Perpetual Succour HospitalPerpetual Succour HospitalDepartment of FamilyDepartment of Family

& & Community MedicineCommunity Medicine

GRANDROUND PRESENTATION BY:

LIZA D. MARIPOSQUE, M.D.2nd Year Famed Resident

February 2010

OBJECTIVESOBJECTIVES

To present a case of a 67 yrs old farmer To present a case of a 67 yrs old farmer with Schistosoma. with Schistosoma.

To discuss Schistosoma To discuss Schistosoma haematobiumhaematobium specie.specie. Epidemiology & EtiologyEpidemiology & Etiology PathophysiologyPathophysiology Diagnostic toolsDiagnostic tools Treatment & PreventionsTreatment & Preventions

B.A., 67 y.o., male, married, farmer from B.A., 67 y.o., male, married, farmer from Bukidnon, presently residing in Cabancalan, Bukidnon, presently residing in Cabancalan, Mandaue City admitted due to hypogastric Mandaue City admitted due to hypogastric pain and inability to urinate.pain and inability to urinate.

Travel History: Agusan del Sur in 1987 as a Travel History: Agusan del Sur in 1987 as a farmer then to Bukidnon.farmer then to Bukidnon.

PAST MEDICAL HISTORYPAST MEDICAL HISTORY

HPN – uncontrolledHPN – uncontrolled (-) DM 2, Bronchial asthma(-) DM 2, Bronchial asthma PREVIOUS HOSPITALIZATION:PREVIOUS HOSPITALIZATION:

2006 – Herniorrhaphy L (Kidapawan 2006 – Herniorrhaphy L (Kidapawan City)City)

Smoker x 20 pack yrsSmoker x 20 pack yrs Alcohol beverage drinkerAlcohol beverage drinker No Food & Drug allergiesNo Food & Drug allergies

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

1 yr PTA-Difficulty voiding 1 yr PTA-Difficulty voiding

4 days PTA- difficulty in urination4 days PTA- difficulty in urination 2 days PTA - sought consult 2 days PTA - sought consult

- Advised UTZ - KUB - Advised UTZ - KUB

-Rx Rowatinex-Rx Rowatinex

On Admission

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

BPBP: : 200/120 mmHg200/120 mmHg HRHR: 84 bpm: 84 bpm RRRR: 20 cpm: 20 cpm

160/90 mmHg160/90 mmHg TT: : 37.637.6 WtWt: 50 kg: 50 kg

SkinSkin: Senile, : Senile, dry, warmdry, warm

HEENTHEENT: : Ecteric ScleraeEcteric Sclerae, pinkish palpebral , pinkish palpebral conjunctivae.conjunctivae.

NECKNECK: : No lymphadenopathyNo lymphadenopathy, no neck vein , no neck vein engorgementengorgement

C/L:C/L: ECE, ECE, decrease breath sound LLF, ralesdecrease breath sound LLF, rales LLLF LLLF

CVSCVS: DHS, NRRR, no murmur : DHS, NRRR, no murmur

ABDOMENABDOMEN: : FlatFlat, , hyperactive bowel soundhyperactive bowel sound, , no no hepatomegalyhepatomegaly, soft, nontender, no mass , soft, nontender, no mass palpated.palpated.

GUTGUT: post-op infraumbilical scar,: post-op infraumbilical scar, enlarged R enlarged R scrotum, no erythema, nontenderscrotum, no erythema, nontender; ; tenderness tenderness hypogastric areahypogastric area

(+) KPS(+) KPS

EXTRIMITIESEXTRIMITIES: No edema, strong pulses.: No edema, strong pulses.

CNSCNS: within normal limit: within normal limit

DREDRE: No skin tags, tight sphincter tone, : No skin tags, tight sphincter tone, no no massmass, , prostate gland not enlargedprostate gland not enlarged, (+) fecal , (+) fecal material on rectal vault, (-) blood on the material on rectal vault, (-) blood on the examining finger.examining finger.

