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Schistosomiasis Treatment & Management

  • Author: Shadab Hussain Ahmed, MD, AAHIVS, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Oct 14, 2015
 

Approach Considerations

Prehospital care should include treating acute complications, such as acute intestinal bleeding. Stabilize patients who have acute complications. If appropriate, include schistosomiasis as one of the differential diagnoses.

Send urine or stool samples to the parasitology laboratory with a special request to look for eggs indicative of schistosomiasis.

Patients with severe complications, such as GI bleeding, GI obstruction, renal failure, cardiac failure, bacteremia due to Salmonella, and CNS complications, need inpatient care.

Acute schistosomiasis and Katayama fever

Patients should receive antischistosomal drugs and corticosteroids, especially if acutely ill. Steroids reduce inflammation and help suppress changes that result from killing of the parasites. As maturing schistosomes are less susceptible to therapy than adult worms, a second course of treatment is necessary. This is given several weeks after the first course of therapy.

The drug of choice for treating all species of schistosomes is praziquantel. Cure rates of 65-90% have been described after a single treatment with praziquantel. In individuals not cured, the drug causes egg excretion to be reduced by 90%.[55] Praziquantel affects the membrane permeability of the parasite, which causes vacuolation of the tegument. It paralyses the worm and exposes it to attack by the host immune system. However, as praziquantel is ineffective on developing schistosomula, it may not abort early infection. Praziquantel can be used in pregnant and lactating women.[56] Resistance to praziquantel occurs in the field and is well defined.[57, 58] Adverse effects include dizziness, headache, nausea, vomiting, diarrhea, abdominal discomfort, bloody stool, urticaria, and fever following initiation of treatment. These are usually mild and last about 24 hours. These are reactions from dying worms.

Neurologic disease

Treatment of schistosomiasis affecting the CNS consists of praziquantel with glucocorticoids. In CNS disease, corticosteroids are used to reduce inflammation and edema around eggs. If patients present with seizures, anticonvulsant therapy may also be needed. Observe patients with suspected or known cysticercosis as they may develop seizures or neurologic effects from dying cysticerci.

Surgical care

Surgical care includes removal of tumor masses, ligation of esophageal varices, and porta-caval shunt surgeries. Large granulomas in urinary bladder or lungs may warrant surgical extirpation.

Consultations

Appropriate consultations depend on the suspected complications but may include an infectious disease physician, urologist, gynecologist, or gastroenterologist.

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Corticosteroids

The symptoms of Katayama syndrome often require administration of corticosteroids to suppress the inflammatory process, but no consensus exists regarding proper antihelminthic treatment. Prednisolone 40mg daily for 5 days can be used for the hypersensitivity reaction. Treatment is essentially supportive.

Persons with CNS involvement should be given corticosteroids to prevent inflammation and edema around eggs. Repeated courses of corticosteroid therapy may be warranted to suppress recrudescent neurologic symptoms.

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Outpatient Care

Response to treatment is evaluated by counting the amount of decrease in egg excretion. In the initial 2 weeks after treatment, the egg count may not decrease, because eggs laid before the treatment require 2 weeks to be shed. Viable eggs can be excreted for 6-8 weeks after treatment.

When measured 5-10 days after treatment, newer tests that measure antigens may help to assess therapeutic response. Persistent circulating antigen and the excretion of eggs indicate residual infection. These patients should be retreated with praziquantel.

Follow-up

Antischistosomal drugs inhibit egg-laying by adult worms. Therefore, patients’ stool and urine should be tested for 6 months after treatment. Treatment is repeated for those excreting eggs. If symptoms recur, hematuria occurs, or eosinophilia is noted, repeat parasite investigation should be performed. However, serology can remain positive for years.

