Urogenital Schistosomiasis: No Longer a Diagnosis of the Developing World, M Weerakoon, D Ow, D Wetherell, BK Beharry

Tags: schistosomiasis, migrant populations, Africa, Australia, Heidelberg, Victoria, Australia Abstract, Schistosoma haematobium, Austin Hospital, Urology Unit, Heidelberg, Victoria, Australia 3Department, patient, Research Article, XNH 6FKLVWRVRPD haematobium causes urogenital, XNHV WUHPDWRGH ZRUPV RI WKH JHQXV 6FKLVWRVRPD 7KHUH DUH WZR PDMRU IRUPV RI VFKLVWRVRPLDVLV LQWHVWLQDO DQG XURJHQLWDO 7KH EORRG, LWK WKH LQFUHDVH RI PLJUDQW SRSXODWLRQV WR, differential diagnosis, Emergency Department, University of Melbourne, infectious disease unit, Damien Bolton1, Heidelberg, Victoria, Australia 2Ludwig Institute for Cancer Research, clinical presentation, health care system, ongoing support, Med Surg Urol Citation, endemic diseases, developed world, developing world, genital lesions, Praziquantel, World Health Organization, anaemia, S. haematobium, hydronephrosis, scale treatment, renal failure, Chronic disease results, development partners
Content: Medical & Surgical Urology- Open Access
Med Surg Urol
Research Article
Open Access
6SPHFOJUBM4DIJTUPTPNJBTJT/P-POHFSB%JBHOPTJTPGUIF%FWFMPQJOH 8PSME
Mahesha Weerakoon1*, Darren Ow1, David Wetherell1, Bhawanie Koonj Beharry1, David Williams3, Ania Sliwinski1, Kiran Manya1, Damien Bolton1 and Nathan Lawrentschuk1,2 1Department of Surgery, University of Melbourne, Urology Unit, Austin Hospital, Heidelberg, Victoria, Australia 2Ludwig Institute for Cancer Research, Austin Hospital, Heidelberg, Victoria, Australia 3Department of Pathology, University of Melbourne, Austin Hospital, Heidelberg, Victoria, Australia
Abstract 6FKLVWRVRPLDVLV LV D FKURQLF SDUDVLWLF GLVHDVH FDXVHG E\ WKH EORRG АXNHV WUHPDWRGH ZRUPV RI WKH JHQXV 6FKLVWRVRPD 7KHUH DUH WZR PDMRU IRUPV RI VFKLVWRVRPLDVLV LQWHVWLQDO DQG XURJHQLWDO 7KH EORRG АXNH 6FKLVWRVRPD haematobium causes urogenital schistosomiasis, with its highest prevalence in Africa and the Middle East. Given the emerging migrant populations in Australia, from the Africa and Middle East, urogenital schistosomiasis needs to be given consideration in differential diagnosis of patients with renal colic, cystitis, haematuria and urinary tract stricture/ obstruction. Travel history is also pertinent to diagnosis. The burden of schistosomiasis in the developing world is UHPDUNDEO\ KLJK ZLWK PLOOLRQ SHRSOH UHTXLULQJ WUHDWPHQW LQ :LWK WKH LQFUHDVH RI PLJUDQW SRSXODWLRQV WR $XVWUDOLDWKHEXUGHQRIGLVHDVHDQGLWVLPSOLFDWLRQVQHHGWREHDFNQRZOHGJHGLQWKHGHYHORSHGZRUOG
Keywords: Schistosoma haematobium; Pathology; Pathogenesis; Epidemiology; Parasitology; Urogenital schistosomiasis; Schistosomiasis; urinary bladder neoplasms case study A 20-year-old African migrant presents to the Emergency Department with a 24-hour history of le ank pain and dysuria. e patient denied any history of trauma, sexual activity or family history of signi cant illness and is otherwise t and healthy. He recently migrated to Australia from the Democratic Republic of the Congo in 2009 as a refugee. Urinalysis revealed erythrocytes and leucocytes. Renal tract imaging in the form of a CT KUB revealed extensive calci cation of his distal le ureter suggestive of renal tract calculi (Figures 1 and 2). e patient underwent cystoscopy, le retrograde pyleogram and ureteroscopy revealing a heavily calci ed ureteric wall with biopsies revealing oval, heavily calci ed, well circumscribed structures characteristic of calci ed schistosoma eggs under the glandular mucosa. On further investigation, the patient had a urine specimen sent externally in 2007 for investigation of macroscopic haematuria, which indicated the presence of Schistosoma haematobium of moderate severity. e patient was subsequently lost for follow up. ey are now under the management of an infectious disease unit, receiving active treatment with praziquantel and are currently well. Background e presentation of urogenital schistosomiasis is relatively uncommon in the developed world with prevalence mainly in tropical and subtropical areas, with exposure to or working in agriculture deemed as the highest risk [1]. Given the recent surge in migrant populations in Australia [2] schistosomiasis as a di erential diagnosis warrants consideration. Since the year 2000, we have had seven case reports of urogenital schistosomiasis at our tertiary centre. Out of the seven patients, ve had recently migrated from Africa; one patient had recently traveled to Africa and one patient having recently migrated from the Middle East. is number is slightly higher in comparison to four presentations in six years at two di erent Australian infectious disease units at two di erent hospitals in Melbourne [3]. Discussion Key facts Schistosomiasis is a chronic, parasitic disease caused by blood ukes
(trematode worms) of the genus Schistosoma [4]. ere are two major forms of schistosomiasis; intestinal and urogenital, with urogenital schistosomiasis caused by the blood uke Schistosoma haematobium, with its highest prevalence in Africa and the Middle East [1]. Epidemiology Schistosomiasis is prevalent in tropical and sub- tropical areas. It is especially common in poor communities without access to safe Figure 1:&7.8%WUDQVYHUVHVHFWLRQUHYHDOLQJFLUFXPVFULEHGFDOFLїHGOHVLRQ of distal left ureter. *Corresponding author:0DKHVKD:HHUDNRRQ5RRP/HYHO+DUROG6WRNHV %XLOGLQJ$XVWLQ+RVSLWDO6WXGOH\5RDG+HLGHOEHUJ9LFWRULD$XVWUDOLD7HO )D[([email protected] Received-XO\Accepted-XO\Published-XO\ Citation::HHUDNRRQM, Ow D:HWKHUHOOD, Beharry BK:LOOLDPVD, et al. 8URJHQLWDO6FKLVWRVRPLDVLV1R/RQJHUD'LDJQRVLVRIWKH'HYHORSLQJ:RUOGMed Surg UrolGRL9 Copyright: © :HHUDNRRQM, et al7KLVLVDQRSHQDFFHVVDUWLFOHGLVWULEXWHG under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Med Surg Urol