ADMITTING ADMITTING IMPRESSIONIMPRESSION

NephrolithiasisNephrolithiasis Hypertensive UrgencyHypertensive Urgency PneumoniaPneumonia Inguinal Hernia, RInguinal Hernia, R

Admitting Orders:Admitting Orders: Soft , low salt, low fat diet. Soft , low salt, low fat diet. IVF PNSS @ 30 gtt/min. IVF PNSS @ 30 gtt/min. Labs:Labs:

CBCCBC SGPTSGPT U/AU/A Uric acidUric acid NaNa++, K, K++++ CreatinineCreatinine Lipid panelLipid panel ECGECG CXR-PACXR-PA UTZ abdomenUTZ abdomen

Straight catheterization.Straight catheterization. Medications:Medications:

Cefuroxime 750 mg IVTT q 8H ANST.Cefuroxime 750 mg IVTT q 8H ANST. Salbutamol Nebulization 1 neb q 8H.Salbutamol Nebulization 1 neb q 8H. Paracetamol 500mg 1 tab q 4H prn for Paracetamol 500mg 1 tab q 4H prn for

T>38C.T>38C. Amlodepine 10 mg 1 tab now then OD.Amlodepine 10 mg 1 tab now then OD. Captopril 25mg 1 tab SL now then prn for Captopril 25mg 1 tab SL now then prn for

BP >140/90 mmHg.BP >140/90 mmHg. Ranitidine 50mg IVTT q 8H.Ranitidine 50mg IVTT q 8H. Nicardipine drip 10mg + 90ml D5W @ Nicardipine drip 10mg + 90ml D5W @

10cc/hr. 10cc/hr.

Fluid challenge.Fluid challenge. I & O monitored q shift.I & O monitored q shift. v/s monitored q 2H.v/s monitored q 2H.

CBCCBC

WBC WBC 12.2012.20 (4.10- (4.10-10.9)10.9) N N 8383 ( 47-80) ( 47-80) L 9 (13-40)L 9 (13-40) M 8 (2-11)M 8 (2-11) E 0 (0-5)E 0 (0-5) B 0 (0-2)B 0 (0-2)

Plt 143 (140-440)Plt 143 (140-440)

Hb 14.6 (13.5-Hb 14.6 (13.5-17.5)17.5)

Hct 42.4 (41-53)Hct 42.4 (41-53) RBC 4.7 (4.5-5.9)RBC 4.7 (4.5-5.9) MCV 89.4 (80-100)MCV 89.4 (80-100) RCDW 14.1 (11.6)RCDW 14.1 (11.6)

UrinalysisUrinalysis

Color: yellowColor: yellowGlucose: NegativeGlucose: NegativeProtein: NegativeProtein: NegativepH: 6pH: 6Sp. Gravity: 1.010Sp. Gravity: 1.010Bilirubin (-)Bilirubin (-)Urine Ketone (-)Urine Ketone (-)Nitrite (-)Nitrite (-)Blood: Blood: ++++

Leukocyte (-)Leukocyte (-)RBC RBC 3-53-5WBC 0-2WBC 0-2Epithelial cells: rareEpithelial cells: rareMucus threads: rareMucus threads: rareAmorphous: rareAmorphous: rareBacteria: rareBacteria: rare

Na 136 mmol/L Na 136 mmol/L

(n.v. 133-146)(n.v. 133-146) K 4.27 mmol/L K 4.27 mmol/L

(n.v. 3.4-5.2)(n.v. 3.4-5.2) Uric Acid Uric Acid 12.23 12.23

mg/dl (n.v. 3-80)mg/dl (n.v. 3-80) SGPT 30 (n.v. 5-50)SGPT 30 (n.v. 5-50) CBS: 135 mg/dlCBS: 135 mg/dl

Crea 10.35 mg/dl Crea 10.35 mg/dl

(n.v. 0.60-1.50)(n.v. 0.60-1.50)

Crea Clearance: 4.84

LIPID PANELLIPID PANELCholesterol: 144.13 mg/dlCholesterol: 144.13 mg/dl

(n.v. 100-200)(n.v. 100-200)TG: 66.93 mg/dlTG: 66.93 mg/dl

(n.v. 60-200)(n.v. 60-200)HDL: 48.69 mg/dlHDL: 48.69 mg/dl

(n.v. 35-65)(n.v. 35-65)LDL: 82 mg/dl (n.v. 0-200)LDL: 82 mg/dl (n.v. 0-200)Glucose: 105.66 mg/dlGlucose: 105.66 mg/dl

(n.v. 76-110)(n.v. 76-110)

UTZ Whole AbdomenUTZ Whole Abdomen

Echogenic lace-like pattern of the liver Echogenic lace-like pattern of the liver consistent with Schistosomiasis.consistent with Schistosomiasis.

