The WHO ultrasonography protocol for assessing hepatic morbidity due to Schistosoma mansoni. Acceptance and evolution over 12 years

Consensus definitions in imported human schistosomiasis: a GeoSentinel and TropNet Delphi study

Terminology in schistosomiasis is not harmonised, generating misunderstanding in data interpretation and clinical descriptions. This study aimed to achieve consensus on definitions of clinical aspects of schistosomiasis in migrants and returning travellers. We applied the Delphi method. Experts from institutions affiliated with GeoSentinel and TropNet, identified through clinical and scientific criteria, were invited to participate. Five external reviewers revised and pilot-tested the statements. Statements focusing on the definitions of acute or chronic; possible, probable, or confirmed; active; and complicated schistosomiasis were managed through REDCap and replies managed in a blinded manner. Round 1 mapped the definitions used by experts; subsequent rounds were done to reach consensus, or quantify disagreement, on the proposed statements. Data were analysed with percentages, medians, and IQRs of a 5-point Likert scale. The study was terminated on the basis of consensus or stability-related and time-related criteria. 28 clinicians and scientists met the criteria for experts. 25 (89%) of 28 experts replied to Round 1, 18 (64%) of 28 to Round 2, 19 (68%) of 28 to Round 3, and 21 (75%) of 28 to at least two rounds. High-level consensus (79-100% agreement and IQRs ≤1) was reached for all definitions. Consensus definitions will foster harmonised scientific and clinical communication and support future research and development of management guidelines for schistosomiasis.

The role of point-of-care ultrasound in the assessment of schistosomiasis-induced liver fibrosis: A systematic scoping review

BACKGROUND

Abdominal ultrasound imaging is an important method for hepatic schistosomiasis diagnosis and staging. Several ultrasound staging systems have been proposed, each attempting to standardise schistosomal periportal fibrosis (PPF) diagnosis. This review aims to establish the role of ultrasound in the diagnosis and staging of schistosomal PPF, and to map the evolution of ultrasound staging systems over time, focusing on internal validation and external reproducibility.

METHODS

A systematic search was undertaken on 21st December 2022 considering the following databases: PubMed/MEDLINE (1946-present), Embase (1974-present), Global Health (1973-present), Global Index Medicus (1901-present), and Web of Science Core Collection-Science Citation Index Expanded (1900-present) and the Cochrane Central Register of Controlled Trials (1996-present). Case reports, systematic reviews and meta-analyses, and studies exclusively using transient or shear-wave elastography were excluded. Variables extracted included study design, study population, schistosomal PPF characteristics, and diagnostic methods. The PRISMA-ScR (2018) guidelines were followed to inform the structure of the scoping analysis.

RESULTS

The initial search yielded 573 unique articles, of which 168 were removed after screening titles and abstracts, 43 were not retrieved due to full texts not being available online or through inter-library loans, and 170 were excluded during full text review. There were 192 remaining studies eligible for extraction. Of the extracted studies, 61.8% (76/123) of studies that reported study year were conducted after the year 2000. Over half of all extracted studies (59.4%; 114/192) were conducted in Brazil (26.0%; 50/192), China (18.8%; 36/192) or Egypt (14.6%; 28/192). For the species of schistosome considered, 77.6% (149/192) of studies considered S. mansoni and 21.4% (41/192) of studies considered S. japonicum. The ultrasound staging systems used took on three forms: measurement-based, feature-based and image pattern-based. The Niamey protocol, a measurement and image pattern-based system, was the most used among the staging systems (32.8%; 63/192), despite being the most recently proposed in 1996. The second most used was the Cairo protocol (20.8%; 40/192). Of the studies using the Niamey protocol, 77.8% (49/63) only used the image patterns element. Where ultrasound technology was specified, studies after 2000 were more likely to use convex transducers (43.4%; 33/76) than studies conducted before 2000 (32.7%; 16/49). Reporting on ultrasound-based hepatic diagnoses and their association with clinical severity was poor. Just over half of studies (56.2%; 108/192) reported the personnel acquiring the ultrasound images. A small number (9.4%; 18/192) of studies detailed their methods of image quality assurance, and 13.0% (25/192) referenced, discussed or quantified the inter- or intra-observer variation of the staging system that was used.

