Schistosomiasis history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Many infections are subclinically symptomatic, with mild anemia and malnutrition being common in endemic areas. Acute schistosomiasis (Katayama's fever) may occur weeks after the initial infection, especially by S. mansoni and S. japonicum.

History

The significant information that needs to focused in the history of the patient includes

• Any history of travel to the endemic areas
• Any ill contact with similar complaints

Symptoms

Clinical manifestations of schistosomiasis can be divided into schistosome dermatitis, acute schistosomiasis (Katayama fever), and chronic schistosomiasis.

Acute schistosomiasis(Katayama fever)

• Acute schistosomiasis occurs 20 to 50 days after primary exposure.
• Malaise, diarrhea, weight loss, cough, dyspnea, chest pain, restrictive respiratory insufficiency, and pericarditis are important symptoms of acute schistosomiasis.
• Mild disease resolves on its own, as the infection progress into an asymptomatic phase, which is often misinterpreted for an effective antibiotic therapy.
• The clinical syndrome (i.e., fever, chills, liver and spleen enlargement, and marked eosinophilia) is specific for ''S. japonicum'' infection.
• Acute disease is not observed in individuals living in endemic areas of schistosomiasis because of the down-modulation of the immune response by antigens or idiotypes transferred from mother to child.

Chronic schistosomiasis

Mild schistosomiasis resolves on its own and progresses into an chronic stage. Depending upon the organ involved symptoms include:

Intestinal schistosomiasis

• In chronic schistosomiasis abdominal pain, irregular bowel movements, and blood in the stool are the main symptoms of intestinal involvement.
• Colonic polyposis may occur.
• Hepatosplenic involvement is the most important cause of morbidity with S. mansoni and S. japonicum infection.
• Patients may remain asymptomatic until the manifestation of hepatic fibrosis and portal hypertension develops.
• Hepatic fibrosis is caused by a granulomatous reaction to Schistosoma eggs that have been carried to the liver.
• Hematemesis from bleeding esophageal or gastric varices may occur.
  • In such cases, anemia and decreasing levels of serum albumin are observed. Some patients have severe hepatosplenic disease with decompensated liver disease. Jaundice, ascites, and liver failure are then observed.
• Concomitant infection by Salmonella species, and less extensively by other gram-negative bacteria, with S. mansoni or S. haematobium leads to a picture of prolonged fever, hepatosplenomegaly, and mild leukocytosis with eosinophilia.

Schistosomal nephropathy

• Patients with schistosomal nephropathy present with fatigue and asthenia.
• Glomerulonephritis is also found in untreated schistosomiasis.

Urogenital schistosomiasis

Patients with urogenital schistosomiasis present with genital pain, pelvic pain, coital bleeding, and dyspareunia.

Pulmonary schistosomiasis

• Patients with acute pulmonary schistosomiasis present with wheezing, cough, and fever.
• Patients with chronic pulmonary schistosomiasis experience dyspnea on exertion, fatigue, and hemoptysis.
• Pulmonary hypertension, which used to be exclusively linked to the hepatosplenic form of the disease, has been documented in patients without liver fibrosis.

Neuroschistosomiasis

• In hospitalized adult patients with S. japonicum infection, cerebral schistosomiasis occurs in 1.7 to 4.3%.
• It may occur as early as 6 weeks after infection, and the most common sign is focal jacksonian epilepsy.
• Signs and symptoms of generalized encephalitis may occasionally be found.
• In S. mansoni infection, neurologic involvement is rare and mainly characterized by transverse myelitis, which occurs mainly in patients without liver fibrosis and hepatosplenomegaly.

Schistosome dermatitis

• Schistosome dermatitis, or swimmer's itch, is an uncommon manifestation seen mainly when avian cercariae penetrate the skin and are destroyed.
• Schistosome dermatitis is a sensitization phenomenon occurring in previously exposed persons.
• The cercariae evoke an acute inflammatory response with edema, early infiltration of neutrophils and lymphocytes, and later invasion of eosinophils.
• A pruritic papular rash occurs within 24 hours after the penetration of cercariae and reaches maximal intensity in 2 to 3 days.

The table below summarizes the symptoms of schistosomiasis

	Symtoms
Acute schistosomiasis (Katayama fever)	Fever Malaise Arthralgia/myalgia Dry cough, wheezing Abdominal pain Diarrhea
Chronic schistosomiasis	Schistosomal nephropathy present with varying degrees of fatigue and asthenia
	Intestinal schistosomiasis may develop episodic intestinal bleeding and tenesmus. Patients infected with S japonicumcan develop upper abdominal pain unrelated to meals, gastric bleeding, and pyloric obstruction due to eosinophilic inflammation and fibrosis. Patients infected with S mansonican develop inflammation with symptoms that resemble those of Crohn disease or ulcerative colitis. Hepatosplenic schistosomiasis may present with cataclysmic esophageal variceal hemorrhage.
	Urinary schistosomiasis presents with hematuria and dysuria Urogenital schistosomiasis present with genital pain, pelvic pain, coital bleeding, and dyspareunia.
	Neuro-schistosomiasis may present with seizures, transverse myelitis or symptoms similar to those of cauda equina syndrome (eg, low back pain, lower extremity weakness, bowel and bladder symptoms) due to inflammation at the nerve roots Granulomatous inflammation in the CNS can result in conus medullaris syndrome or schistosomal cerebritis (most commonly caused by S. japonicum)
	Pulmonary schistosomiasis experience dyspnea on exertion, fatigue, and hemoptysis.
Schistosome dermatitis ( swimmer's itch)	Uncommon manifestation. A pruritic papular rash occurs within 24 hours after the penetration of cercariae and reaches maximal intensity in 2 to 3 days.