Gallbladder, common duct, pancreas, Gallbladder, common duct, pancreas, spleen – negative.spleen – negative.

KUB – negative.KUB – negative. NORMAL SIZE Prostate gland, 1.0cm NORMAL SIZE Prostate gland, 1.0cm

cyst in the L lobe.cyst in the L lobe. Aorta – normal in course & caliber.Aorta – normal in course & caliber.

COURSE IN THE COURSE IN THE

WARDSWARDS

PP: : hypogastric pain, hypogastric pain, inability to urinate, BPinability to urinate, BP

SS: : hypogastric pain, slightly dyspnichypogastric pain, slightly dyspnic

OO: conscious, coherent & not in : conscious, coherent & not in respiratory distress.respiratory distress.

BP: 130/70-BP: 130/70-160/70 160/70 mmHgmmHg PR: 72-85 PR: 72-85 bpm bpm

RR: 19-20 cpmRR: 19-20 cpm T: 36-T: 36-37 37 00CC

Total Fluid Intake: 300Total Fluid Intake: 300 UO: UO: 1,050 cc1,050 cc

AssessmentAssessment:: Schistosomiasis (S. haematobium)Schistosomiasis (S. haematobium) ARF 2ndary to Hypertensive ARF 2ndary to Hypertensive

Nephrosclerosis vs. Uric Acid Nephrosclerosis vs. Uric Acid NephropathyNephropathy

HPNHPN CAP, Moderate RiskCAP, Moderate Risk

PlanPlan::

Cefuroxime 750 mg IVTT OD.Cefuroxime 750 mg IVTT OD. Allopurinol 100 mg 1 tab OD.Allopurinol 100 mg 1 tab OD. Dolcet 1tab TID.Dolcet 1tab TID. All other meds continued.All other meds continued. Foley Bag Catheter inserted.Foley Bag Catheter inserted. Referred to Nephrologist for co-mgt.Referred to Nephrologist for co-mgt. Additional labs requested …..Additional labs requested …..

Ca 7.85 mg/dl Ca 7.85 mg/dl

(n.v.8.4-10.3)(n.v.8.4-10.3) BUN 104 mg/dl BUN 104 mg/dl

(n.v. 7-18)(n.v. 7-18) Phosphorus 6.30 mg/dl (2.5-Phosphorus 6.30 mg/dl (2.5-

4.7)4.7)

O2 inhalation @ 2 Lpm.O2 inhalation @ 2 Lpm. IVF changed into D5 0.3% NaCl @ IVF changed into D5 0.3% NaCl @

10 gtt/min.10 gtt/min. I & O q hourly.I & O q hourly. Hold Allopurinol & Captopril.Hold Allopurinol & Captopril.

PP: : hypogastric pain, hypogastric pain, inability to urinate, inability to urinate, BP, dyspnea, creaBP, dyspnea, crea

SS: w/ mild hypogastric pain, no dyspnea: w/ mild hypogastric pain, no dyspnea

OO: conscious, coherent & not in : conscious, coherent & not in respiratory distress.respiratory distress.