CONCLUSIONS

The exclusive use of the image patterns in many studies despite lack of specific acquisition guidance, the increasing number of studies over time that conduct ultrasound staging of schistosomal PPF, and the advances in ultrasound technology used since 2000 all indicate a need to consider an update to the Niamey protocol. The protocol update should simplify and prioritise what is to be assessed, advise on who is to conduct the ultrasound examination, and procedures for improved standardisation and external reproducibility.

Baseline Liver Ultrasound Findings in Preschool Children From the Praziquantel in Preschoolers Trial in Lake Albert, Uganda

BACKGROUND

Periportal fibrosis is a late-stage manifestation of chronic infection with Schistosoma mansoni . Praziquantel (PZQ), the only drug available for the treatment of schistosomiasis, has limited effect in treating established morbidity. Preschool-age children (PSAC) are not considered to be an at-risk population for severe morbidity. However, the prevalence of periportal fibrosis in PSAC in S. mansoni endemic settings is unknown.

METHODS

As part of a phase II clinical trial comparing different dosing regimens of PZQ in children age 12-47 months infected with S. mansoni in Uganda ("praziquantel in preschoolers" trial), we present baseline results assessing liver ultrasound (US) findings as per the WHO Niamey Protocol.

RESULTS

A total of 7/347 (2%) PSAC had Image Pattern C with pipe stems and echogenic rings suggestive of periportal fibrosis, 29/347 (8%) had Image Pattern B and 58 (17%) had evidence of periportal thickening There were higher adjusted odds of periportal thickening with older age [odds ratio (OR): 1.04; 95% confidence interval (CI): 1.00-1.07], primary maternal education (OR: 1.04; 95% CI: 1.00-1.07) and being taken to the lake weekly (OR: 3.02; 95% CI: 1.19-7.63). A further 44/347 children (13%) had a rounded caudal liver edge which was associated with high S. mansoni infection intensity (adjusted OR: 3.31; 95% CI: 1.46-7.51).

CONCLUSIONS

Incipient schistosomiasis-related liver morbidity was detected in young children enrolled in the praziquantel in preschoolers trial. Adequate age-adjusted reference measurements for liver ultrasound findings in very small children are lacking but urgently needed. Schistosomiasis-related fibrosis may be delayed or averted with early and repeated PZQ treatment.

Epidemiology of pediatric schistosomiasis in hard-to-reach areas and populations: a scoping review

BACKGROUND

Schistosomiasis affects over 250 million people worldwide. Despite children and the poor being key risk groups, limited research and control activities target pre-school aged children (PSAC) and hard-to-reach populations. As endemic countries shift the goals of their schistosomiasis programs from morbidity control to disease elimination, there is a need for inclusive planning to cover all affected age groups from all geographical areas and populations to achieve sustainable impact and health equity.

METHODS

We conducted searches in MEDLINE, Web of Science, Embase (Ovid), and LILACS per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews (PRISMA-ScR) guidelines. Quality assessment of identified articles was done using the Joanna Briggs Institute Prevalence Critical Appraisal Tool. Relevant study data were extracted from the articles and entered into Microsoft Excel 2016 for descriptive analysis.

RESULTS

From the 17,179 screened articles, we identified 13 eligible studies on schistosomiasis in PSAC living in hard-to-reach areas and populations. All identified studies were from sub-Saharan Africa. The mean sample size of the retained studies was 572, with a balanced sex distribution among the young children sampled in each study. Ten studies investigated Schistosoma mansoni, one investigated Schistosoma haematobium, while two covered both S. mansoni and S. haematobium in the target population. The prevalence of S. mansoni among PSAC in the included studies was estimated at 12.9% in Ghana, 80.3-90.5% in Kenya, 35.0% in Madagascar, 9.6-78.0% in Senegal, 11.2-35.4% in Sierra Leone, 44.4-54.9% in Tanzania and 39.3-74.9% in Uganda. Out of the three studies that investigated S. haematobium, the presence of the infection was reported in only one study carried out in Nigeria. Schistosome infections reported in nearly all studies included in this review were of light intensity. Only one study conducted in Nigeria documented visible hematuria in 17.7% of the PSAC studied.

CONCLUSIONS

The findings document the high prevalence of schistosomiasis among PSAC in hard-to-reach populations and underscore the need to consider this population subgroup when designing the expansion of preventive chemotherapy and schistosomiasis control activities.

