highlight the role of chronic liver disease and schistossomiasis.

Splenic artery ligature associated with endoscopic banding for schistosomal portal hypertension

AIM: To propose a less invasive surgical treatment for schistosomal portal hypertension.

METHODS: Ten consecutive patients with hepatosplenic schistosomiasis and portal hypertension with a history of upper gastrointestinal hemorrhage from esophageal varices rupture were evaluated in this study. Patients were subjected to a small supraumbilical laparotomy with the ligature of the splenic artery and left gastric vein. During the procedure, direct portal vein pressure before and after the ligatures was measured. Upper gastrointestinal endoscopy was performed at the 30^th postoperative day, when esophageal varices diameter were measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings.

RESULTS: There was no intra-operative mortality and all patients had confirmed histologic diagnoses of schistosomal portal hypertension. During the immediate postoperative period, two of the ten patients had complications, one characterized by a splenic infarction, and the other by an incision hematoma. Mean hospitalization time was 4.1 d (range: 2-7 d). Pre- and post-operative liver function tests did not show any significant changes. During endoscopy thirty days after surgery, a decrease in variceal diameters was observed in seven patients. During the follow-up period (57-72 mo), endoscopic therapy was performed and seven patients had their varices eradicated. Considering the late postoperative evaluation, nine patients had a decrease in variceal diameters. A mean of 3.9 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence at the late postoperative period, which was controlled with endoscopic banding in one patient due to variceal rupture and presented as secondary to congestive gastropathy in the other patient. Both bleeding episodes were of minor degree with no hemodynamic consequences or need for blood transfusion.

CONCLUSION: Ligature of the splenic artery and left gastric vein with supraumbilical laparotomy is a promising and less invasive method for treating presinusoidal schistosomiasis portal hypertension.

[Endoscopic variceal ligation in prevention from esophageal variceal hemorrhage of advanced schistosomiasis patients]

OBJECTIVE

To evaluate the effect of the endoscopic esophageal variceal ligation on the prevention from recurrence of esophageal varices and variceal hemorrhage.

METHODS

Forty-two advanced schistosomiasis patients with variceal hemorrhage in the treatment group received the endoscopic esophageal variceal ligation, and 30 patients in the control group did not, and all of them had oral propranolol, spironolactone and 5 single-isosorbide dinitrate etc. in hospital for the same period and had these drugs for 3-6 months after discharge. The re-examinations of endoscopy were performed once 3 to 6 months.

RESULTS

The time of follow-up was from 2 to 3 years and the average was 29 months. In the treatment group, the rate of recurrence of esophageal varices was 19.0% (8/42) and the average time was 30 months; the incidence of esophageal variceal bleeding was 11.9% (5/42) and 2 patients died. In the control group, the rate of recurrence of esophageal varices was 43.3% (13/30) and the average time was 18 months; the incidence of esophageal variceal bleeding was 36.7% (11/30) and 7 patients died. The therapeutic efficacy of the treatment group was much superior to that of the control group.

CONCLUSION

The endoscopic esophageal variceal ligation is effective and safe, and can become one of the preferred methods in the prevention from variceal hemorrhage.

[Case report: Budd-Chiari syndrome and esophageal variceal bleeding due to alveolar echinococcosis]

Alveolar echinococcosis of the liver is a rare larval cestode disease which is due to the intrahepatic growth of the tapeworm Echinococcus multilocularis. This cestode naturally evolves as a larval stage within cysts in the body of carnivores. Humans are accidental intermediate hosts and become infected, either by eating food contaminated with carnivore-originated eggs or by touching foxes. It behaves as malignant liver tumour and rarely causes Budd-Chiari syndrome and variceal bleeding. Budd-Chiari syndrome is a hepatic venous outflow tract obstruction and may be present abdominal pain, hepatomegaly and ascites. Parasitic cysts may cause compression and thrombosis of the hepatic venous outflow tract. It may present as portal hypertension and variceal upper gastrointestinal bleeding. We here in report a 47-year-old woman without a prior history of liver disease presented with Budd-Chiari syndrome and variceal bleeding due to Alveolar echinococcosis. The course of this rare disease is demonstrated by means of the most important laboratory, serologic and radiologic parameters.