BP: 130/70-BP: 130/70-150/90150/90 mmHg mmHg PR: 68-74 PR: 68-74 bpm bpm

RR: 19-20 cpmRR: 19-20 cpm T: 36-T: 36-36.8 36.8 00CC

Total Fluid Intake: 2590 ccTotal Fluid Intake: 2590 cc UO: UO: 2,705 cc2,705 cc

Schistosomiasis (S. Schistosomiasis (S. haematobium)haematobium)

ARF 2ndary to ARF 2ndary to Hypertensive Hypertensive Nephrosclerosis vs. Uric Nephrosclerosis vs. Uric Acid NephropathyAcid Nephropathy

HCVDHCVD CAP, Moderate RiskCAP, Moderate Risk

Assessment:Assessment:

CaCO3 (Tums) 500mg 1tab TID.CaCO3 (Tums) 500mg 1tab TID. NaHCO3 Gr. X 650mg 2tabs TID.NaHCO3 Gr. X 650mg 2tabs TID. Ranitidine IV shifted to P.O 150mg Ranitidine IV shifted to P.O 150mg

1tab OD. 1tab OD. Hold Nicardipine drip.Hold Nicardipine drip. Cefuroxime IV shifted to P.O 250mg Cefuroxime IV shifted to P.O 250mg

1tab OD.1tab OD. Increase IVF rate to 20gtt/min.Increase IVF rate to 20gtt/min.

Plan:Plan:

Repeat Crea on 12/31/09.Repeat Crea on 12/31/09. PSA determination requested.PSA determination requested. For infectious consult…For infectious consult…

A:A: Schistosoma probably due to Schistosoma probably due to S. S. hematobiumhematobium

P:P: > > Rectal ImprintRectal Imprint

> Praziquantel 25mg/kg in 2 > Praziquantel 25mg/kg in 2 divided doses at 4 hours interval.divided doses at 4 hours interval.

> Referral to DOH.> Referral to DOH.

Infectious ConsultInfectious Consult

S:S: No complaints No complaints

O:O: conscious, coherent & not in conscious, coherent & not in respiratory distress.respiratory distress.

BP: 130/80-140/80 mmHgBP: 130/80-140/80 mmHg PR: 60-65 PR: 60-65 bpm bpm

RR: 20-21 cpmRR: 20-21 cpm T: 36.2-T: 36.2-36.5 36.5 00CC

Total Fluid Intake: 1660 ccTotal Fluid Intake: 1660 cc UO: UO: 480cc480cc

Plan: Plan: crea, BP, crea, BP,

Schistosomiasis (S. haematobium)Schistosomiasis (S. haematobium) ARF 2ndary to Uric Acid ARF 2ndary to Uric Acid

NephropathyNephropathy HCVDHCVD CAP, Moderate Risk CAP, Moderate Risk

Assessment:Assessment:

Discharge against medical advised.Discharge against medical advised. Take home meds:Take home meds:

Cefuroxime 250 mg 1tab OD x 7 days.Cefuroxime 250 mg 1tab OD x 7 days. NaHCO3 Gr. X 2tabs TID x 1 month.NaHCO3 Gr. X 2tabs TID x 1 month. CaCa3 (Tums) 500mg 1tab TID.CaCa3 (Tums) 500mg 1tab TID. Amlodepine 10mg 1tab OD as Amlodepine 10mg 1tab OD as

maintenance.maintenance. Advised and referred to DOHAdvised and referred to DOH Ff-up with APs.Ff-up with APs.

Plan:Plan:

What is Schistosomiasis?What is Schistosomiasis? SchistosomiasisSchistosomiasis or or bilharziabilharzia oror Snail Snail

FeverFever It is a parasitic disease common among It is a parasitic disease common among

farmers, fishermen and their families in farmers, fishermen and their families in Africa & certain parts of the Philippines.Africa & certain parts of the Philippines.

parasitic disease that leads to chronic ill-parasitic disease that leads to chronic ill-health. health.

caused by trematode flatworms of the caused by trematode flatworms of the genus genus SchistosomaSchistosoma..

Parasitic disease carried by fresh Parasitic disease carried by fresh water snails infected with one of the water snails infected with one of the five varieties of the parasite five varieties of the parasite SchistosomaSchistosoma. . Urinary schistosomiasis - caused by Urinary schistosomiasis - caused by

Schistosoma haematobium Schistosoma haematobium Intestinal schistosomiasis - Intestinal schistosomiasis - S. S.

intercalatumintercalatum, , S. mansoniS. mansoni, , S. japonicumS. japonicum, , and and S. mekongiS. mekongi. .