A cross-sectional study of periportal fibrosis and Schistosoma mansoni infection among school-aged children in a hard-to-reach area of Madagascar

BACKGROUND

A cross-sectional survey was performed to estimate the prevalence of periportal fibrosis in children based on ultrasound examination in the Marolambo district of the Atsinanana region of Madagascar. This is a remote area known to have a high prevalence of intestinal schistosomiasis.

METHODS

School-aged children (5-14 y) were selected from six villages for parasitological and sonographic examination. Circulating cathodic antigen (CCA) tests and Kato Katz (KK) stool microscopy were performed. Video-clips of liver views were recorded with a SonoSite iViz and interpreted in the UK by comparison with standardised images (WHO protocol).

RESULTS

The prevalence of schistosomiasis according to CCA testing was 97.8% (269/275) and 73.8% (203/275) by KK. Sonographic evidence of periportal fibrosis was observed in 11.3% (31/275). The youngest children with fibrosis were aged 6 y. Fibrosis was more common in older children (p=0.03) but was not associated with either infection intensity category (p=0.07) or gender (p=0.67).

CONCLUSIONS

Findings of periportal fibrosis among children in these hard-to-reach villages suggests chronic Schistosoma mansoni infection from a very young age. This may reflect other similarly remote schistosomiasis-endemic areas and reinforces the need to investigate morbidity in neglected communities to understand the true extent of disease burden in endemic countries.

Evaluation of hepatic fibrosis by elastography in patients with schistosomiasis mansoni

BACKGROUND

Periportal fibrosis is associated with the main complications of schistosomiasis mansoni. The usefulness of hepatic transient elastography (TE) in its evaluation remains to be clarified.

METHODS

We conducted a cross-sectional study of schistosomal patients, where the measurements obtained by FibroScan TE were correlated with the degree of liver fibrosis according to the Niamey sonographic protocol, adopted as the gold standard, and its performance was calculated as the area under the receiver operating characteristics curve (AUROC).

RESULTS

A total of 117 of 141 adult schistosomiasis patients from endemic areas were selected between May and August 2015. Applying the Niamey protocol, the patients were regrouped into absent fibrosis (A; 34.2%), mild to moderate fibrosis (MM; 27.4%) and intense fibrosis (I; 38.5%). The median of the TE values in the patients of group A was 4.7 kPa, the group MM 9.3 kPa and the group I 10.3 kPa. There was a difference in the TE values between the group A and the groups MM and I (p < 0.05). The TE also presented strong and direct correlation with the clinical form (r ≥ 0.77). The AUROC value to define the presence of fibrosis was 0.92 and for significant fibrosis was 0.79, with cut-offs of 6.1 kPa and 8.9 kPa, respectively.

CONCLUSIONS

In this study, the TE was effective in the diagnosis of schistosomal fibrosis, being able to identify the advanced forms of the disease and thus predict the risk of clinical complications in endemic regions.

Associations between infection intensity categories and morbidity prevalence in school-age children are much stronger for Schistosoma haematobium than for S. mansoni

BACKGROUND

World Health Organization (WHO) guidelines for measuring global progress in schistosomiasis control classify individuals with Schistosoma spp. infections based on the concentration of excreted eggs. We assessed the associations between WHO infection intensity categories and morbidity prevalence for selected S. haematobium and S. mansoni morbidities in school-age children.

METHODOLOGY

A total of 22,488 children aged 6-15 years from monitoring and evaluation cohorts in Burkina Faso, Mali, Niger, Uganda, Tanzania, and Zambia from 2003-2008 were analyzed using Bayesian logistic regression. Models were utilized to evaluate associations between intensity categories and the prevalence of any urinary bladder lesion, any upper urinary tract lesion, microhematuria, and pain while urinating (for S. haematobium) and irregular hepatic ultrasound image pattern (C-F), enlarged portal vein, laboratory-confirmed diarrhea, and self-reported diarrhea (for S. mansoni) across participants with infection and morbidity data.

PRINCIPAL FINDINGS

S. haematobium infection intensity categories possessed consistent morbidity prevalence across surveys for multiple morbidities and participants with light infections had elevated morbidity levels, compared to negative participants. Conversely, S. mansoni infection intensity categories lacked association with prevalence of the morbidity measures assessed.

