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Pediatric Schistosomiasis Clinical Presentation

  • Author: Vinod K Dhawan, MD, FACP, FRCPC, FIDSA; Chief Editor: Russell W Steele, MD  more...
 
Updated: Feb 26, 2015
 

History

Symptoms of schistosomiasis depend on the species of the schistosome and the stage of disease. Most infected individuals are asymptomatic or have only mild nonspecific symptoms. Only 5-10% of infected individuals develop severe clinical symptoms, which are usually associated with heavy infestations.

Edema and pruritus are symptoms of cercarial dermatitis and are rarely observed in primary exposure (see the image below).

Cercarial dermatitis secondary to avian schistosom Cercarial dermatitis secondary to avian schistosomes is shown. Photography taken by A. Joseph Bearup and provided by John Walker, MD.

High fever or Katayama fever is described in heavy primary infections. Nausea is observed in acute schistosomiasis and at the onset of fevers. Vomiting may be experienced in acute schistosomiasis. Generalized lymphadenopathy is described as part of the Katayama fever syndrome. Profuse diarrhea or dysentery is associated with Katayama fever.

Hematemesis or melena is the usual presenting symptom of chronic schistosomiasis due to S japonicum and S mansoni. Abdominal pain may be observed with acute and chronic schistosomiasis secondary to liver and splenic enlargement (see following image).

Two 10-year-old boys with abdominal distension sec Two 10-year-old boys with abdominal distension secondary to chronic Schistosoma japonicum infection.

Urticaria may occur with cercarial dermatitis or may be more extensive, affecting large body areas in acute schistosomiasis. Malaise, generalized fatigue, and weakness are sometimes observed with acute schistosomiasis.

Focal epilepsy is a recognized complication of chronic S japonicum infection in East Asia (see the image below). Spinal cord lesions due to S mansoni or S haematobium can cause a myelopathy.

CT scan of the brain reveals a right cerebral hemi CT scan of the brain reveals a right cerebral hemisphere lesion due to Schistosoma japonicum. The patient presented with focal motor seizures.

A dry cough (with or without hemoptysis) secondary to inflammation in the lungs can be experienced in acute schistosomiasis and is associated with migration of schistosomula through the lungs. Cough is also a symptom of cor pulmonale resulting from chronic pulmonary schistosomiasis. The subsequent pulmonary hypertension may lead to hemoptysis.

Palpitations may be felt as a complication of cor pulmonale in chronic pulmonary schistosomiasis. Shortness of breath may be observed in both acute and chronic pulmonary schistosomiasis as a result of cor pulmonale in chronic cases. Acute pulmonary symptoms of cough and dyspnea may occur 3-6 weeks after exposure and occur without fever.

Weight loss may be experienced as a consequence of vomiting and profuse diarrhea.

Urinary frequency is regularly associated with acute S haematobium infection. Dysuria is a common feature of acute S haematobium infection. Terminal hematuria is also a regular presenting symptom for S haematobium infection or bilharzia. Referred suprapubic or perineal pain may be associated with S haematobium infection.

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Physical Examination

Physical findings vary with the species and the stage of the disease.

Urticaria may be observed in cases with cercarial dermatitis or acute schistosomiasis with Katayama fever. Papular lesions may develop from cercarial dermatitis and remain for 5-7 days and up to 10 days after water exposure. However, this is more often observed with avian schistosomiasis.

General enlargement of lymph nodes may be detected in acute schistosomiasis with Katayama fever.

Areas of moist crackles may be heard over both lung fields in acute schistosomiasis.

Hepatosplenomegaly is often detected in acute and chronic schistosomiasis with S japonicum and S mansoni. Jaundice is a rare clinical finding. Purpura resulting from thrombocytopenia is observed with hypersplenism.

Hematuria with S haematobium typically progresses from microscopic to frank bloody urine as the bladder mucosa ulcerates.

A transverse myelitislike syndrome may be observed with S mansoni or S haematobium disease. Focal neurologic deficits may be found due to cerebral granulomas in cases with seizures and chronic S japonicum infection.

Clinical signs of right ventricular hypertrophy are observed in cases with cor pulmonale and chronic schistosomiasis. This includes palpable sternal heave and increased and delayed pulmonary second heart sound.

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Complications

Possible complications of schistosomiasis include fibro-occlusive disease secondary to the immune stimulus of schistosome eggs, end-organ damage, end-stage liver disease, and others.

Possible complications of female genital schistosomiasis (defined as the presence of schistosome eggs or worms in the upper or lower genital tract) include hypogonadism, retarded puberty, infertility (primary and secondary), ectopic and tubal pregnancy, tubal abortion, hemoperitoneum, anemia due to chronic blood loss, metaplasia, miscarriage and preterm delivery, carcinoma, increased risk for sexually transmitted diseases, destruction of the hymen or clitoris, and vesicovaginal fistula.

Persistent bacteremia with Salmonella typhi and other Salmonella species has been reported in persons chronically infected with S mansoni, S japonicum, S intercalatum, and S haematobium. Chronic Salmonella bacteria may be noted in patients infected with S haematobium.

Immune complexes formed in response to schistosomal infection may be deposited on glomerular capillaries and renal basement membranes, leading to mesangioproliferative glomerulonephritis, nephrosclerosis, and renal failure. The severity of renal disease is related to the worm burden and to the extent and duration of hepatic fibrosis and collateral circulations.

Schistosomiasis has been associated with high HIV viral loads and a theoretical risk of increased progression of HIV disease.[5]

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Contributor Information and Disclosures
Author

Vinod K Dhawan, MD, FACP, FRCPC, FIDSA Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Infectious Diseases, Rancho Los Amigos National Rehabilitation Center

Vinod K Dhawan, MD, FACP, FRCPC, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Pfizer Inc for speaking and teaching.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Leslie L Barton, MD Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Michael D Nissen, MBBS, FRACP, FRCPA, Associate Professor in Biomolecular, Biomedical Science & Health, Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory, Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital

Michael D Nissen, MBBS, FRACP, FRCPA is a member of the following societies : American Academy of Pediatrics, American Society for Microbiology, Pediatric Infectious Diseases Society,Royal Australasian College of Physicians, Royal College of Pathologists of Australasia

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

John Charles Walker, MSc, PhD Head, Department of Parasitology, Center for Infectious Diseases and Microbiology, Westmead Hospital, Westmead, Australia; Senior Lecturer, Department of Medicine, University of Sydney, Australia

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
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Cercarial dermatitis secondary to avian schistosomes is shown. Photography taken by A. Joseph Bearup and provided by John Walker, MD.
Two 10-year-old boys with abdominal distension secondary to chronic Schistosoma japonicum infection.
CT scan of the brain reveals a right cerebral hemisphere lesion due to Schistosoma japonicum. The patient presented with focal motor seizures.
Egg of Schistosoma japonicum from a fecal smear is shown. Note lateral umbilicated spine on the right side of the egg.
Egg of Schistosoma mekongi (53 X 45 μm) in the feces of a woman from Laos.
Egg of Schistosoma mansoni from a fecal smear.
Egg of Schistosoma haematobium from a fecal smear.
Eggs of Schistosoma japonicum within the intestinal mucosa.
Liver granulomata secondary to Schistosoma japonicum infestation.
Granuloma within the intestinal mucosa secondary to Schistosoma mansoni infestation.
Eggs of Schistosoma haematobium isolated from urinary sediment.
Eggs of Schistosoma haematobium detected in the bladder.
 
 
 
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