Epidemiology:Epidemiology: affects at least 200 million people worldwide,affects at least 200 million people worldwide, >700 million people live in endemic areas.>700 million people live in endemic areas. Prevalent in 74 countries worldwide, but over Prevalent in 74 countries worldwide, but over

half of all documented cases are in Africahalf of all documented cases are in Africa

Prevalence:Prevalence: tropical areastropical areas sub-tropical areassub-tropical areas poor communities without potable poor communities without potable

water and adequate sanitation. water and adequate sanitation.

Endemic in 12 regions in the Philippines.Endemic in 12 regions in the Philippines. Affecting 28 of the 79 provinces in the Affecting 28 of the 79 provinces in the

country. country.

Morbidity rate- declined from 17.5 Morbidity rate- declined from 17.5 cases/100,000 population in 1997 to cases/100,000 population in 1997 to 5.6/100,000 in 2000.5.6/100,000 in 2000.

Case fatality ratio has also continued Case fatality ratio has also continued to decline from 0.9 death/100,000 to decline from 0.9 death/100,000 population in 1980 to 0.3/100,000 in population in 1980 to 0.3/100,000 in 1997 and has reached a plateau 1997 and has reached a plateau since then.since then.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Life cycle - common to all speciesLife cycle - common to all species sexual generation in vascular sexual generation in vascular

system of the definitive host system of the definitive host (human) (human)

asexual generation in the asexual generation in the intermediate hosts (snails). intermediate hosts (snails).

1) Embrionated eggs are 1) Embrionated eggs are discharged in faeces and urine.discharged in faeces and urine. in water miracidia hatch from the in water miracidia hatch from the

egg and penetrate the intermediate egg and penetrate the intermediate hosts: hosts:

Schistosome species Snails

S.mansoni Biomphalaria spp.

S.haematobium Bulinus spp.

S.intercalatum Bulinus spp.

S.japonicum Oncomelania spp.

S.mekongi  Neotricula spp.

2) after penetration in the snail 2) after penetration in the snail the miracidium develops into the miracidium develops into sporocysts.sporocysts. 4 weeks thousand of 4 weeks thousand of cercariaecercariae

are produced (asexual are produced (asexual multiplication).multiplication). infective forms. infective forms. 500 micron.500 micron.

3) the infection of the definitive host 3) the infection of the definitive host occurs by penetration of the skin.occurs by penetration of the skin.

During the penetration process During the penetration process the the cercariaecercariae lose their tail and lose their tail and transform into the larval stage: transform into the larval stage: the the schistosomulumschistosomulum..

antibody depended antibody depended

cytotoxicity of schistosomulumcytotoxicity of schistosomulum

3-4 days

BodyBody: larvae adult : larvae adult schistosomes schistosomes

(blood vessels)(blood vessels)

femalesfemales EGGS Immune reaction

feces

URINE

S.haematobium:S.haematobium: adult schistosomes live in pairs adult schistosomes live in pairs

in the pelvic veins in the pelvic veins (especially in the venous plexus (especially in the venous plexus surrounding the bladder).surrounding the bladder).

Males = 10-15 mm in lenght by Males = 10-15 mm in lenght by 0.8-1 mm in diameter.0.8-1 mm in diameter. have a ventral infolding from the have a ventral infolding from the

ventral sucker ventral sucker to the posterior end forming the to the posterior end forming the gynecophoric canal. gynecophoric canal.

Females = slender ( 0.25 mm in Females = slender ( 0.25 mm in diameter) diameter) and longer (up to 20 mm in and longer (up to 20 mm in lenght)lenght)

Each female lays about 150 eggs Each female lays about 150 eggs per day. per day.

Schistosoma haematobiumSchistosoma haematobium eggs eggs Concentrated in the tissue of the Concentrated in the tissue of the

bladder.bladder. the main agent of pathology the main agent of pathology

inducing granuloma formationinducing granuloma formation Hyperplasia Hyperplasia

of the mucosa of the mucosa fibrosis and calcification fibrosis and calcification

polyps formation in bladder polyps formation in bladder & ureter & ureter stenosis. stenosis.