CONCLUSIONS/SIGNIFICANCE

Current status infection intensity categories for S. haematobium were associated with morbidity levels in school-age children, suggesting urogenital schistosomiasis morbidity can be predicted by an individual's intensity category. Conversely, S. mansoni infection intensity categories were not consistently indicative of childhood morbidity at baseline or during the first two years of a preventive chemotherapy control program.

Macroscopic and microscopic imaging modalities for diagnosis and monitoring of urogenital schistosomiasis

Urogenital schistosomiasis remains a major global challenge. Optimal management of this infection depends upon imaging-based assessment of sequelae. Although established imaging modalities such as ultrasonography, plain radiography, magnetic resonance imaging (MRI), narrow band imaging, and computerized tomography (CT) have been used to determine tissue involvement by urogenital schistosomiasis, newer refinements in associated technologies may lead to improvements in patient care. Moreover, application of investigational imaging methods such as confocal laser endomicroscopy and two-photon microscopy in animal models of urogenital schistosomiasis are likely to contribute to our understanding of this infection's pathogenesis. This review discusses prior use of imaging in patients with urogenital schistosomiasis and experimentally infected animals, the advantages and limitations of these modalities, the latest radiologic developments relevant to this infection, and a proposed future diagnostic standard of care for management of afflicted patients.

Diagnosis and clinical management of hepatosplenic schistosomiasis: A scoping review of the literature

BACKGROUND

Hepatosplenic schistosomiasis (HSS) is a disease caused by chronic infection with Schistosma spp. parasites residing in the mesenteric plexus; portal hypertension causing gastrointestinal bleeding is the most dangerous complication of this condition. HSS requires complex clinical management, but no specific guidelines exist. We aimed to provide a comprehensive picture of consolidated findings and knowledge gaps on the diagnosis and treatment of HSS.

METHODOLOGY/PRINCIPAL FINDINGS

We reviewed relevant original publications including patients with HSS with no coinfections, published in the past 40 years, identified through MEDLINE and EMBASE databases. Treatment with praziquantel and HSS-associated pulmonary hypertension were not investigated. Of the included 60 publications, 13 focused on diagnostic aspects, 45 on therapeutic aspects, and 2 on both aspects. Results were summarized using effect direction plots. The most common diagnostic approaches to stratify patients based on the risk of variceal bleeding included the use of ultrasonography and platelet counts; on the contrary, evaluation and use of noninvasive tools to guide the choice of therapeutic interventions are lacking. Publications on therapeutic aspects included treatment with beta-blockers, local management of esophageal varices, surgical procedures, and transjugular intrahepatic portosystemic shunt. Overall, treatment approaches and measured outcomes were heterogeneous, and data on interventions for primary prevention of gastrointestinal bleeding and on the long-term follow-up after interventions were lacking.

CONCLUSIONS

Most interventions have been developed on the basis of individual groups' experiences and almost never rigorously compared; furthermore, there is a lack of data regarding which parameters can guide the choice of intervention. These results highlight a dramatic need for the implementation of rigorous prospective studies with long-term follow-up in different settings to fill such fundamental gaps, still present for a disease affecting millions of patients worldwide.

Evaluation of Schistosomiasis Mansoni Morbidity by Hepatic and Splenic Elastography

In patients with Mansoni schistosomiasis, it is fundamental to evaluate the disease morbidity, which is reflected by the severity of periportal fibrosis (PPF) and parameters of portal hypertension, as analyzed by ultrasonography (US). This study aimed to evaluate the morbidity of schistosomiasis by hepatic and splenic point shear-wave elastography (pSWE) and relate this to US parameters. The PPF pattern, the diameter of the portal and splenic veins and the size of the spleen were evaluated by US. Then, liver and spleen pSWEs were assessed in 74 patients using the same equipment. As the PPF pattern progressed, the splenic pSWE values significantly increased. Significant correlations between splenic pSWE, the longitudinal and transverse lengths of the spleen and the diameters of the portal and splenic veins were observed. These findings, however, were not observed through hepatic pSWE. In conclusion, the splenic pSWE has the potential for assessing morbidity in schistosomiasis mansoni.

The diagnostic accuracy of routine clinical findings for detection of esophageal varices in rural sub-Saharan Africa where schistosomiasis is endemic

BACKGROUND

Variceal upper gastrointestinal bleeding (UGIB) is common in sub-Saharan Africa (SSA). However, poor access to endoscopy services precludes the diagnosis of varices.