Citation: :HHUDNRRQM, Ow D:HWKHUHOOD, Beharry BK:LOOLDPVD, et al. 8URJHQLWDO6FKLVWRVRPLDVLV1R/RQJHUD'LDJQRVLVRIWKH'HYHORSLQJ :RUOGMed Surg UrolGRL9
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Figure 2:&RURQDOVHFWLRQUHYHDOLQJZHOOFLUFXPVFULEHGFDOFLїFDWLRQWKURXJKRXW the distal left ureter. drinking water and adequate sanitation; hence people at highest risk are those involved with agricultural, domestic and recreational activities, which expose them to infested water [3]. Currently, at least 90% of people requiring treatment for Schistosomiasis live in Africa. S.haematobium, the primary cause for urogenital schistosomiasis has the highest prevalence in Africa and the Middle East [1]. WHO statistics indicate that 243 million people required treatment for schistosomiasis in 2011 [1,5]. In areas of overall higher levels of infection, urogenital schistosomiasis is known to peak in the 6-20 age groups with areas of lower levels of infection more prevalent in older age groups. is observation is attributed to the development of acquired immunity [6]. Transmission and pathogenesis Freshwater snails release the parasite (larval forms) into the water, which is then penetrates the skin during contact with infested water. e female parasite S. haematobium then in ltrates pelvic veins and releases terminal spine eggs, which then penetrate the tissues of the pelvic organs, where they are eventually excreted through the urine [7]. Some of these eggs fail to exit the bladder thus embolize within the capillary necks of the pelvic end organs and tissues [7]. ey induce granulomas and small brotic nodules known as `sandy patches' [8]. is then causes bladder and urethral in ammation associated with haematuria in greater than 50% of cases and associated deformities of the collecting system, primarily ureteric stricture and obstructions, cystitis, hydronephrosis and ultimately renal failure if le untreated. e in ammatory cascade caused by S. haematobium also activates oncogenes, inactivates tumour suppressor gens and alternates in apoptotic gene products, hence predisposing patients to carcinoma of the bladder [8]. S. haematobium also predisposes women (more than men) to HIV infection through immunomodulation mechanisms [9]. clinical signs and symptoms Signs and symptoms of schistosomiasis exhibited are as a result of the body's reaction to the parasites' eggs, as opposed to the worms themselves [7]. With urogenital schistosomiasis, the most common presentations are dysuria, frequency and haematuria [10]. Fibrosis,
cystitis and strictures associated with the bladder and ureter, as well as hydronephrosis and renal failure are sequelae of advanced disease. Carcinoma of the bladder is also a late complication [9,11]. Women may present with genital lesions, vaginal bleeding, dyspareunia, and nodules of the vulva [5]. Genital lesions may cause epididymitis, salpingitis, endometritis and cervicitis, which may induce sterility [1,10]. e largest burden and commonest presentation in children is chronic anaemia, due to blood loss from haematuria and production of hemolytic factors by schistosoma [8]. Investigations Diagnosis is based on the presence of S. haematobium eggs in the urine. Urine collection should be between 11 am and 2 pm (peak output) with an egg count as an indicator to severity of disease (<100 eggs- light infection, 100 - 400 ­ moderate infection, >400 severe infection). Congo red stain is o en used in conjunction to assess for viability of eggs [10]. Economic and health burden e burden of disease associated with S. haematobium (accounting for up to 2/3 of all diagnosed schistosomiasis) is considerable with up to two- thirds of schistosomiasis accounting for S. haematobium [6]. Anaemia in children results in stunting of growth and reduced ability to learn although these e ects are reversible with treatment [9]. Chronic disease results in long-term inability for people to work and in some instances results in death associated with chronic diseases related to anaemia. In sub- Saharan Africa alone, there are around 200,000 deaths per year due to schistosomiasis[1,5]. Treatment and prevention control Praziquantel is the Gold Standard in treatment against all forms of schistosomiasis. Metrifonate is also an alternative source however is not available in all countries [10]. Praziquantel works by disturbing the ionic exchange through the worms membrane resulting in tetanic paralysis and reduced glucose absorption [10]. Praziquantel is e ective, safe and low- cost. Despite the risk of re- infection post treatment, the risk of developing severe disease is diminished and even reversed when treatment is initiated and repeated in childhood [1]. e control of schistosomiasis relies on large- scale treatment of atrisk population groups, with access to safe water improved sanitation, hygiene education and snail control at high priority. At risk populations according to the World Health Organizations' targeted for treatments include school- aged children in endemic areas; adults considered to be at risk in endemic areas, people with occupations involving contact with infested water such as shermen, farmers, irrigation workers, and women, whose domestic tasks bring them into contact with infested water. Entire communities living in highly endemic areas have also been targeted [1]. Success in treatment and prevention control relies on access to praziquantel, with evidence suggesting that only 10% of people requiring treatment were reached in 2011. Monitoring is essential and the key tool in determining the impact of control interventions [5]. e World Health Organization's response to schistosomiasis involves coordinating the strategy of preventive chemotherapy in consultation with collaborating centers, academic and research institutions, international development agencies and other United Nations organizations. Working with partners, WHO has advocated for increased access to praziquantel and resources for implementation [1]. A substantial amount of praziquantel, to treat more than 100
Med Surg Urol