Death related to albendazole-induced pancytopenia: case report and review

Albendazole is a benzimidazole with wide spectrum coverage as an antiparasitic drug. Reported side effects have been minimal. We report the case of a patient who died with severe prolonged pancytopenia beginning during the third week of therapy for a pulmonary echinococcal cyst. This case was a 68-year-old man who presented with a large cystic lung mass. His medical history was significant for Child-Pugh class B cirrhosis. A prolonged course of albendazole was initiated. Two weeks later, the patient presented in septic shock with severe pancytopenia. The patient was initially resuscitated, but died after 10 days with no marrow recovery. Autopsy was consistent with albendazole-induced pancytopenia. This is the third human case of pancytopenia and the first death reported in relation to albendazole-induced pancytopenia. Neutropenia seems to be related more to higher dosage and longer duration of use. Albendazole sulfoxide peak dose and half life are significantly prolonged by liver disease and concomitant administration of certain drugs. The severity and duration of albendazole-induced pancytopenia in this case was likely related to the underlying liver disease. Frequent serial monitoring of blood counts and cessation of medication with any evidence of marrow toxicity in such patients is warranted.

Magnetic resonance imaging and ultrasound in hepatosplenic schistosomiasis mansoni

We report the findings of abdominal ultrasound and magnetic resonance imaging observed in a patient with advanced schistosomiasis mansoni. A 25-year-old man with hepatosplenic schistosomiasis and variceal bleeding confirmed by upper endoscopy was submitted to abdominal ultrasound and magnetic resonance imaging. During surgery for portal hypertension, a liver biopsy was taken and the diagnosis of Symmers' fibrosis was confirmed. magnetic resonance imaging scans gave more precise information about the gallbladder, periportal thickening and abdominal venous system than did the ultrasound.

[Decompensated post-schistosomiasis portal hypertension in Richard-Toll, Senegal: first case treated by splenorenal anastomosis in Dakar]

Since the Diama dam on the Senegal river became operative in 1986, an exceptional outbreak of intestinal schistosomiasis occurred in northern Senegal. This is the first case report from this region of a splenorenal derivation performed in Dakar to cure decompensated portal hypertension due to Schistosoma mansoni.

CASE REPORT

In June 1998, a 16-year old boy, native from Richard-Toll in the Senegal River Basin, was admitted to the paediatric department of Hôpital Principal, Dakar, Senegal, with a 3 years of recurrent hematemesis. Blood transfusions were required despite propranolol and multiple oesophageal varices sclerotherapies. On admission he weighed 33 kg and was noted to have pallor and moderate hepatosplenomegaly. Lab work included normal liver function tests, a Hgb of 58 mg/L, negative HBs antigen, and high titers of schistosomiasis antibodies (> 1/2000 by the hemagglutination method). Ultrasound revealed an homogeneously enlarged liver, periportal fibrosis and spleen with a grade 2 portal hypertension (WHO score). Endoscopy showed stage 3 oesophageal varices with red spots but no active haemorrhage. After transfusions, a Warren distal splenorenal anastomosis was performed. During the operation, a liver biopsy was obtained, showing periportal fibrosis and schistosomiasis granulomas. The patient was discharged without complication. After 4 years he remains free of any recurrence of his upper gastrointestinal haemorrhage and haemoglobin rate is normal.

COMMENTS

Before the inauguration of the dam in 1986, S. mansoni infection was never reported from the Senegal River Basin. But as early as 1988, the first cases of intestinal schistosomiasis began to show up. A few years later, this focus had dramatically extended and in 1991 the first cases of hepatic fibrosis were detected in ultrasonography surveys. The present case involves the first patient from northern Senegal who required surgery for haemorrhagic complications of schistosomiasis induced by liver disease. Considering the high prevalence in this area, and the difficulties of medical management, the need for porto-systemic derivations is likely to rise. These operations are difficult and require specially trained surgeons. They have been largely unavailable in Senegal until now. This case report, involving a child only 10 years after the beginning of the epidemic, underlines the acute need for improving both prevention and medical treatment in order to avoid progression to clinical stages of hepatic schistosomiasis where surgery is unavoidable. In addition, the training of local surgical teams able to deal with these complications is urgently needed in Senegal.