HydronephrosisHydronephrosis Bladder CancerBladder Cancer

Not uncommonly found in male Not uncommonly found in male genital organs.genital organs.

A relationship between the presence A relationship between the presence of eggs in seminal fluid and male of eggs in seminal fluid and male infertility has not been infertility has not been demonstrated. demonstrated.

The damage of the seminal vescicles The damage of the seminal vescicles seems to correlate with the degree seems to correlate with the degree of the obstructive uropathy. of the obstructive uropathy.

Less commonly affected are the Less commonly affected are the prostate, the testes and the prostate, the testes and the epididymis.epididymis.

Manifestations:Manifestations:

Initial itching and rash at infection site Initial itching and rash at infection site (“swimmer’s itch”)(“swimmer’s itch”)

Fever, chills and muscle aches Fever, chills and muscle aches Frequent, painful or bloody urine.Frequent, painful or bloody urine. Bladder, ureteral fibrosis and Bladder, ureteral fibrosis and

hydronephrosis - advanced caseshydronephrosis - advanced cases Bladder cancer - late-stage Bladder cancer - late-stage

complications.complications.

DIAGNOSTIC TOOLSDIAGNOSTIC TOOLS

Stool Exam Stool Exam Urinalysis – visible hematuria Urinalysis – visible hematuria

&/macrohematuria&/macrohematuria Urine filtration kitUrine filtration kit UTZ abdomenUTZ abdomen Immunodiagnostic/Serological testImmunodiagnostic/Serological test Monoclonal antibodies Monoclonal antibodies

Diagnosis - identification of eggs Diagnosis - identification of eggs in urinary sediment. in urinary sediment.

viable eggs contain a motile viable eggs contain a motile miracidium. miracidium.

Serological tests - useful for Serological tests - useful for travellers returning from endemic travellers returning from endemic areas and in patients with light or areas and in patients with light or ectopic infection, with no ectopic infection, with no detectable eggs in the faeces, urine detectable eggs in the faeces, urine or intestinal biopsies (i.e. hepatic, or intestinal biopsies (i.e. hepatic, CNS infections).CNS infections). (+) test may reflect previous exposure (+) test may reflect previous exposure

to the agent rather than an active to the agent rather than an active infection.infection.

a slow decrease in titer - after effective a slow decrease in titer - after effective treatmenttreatment

Environmental sanitationEnvironmental sanitation Safety of supply waterSafety of supply water EducationEducation snail control with spraying snail control with spraying

& drip feeding& drip feeding..

Treatment & PreventionsTreatment & Preventions

Molluscisciding drip feeding

Education – the risk of getting Education – the risk of getting infected by bathing in fresh water infected by bathing in fresh water lakes and ponds/dams.lakes and ponds/dams.

Heating bathing water to 50°C Heating bathing water to 50°C (122°F) for 5 minutes or filtering (122°F) for 5 minutes or filtering water with fine-mesh filters.water with fine-mesh filters.

Allow bathing water to stand for 2 Allow bathing water to stand for 2 days because cercariae rarely remain days because cercariae rarely remain infective longer than 24 hrs.infective longer than 24 hrs.

Swimming in adequately chlorinated Swimming in adequately chlorinated pools.pools.

Vigorous towel drying after Vigorous towel drying after accidental exposure.accidental exposure.

Topical application of the insect Topical application of the insect repellent DEET can block repellent DEET can block penetrating cercariae.penetrating cercariae.

A schistosomiasis vaccine is currently A schistosomiasis vaccine is currently developed by Sabin’s vaccine developed by Sabin’s vaccine development teamdevelopment team

Praziquantel –Praziquantel – DOC; DOC; A single dose of it A single dose of it has been shown to reduce the severity of has been shown to reduce the severity of symptoms in cases of subsequent re-symptoms in cases of subsequent re-infection.infection. PZQ 40 mg/kg (WHO Recommendation)

Oxamniquine has been effective in Oxamniquine has been effective in treating infections caused by treating infections caused by S. mansoniS. mansoni. .

Metrifonate & Albendazol - alternative

Oxamniquine and Metrifonate. Albendazol also is

used