Citation: :HHUDNRRQM, Ow D:HWKHUHOOD, Beharry BK:LOOLDPVD, et al. 8URJHQLWDO6FKLVWRVRPLDVLV1R/RQJHUD'LDJQRVLVRIWKH'HYHORSLQJ :RUOGMed Surg UrolGRL9
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million children of school age per year has been pledged by the private sector and development partners [1,5]. Conclusion e economic and health burden of schistosomiasis in the developing world is substantial. Given the current uctuations in migration populations to the developed world, it is essential that diseases endemic to a patient's country of origin or exposure be seriously considered in the di erential diagnosis of their clinical presentation. As already highlighted, the implications of advanced disease and misdiagnosis pose a severe burden of disease on the patient. is also stipulates a burden on the economic and health care system as well. Great care and ongoing support into the treatment and prevention controls of such endemic diseases must be a consideration of the developed world, in lieu of the dynamics in population growth and development. Con ict of Interest Authors declared that there is no con ict of interest. References 1. :RUOG+HDOWK2UJDQLVDWLRQ0HGLFD&HQWUH6FKLVWRVRPLDVLV. 2. $XVWUDOLDQ%XUHDXRI6WDWLVWLFV3HUVSHFWLYHRQ0LJUDQWV
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Med Surg Urol


M Weerakoon, D Ow, D Wetherell, BK Beharry

File: urogenital-schistosomiasis-no-longer-a-diagnosis-of-the-developing.pdf
Title: Urogenital Schistosomiasis: No Longer a Diagnosis of the Developing World
Author: M Weerakoon, D Ow, D Wetherell, BK Beharry
Author: Mahesha Weerakoon
Subject: Weerakoon M, Ow D, Wetherell D, Beharry BK, Williams D, et al. (2013) Urogenital Schistosomiasis: No Longer a Diagnosis of the Developing World. Med Surg Urol 2: 109. doi:10.4172/2168-9857.1000109
Keywords: Schistosoma haematobium; Pathology; Pathogenesis; Epidemiology; Parasitology; Urogenital schistosomiasis; Schistosomiasis; Urinary bladder neoplasms
Published: Fri Dec 27 22:45:31 2013
Pages: 3
File size: 0.86 Mb


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