Measuring morbidity in schistosomiasis mansoni: relationship between image pattern, portal vein diameter and portal branch thickness in large-scale surveys using new WHO coding guidelines for ultrasound in schistosomiasis

OBJECTIVE

World Health Organization consensus meetings on 'Ultrasound in Schistosomiasis' in 1996 and 1997 anticipated further challenges in the global implementation of a standardized protocol for morbidity assessment in schistosomiasis mansoni. We evaluated the performance of the qualitative and quantitative components of the new Niamey criteria.

METHOD

Use of the Niamey protocol among 3954 subjects in two linked, cross-sectional ultrasound surveys of Schistosoma mansoni-endemic populations in Egypt and Kenya.

RESULTS

There were significant differences between Egyptian and Kenyan sites in prevalence and age distribution of S. mansoni-related hepatic fibrosis (36%vs. 3%, P < 0.001). Protocol image pattern scoring could be performed quickly and was stable to interobserver variation. However, there were unintended but systematic differences between study sites in the measurement of portal vein diameter (PVD) and wall thickness. By Niamey criteria, a high prevalence of portal dilation was scored for normal Egyptian subjects, which reduced the predictive value of image pattern for portal hypertension. Using alternative height-indexing of PVD, image pattern plus PVD findings predicted 15% of Egyptians and 2.5% of Kenyans were at risk for variceal bleeding, whereas locally derived PVD norms estimated 25% of Egyptians and 12% of Kenyans to be at possible risk.

CONCLUSION

Niamey scoring criteria performed acceptably as a relative grading system for disease in schistosomiasis mansoni, but failed to account fully for site-to-site variation in test performance and morbidity prevalence. Consequently, standardized image pattern scoring appears to provide the most useful tool for detection and comparison of S. mansoni-associated morbidity in large-scale surveys.

[Predictive ultrasonographic criteria for portal hypertension due to Schistosoma mansoni in a recently established endemiz zone]

The first cases of Schistosoma mansoni infection were reported in the Senegal River Basin ten years ago. Today endemicity is so high that prevalence rates exceed 90 p. 100 in some areas. Schistosomiasis sometimes goes undiagnosed until the occurrence of portal hypertension with rupture of esophageal varices. Endoscopy is the gold standard for detection of esophageal varices but it is impractical in remote areas. Ultrasonography has been proposed as a non-invasive alternative. The purpose of this study is to describe the results of simultaneous endoscopic and ultrasonographic assessment in 101 subjects from the Richard-Toll area of the Senegal River Basin. Findings showed that severe forms of schistosomiasis complicated by portal hypertension were already present in the region less 10 years after description of the first case. This study also proposes a diagnostic score for portal hypertension based on ultrasonographic findings. The features included in this score are thickening of portal vessel walls, portal vessel diameter, and collapsed appearance of the splenic vein during inspiration. In our hands this score allowed reliable prediction of the development of esophageal varices. Ultrasonography is a good tool for identifying severe forms of schistosomiasis. It should be useful for routine screening in recently established endemic zones.

Effects of single-dose praziquantel on morbidity and mortality resulting from intestinal schistosomiasis

The long-term effect of single-dose praziquantel on morbidity and mortality from Schistosoma mansoni was investigated in surveys in 1987 and 1994 in central Sudan. Prevalence of infection dropped from 53% to 34%, and intensity of infection (> or = 400 eggs/g of faeces) from 31% to 18%. There was a reduction in hepatomegaly and hepatosplenomegaly, although splenomegaly alone was unchanged. Prevalence of periportal fibrosis decreased from 14% to 10%. Endoscopic investigation of patients with fibrosis showed a reduction in oesophageal varices from 47% to 30%. Mortality due to bleeding varices was high (community-wide, up to 11/100 infected patients with bleeding). Thus praziquantel mass treatment can be spaced to a much longer period, reducing the expense of treatment, delivery and distribution.