OBJECTIVES

We determined the diagnostic accuracy of routine clinical findings for detection of esophageal varices among patients with UGIB in rural SSA where schistosomiasis is endemic.

METHODS

We studied patients with a history of UGIB. The index tests included routine clinical findings and the reference test was diagnostic endoscopy. Multivariable regression with post-estimation provided measures of association and diagnostic accuracy.

RESULTS

We studied 107 participants with UGIB and 21% had active bleeding. One hundred and three (96%) had liver disease and 86(80%) varices. Factors associated with varices (p-value <0.05) were ≥ 4 lifetime episodes of UGIB, prior blood transfusion, splenomegaly, liver fibrosis, thrombocytopenia, platelet count spleen diameter ratio <909, and a dilated portal vein. Two models showed an overall diagnostic accuracy of > 90% in detection of varices with a number needed to misdiagnose of 13(number of patients who needed to be tested in order for one to be misdiagnosed by the test).

CONCLUSION

Where access to endoscopy is limited, routine clinical findings could improve the diagnosis of patients with UGIB in Africa.

The diagnostic accuracy of routine clinical findings for detection of esophageal varices in rural sub-Saharan Africa where schistosomiasis is endemic.

Sound Around the World: Ultrasound for Tropical Diseases

Ultrasound for diagnosis and staging of schistosomiasis and echinococcosis have paved the way over the past several decades for the application of ultrasound in tropical diseases. Until recently, the size and cost of ultrasound systems limited the application in low-resource settings. The increase in portable ultrasound systems has given more clinicians access to ultrasound, and clinically based protocols for the care of patients have emerged, such as focused assessment with sonography for HIV/TB and tropical cardiac ultrasound. This article explores the history and current use of ultrasound in these diseases and highlights their application in the care of patients.

Schistosomiasis Diagnosed Using Laparoscopy and Colonoscopy

Schistosomiasis infection is a major cause of morbidity and mortality in endemic areas. Developed countries have declared that schistosomiasis has been eradicated; however, residents of these countries may travel and stay in endemic areas and the number of foreign travelers is increasing in the recent years. Thus, schistosomiasis is regarded as an imported infection. Ultrasonography and serum antibody titer tests are well established as diagnostic methods for schistosomiasis. However, a definitive diagnosis cannot be obtained using these tests in some cases. We herein report a case in which schistosomiasis was confirmed based on laparoscopic liver biopsy without a definitive diagnosis by blood test, fecal examination, or imaging.

Ultrasound and intestinal lesions in Schistosoma mansoni infection: A case-control pilot study outside endemic areas

Background

Infection with Schistosoma mansoni is a major cause of morbidity and mortality in endemic areas, and is increasingly diagnosed in migrants and travellers outside transmission areas. Markers for the assessment of morbidity and impact of control programs in endemic areas and for the clinical management of patients in the clinical setting are scant, especially for intestinal involvement. Ultrasonography is well established to evaluate hepatosplenic pathology; on the contrary, ultrasound evaluation of intestinal schistosomiasis is virtually unexplored. In this pilot study, we aimed to describe and evaluate the accuracy of unenhanced intestinal ultrasound for morbidity due to intestinal S. mansoni infection.

Methodology/Principal findings

We performed a blind case-control study of unenhanced intestinal ultrasound on 107 adults accessing the outpatient clinic of our Centre for Tropical Diseases between January-July 2018 as part of a screening for tropical diseases in migrants and travellers returning from endemic areas. Other clinical and laboratory data were obtained routine examination reports. We could not find any overtly pathological thickness of the gut wall in the sigma, proximal ascending colon, and terminal ileum, in patients with S. mansoni infection (n = 17), S. haematobium infection (n = 7), positive anti-Schistosoma serology (n = 31), and uninfected individuals (n = 52), with no difference among groups as assessed by ANOVA. No polyps or other intestinal abnormalities were visualized. There was no significant change in gut wall thickness one month after treatment with praziquantel in patients with S. mansoni infection (n = 11).