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Pregnancy

Schistosomiasis affects the uterine environment during pregnancy. These pregnant women develop severe anemia, have low ̶ birth-weight infants, and are at increased risk for infant and maternal mortality. Schistosomiasis has been found in placenta, and newborns have been diagnosed with this condition, thus confirming congenital infection.[4] Infected pregnant women have a higher rate of spontaneous abortions and a higher risk for ectopic pregnancies. In addition, increased pelvic blood flow during pregnancy is thought to increase the infection load. WHO recommends giving praziquantel to pregnant and lactating women to decrease the disease burden and improve the pregnancy and fetal outcomes.[30]

A retrospective study of 88 women with schistosomiasis who received praziquantel during pregnancy, in a mass treatment campaign, did not show an increase in the rate of abortion, preterm deliveries, or congenital abnormalities compared with untreated women.[59]

Starting treatment after the first trimester may be advisable.[60] Praziquantel is excreted in human breast milk. No adverse effects of praziquantel administration during lactation have been reported.[60, 61]

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Deterrence and Prevention

No vaccine or prophylactic chemotherapy for schistosomiasis is currently available. However, clinical trials involving human volunteers are underway to develop an effective vaccine against schistosomiasis. Moreover, clinical studies show that artemether may be used as a prophylactic agent if given once every 2-4 weeks.[62]

Travelers to endemic areas should avoid contact with fresh water. Suspect acute schistosomiasis in a setting of recent contact with fresh water and treat early if diagnostic test results are positive or clinical suspicion is high. Early treatment after high-risk exposures should minimize morbidity.

People returning from endemic areas with history of exposure to fresh water should be screened by serologic testing for schistosomiasis. Many infections are silent and may remain asymptomatic. Urine and stool screening should be obtained in patients with positive serologies for species identification.[60] Rates of schistosomiasis seropositivity have been recorded as 44% and 23% in African refugees.[63]

Topical lipid formulations of N,N-diethyl-m-toluamide (DEET), such as LipoDEET, are effective in killing schistosome cercariae. Minimal absorption, low cost, and a range of activity against insects and schistosomes make this compound an excellent prophylactic agent against human and animal schistosomiasis, especially for travelers.[64]

Endemic regions

Controlling schistosomiasis in an endemic area should include the following:

  • Population-based preventive chemotherapy - WHO has recommended preventive chemotherapy for at-risk populations in endemic areas [65]
  • Provision of a safe water supply
  • Health education that includes improvement of water sanitation and avoidance of schistosome-contaminated urine or stool
  • Snail control
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Contributor Information and Disclosures
Author

Shadab Hussain Ahmed, MD, AAHIVS, FACP, FIDSA Professor of Clinical Medicine, The School of Medicine at Stony Brook University Medical Center; Adjunct Clinical Associate Professor, Department of Medicine, New York College of Osteopathic Medicine of New York Institute of Technology; Attending Physician, Department of Medicine, Division of Infectious Diseases, Director of HIV Prevention Services, Administrative HIV Designee, Nassau University Medical Center

Shadab Hussain Ahmed, MD, AAHIVS, FACP, FIDSA is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Joseph F John Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

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Egg of Schistosoma hematobium, with its typical terminal spine.
Granuloma in the liver due to Schistosoma mansoni. The S mansoni egg is at the center of the granuloma.
Table 1. Parasitic Species and Geographical Distribution of Schistosomiasis [1, 8]
Species Geographical distribution
Intestinal schistosomiasis Schistosoma mansoni



(mesenteric venules of the colon)



Africa, the Middle East, the Caribbean, and South America
Schistosoma japonicum



(mesenteric venules of the small intestine)



Asia only: China, Indonesia, the Philippines, and Thailand
Schistosoma mekongi



(mesenteric venules of the small intestine)



Several districts of Cambodia and the Lao People’s Democratic Republic. 200-km area of Mekong river basin; now extending toward northern provinces
Schistosoma intercalatum



(mesenteric venules of the colon) and related S guineensis



Rain forest areas of Central and West Africa
Urogenital schistosomiasis Schistosoma haematobium



(vesical venous plexus)



Africa, the Middle East, India, and Turkey
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