Sonographic prediction of variceal bleeding in patients with liver fibrosis due to Schistosoma mansoni

Several studies have shown that the characteristic hepatic abnormalities induced by Schistosoma mansoni detectable by ultrasound correlate with the degree of oesophageal varices. So far the value of ultrasound for predicting variceal haemorrhage has not been assessed. Fifty Brazilian patients with schistosomal periportal fibrosis from Alagoas State, 18 of whom had already bled from oesophageal varices, were enrolled in a combined cross-sectional and longitudinal study and investigated clinically, by endoscopy and by ultrasound. Twenty-seven of the patients were monitored until another bleeding episode, death or for a minimum of 28 months. Eight of these patients could be followed up for a further three years. A sonographic score, which accounts for the degree of echogenic periportal thickening and of portal vein dilatation, was calculated for all patients. A highly significant correlation (P < 0.0001) existed between the sonographic score and the occurrence of previous variceal haemorrhage, paralleled by a similar correlation between the sonographic score and the degree of oesophageal varices (P < 0.001). In the 27 patients monitored longitudinally, the sonographic score indicated the risk of future variceal bleeding (P < 0.0001). The sonographic score reliably predicts the risk of variceal bleeding in individual patients with periportal fibrosis. Hence, the application of endoscopy, if available at all in endemic areas, may be restricted to the patients at risk of future variceal bleeding, as determined by ultrasound. Since portable devices can be carried even to remote areas, the application of the proposed score in community surveys could provide a new means for the identification of high-risk patients in S. mansoni-infected populations.

Clinical and endoscopic aspects of hepatosplenic schistosomiasis in Uganda

INTRODUCTION

Hepatosplenic schistosomiasis is characterized by hepatic periportal fibrosis (Symmers' fibrosis), portal venous obstruction that leads to portal hypertension and its complications, and splenomegaly. Demonstration of pathological lesions due to Schistosoma mansoni can be achieved by using different techniques but because of its sensitivity, specificity and simplicity, ultrasound has replaced wedge biopsy of the liver as the gold standard for detecting schistosomal periportal fibrosis. The aims of the study were to evaluate clinical aspects of schistosomiasis in a well defined area and to assess whether there was a relationship between the grade of periportal fibrosis and the presence of oesophageal varices and their features.

MATERIALS AND METHODS

A total of 122 patients with proven schistosome infection were enrolled in the study. Each underwent ultrasound examination to assess hepatosplenic involvement and staging, and upper digestive endoscopy to assess the presence of oesophageal varices and their features. For all the patients, the main characteristics and symptoms, possibly related to schistosomiasis, were also recorded.

RESULTS

A close relationship was found between the grade of periportal fibrosis and the presence of oesophageal varices, their grade and localization in the oesophagus. There was also was a relationship between haematemesis and size of varix, localization of varix and presence of cherry-red spots, but no correlation was found with other endoscopic features of varices.

CONCLUSION

Clinical aspects of schistosomiasis in Hoima District are similar to what is known from the literature and there are no specific features. The study shows that ultrasonography is an important tool for accurate staging of hepatosplenic schistosomiasis. Although it cannot replace endoscopy, it can direct the need for performing it. In fact, the higher the grade of periportal fibrosis the greater the possibility of having oesophageal varices. Endoscopy is of value in detecting oesophageal varices especially in advanced stages of liver schistosomiasis, in describing their endoscopic features so as to detect those more at risk of bleeding, and for emergency sclerotherapy.

[Imported schistosomiasis with late complications]

Schistosomiasis is a worm disease which causes a high mortality rate all over the world. The life span of worms can be 20-30 years, so if the acute phase of the disease is not fatal very often late complications can happen. Here we demonstrate two patients who suffered from different late complications of Schistosomiasis imported to our country. These two cases show the difficulty of diagnosis and therapy of such illnesses.

Tropical splenomegaly syndrome: who gets oesophageal varices?

Of sixty eight patients with tropical splenomegaly syndrome (TSS), 12 had asymptomatic oesophageal varices (OV). All 12 had massive splenomegaly (Hackett's stage 4 or 5). Eight of the 12 were multiparous females, mainly of Rwandese origin. Endoscopic appearance of the varices suggested that TSS varices were not likely to bleed. None of the patients with the varices had abdominal collaterals belonging to the portal system.

Predictors of upper gastrointestinal bleeding in patients with schistosomal periportal fibrosis

A case-control study was conducted between 1985 and 1987 in the Gezira-Managil area of central Sudan to assess the major predictors of haematemesis. Eighty-four patients who had suffered at least one attack of oesophageal bleeding and had schistosomal periportal fibrosis demonstrated by ultrasonography were compared with 173 subjects without bleeding but with ultrasonographic evidence of periportal fibrosis. A splenic longitudinal dimension of more than 11 cm, periportal fibrosis worse than grade I and varices more than grade I were independently associated with a significant risk of variceal bleeding. Age, sex, presence of a palpable liver and portal vein diameter were not associated with a significant risk of bleeding after adjustment for potential confounding variables. Factors identified in this study could be helpful in the prophylactic management of patients with complicated schistosomiasis.

[Sclerotherapy of esophageal varices in schistosomiasis patients]

To assess the therapeutic possibilities of injection sclerosis in schistosomotic portal hypertension, a 5-year prospective study was conducted in northeast Brazil, where this parasitosis is endemic. Fifty patients undergoing endoscopy for upper gastrointestinal hemorrhage from rupture of esophageal varices from July through December 1981 were chosen for the study. The 32 consenting patients were submitted to injection sclerotherapy paravariceally, using ethanolamine oleate; the 18 refusing to participate were assigned to the control group. The incidence of rebleeding was 28.1% in the former and 44.5% in the latter, a difference which was not statistically significant (Fisher's test, p = 0.375). Mortality from rupture of esophageal varices was 3.1% in the sclerotherapy group and 27.7% in the control group, a statistically significant difference (Fischer's test, p = 0.017). Since sclerotherapy markedly improved the long-term survival rate of the patients, this procedure is advocated for the treatment of esophageal varices in cases of portal hypertension due to schistosomiasis.

[Critical evaluation of schistosomiasis portal hypertension surgery]

There are over 100,000 patients affected by schistosomotic portal hypertension, that may suffer rupture of the esophageal varices. Besides the portal hypertension, local factors must be emphasized as responsible for the three distal centimeters of the esophagus, called "zona vulnerável" (vulnerable zone). The better liver functional reserve of these schistosomotic patients as compared to the cirrhotic, present two favorable conditions: (1) better possibility of conservative treatment during acute hemorrhage; (2) elective surgical treatment may be undergo without a mandatory step of large portal decompression. The Author only indicate surgical treatment in patients with hemorrhage antecedent and his preference consist in splenectomy plus obliterative suture of the varices at the "vulnerable zone" and when possible, ligature of left gastric vein also; 358 patients were undergone surgery with operative mortality 3.07%; 347 were followed during 1 to 25 years; late mortality 8.38%; recurrence hemorrhage 11.58%; none porto-systemic encephalopathy was observed.

Schistosomal periportal fibrosis in Zimbabwe: use of ultrasound in patients with oesophageal varices

Ultrasound (U/S) imaging of liver was used in a prospective study of 62 consecutive patients with oesophageal varices in the central hospitals in Harare; 50 had haematemesis. U/S changes of Symmers's periportal fibrosis (PPF) were graded from mild (grade 1) to gross (grade 4). 46 patients (74%) had U/S features of PPF: 7 were grade 1, 7 grade 2, 29 grade 3, and 3 grade 4. Patients with PPF were more likely to have bled (P less than 0.05) and were less likely to have ascites (P less than 0.05) than those without PPF. Spleen or liver size or grade of varices did not correlate with the U/S grade of PPF. Rectal snips were positive for schistosome ova in 19 of 28 cases with PPF and 2 of 7 cases without PPF. Patients with PPF were more likely than those without PPF (P less than 0.005) or controls (P less than 0.0001) to have spent their childhood in an area of Zimbabwe with a high prevalence of Schistosoma mansoni. Schistosomal PPF appears to be a common cause of portal hypertension in Zimbabwe. It is strongly associated with childhood spent in areas of high S. mansoni prevalence.