Conclusions/Significance

Our preliminary results suggest that intestinal ultrasound might not be a sensitive tool for detecting minor intestinal morbidity due to schistosomiasis. Further studies in a hospital setting comparing colonoscopy and ultrasonography may be envisaged; in endemic areas, further studies are needed to describe and assess the usefulness of intestinal ultrasound in patients stratified by infection intensity and compared with markers such as calprotectin and fecal occult blood.

Liver ultrasound elastography for the evaluation of periportal fibrosis in schistosomiasis mansoni: A cross-sectional study

BACKGROUND

ARFI elastrography has been used as a noninvasive method to assess the severity of liver fibrosis in viral hepatitis, although with few studies in schistosomiasis mansoni. We aimed to evaluate the performance of point shear wave elastography (pSWE) for predicting significant periportal fibrosis (PPF) in schistosomotic patients and to determine its best cutoff point.

METHODOLOGY/PRINCIPAL FINDINGS

This cross-sectional study included 358 adult schistosomotic patients subjected to US and pSWE on the right lobe. Two hundred two patients (62.0%) were women, with a median age of 54 (ranging 18-92) years. The pSWE measurements were compared to the US patterns of PPF, as gold standard, according to the Niamey classification. The performance of pSWE was calculated as the area under the ROC curve (AUC). Patients were further classified into two groups: 86 patients with mild PPF and 272 patients with significant PPF. The median pSWE of the significant fibrosis group was higher (1.40 m/s) than that of mild fibrosis group (1.14 m/s, p<0.001). AUC was 0.719 with ≤1.11 m/s as the best cutoff value for excluding significant PPF. Sensitivity and negative predictive values were 80.5% and 40.5%, respectively. Whereas, for confirming significant PPF, the best cutoff value was >1.39 m/s, with specificity of 86.1% and positive predictive value of 92.0%.

CONCLUSIONS/SIGNIFICANCE

pSWE was able to differentiate significant from mild PPF, with better performance to predict significant PPF.

Ultrasound findings and associated factors to morbidity in Schistosoma haematobium infection in a highly endemic setting

OBJECTIVE

To evaluate the usefulness of the WHO classification of ultrasound pathological changes and to establish risk factors for morbidity in a highly endemic setting.

METHODS

One hundred and fifty-seven ultrasounds were performed on school-aged children previously diagnosed with urinary schistosomiasis in Cubal, Angola. The findings were analysed according to the WHO guidelines. Factors for morbidity were studied.

RESULTS

Mean age of the children was 8.7 (SD 3.2) years. Pathological changes were found in 85.3% (84.7% in the bladder, 34.4% the ureter and 6.3% kidney lesions). The global score according to the WHO classification was 5.74. Male gender [OR 2.61 (1.04-6.58); P 0.043] and older age [OR 2.96 (1.17-7.46); P 0.023] were associated with a higher risk of developing any kind of urinary abnormality. Proteinuria was present in 61.7% of the children. Macroscopic haematuria [OR 2.48 (1.11-5.58); P = 0.02)] and a high level of proteinuria > 300 mg/dl [OR 5.70 (2.17-14.94); P 300 mg/dl)] were associated with abnormalities of the upper urinary tract and showed good positive and negative predictive values for the detection of pathology in the upper urinary tract (65.5% and 71.1%, respectively).

CONCLUSIONS

Severe urinary tract pathology was found in a high percentage of the children in our setting. Microhaematuria and proteinuria were good markers of morbidity, proteinuria being more precise for severe alterations of the upper urinary tract. We suggest initial and evolutive ultrasound in children diagnosed with schistosomiasis, and close monitoring including periodic controls. As schistosomiasis control efforts are currently focused on reducing morbidity, tests that detect the presence or degree of morbidity are essential for targeting treatment and tracking the progress of control campaigns.

Organomegaly in Mali before and after praziquantel treatment. A possible association with Schistosoma haematobium

Continuous exposure to schistosome-infested water results in acute and chronic morbidity in all ages. We analysed occurence of organomegaly via ultrasonography and investigated a possible additive effect of dual-dose drug administration in 401 Schistosoma haematobium infected individuals from a highly endemic area in Mali. Mean intensity of infection at baseline (22.0 eggs per 10 ml) was reduced to 0.22 eggs per 10 ml 9 weeks after treatment (both treatments combined). Odds of persistent infection among those given dual-dose treatment was 41% of that in people given single dose (b = 0.41; p = 0.05; 95% CI 0.17-1.00), but after two years, 70.7% of the 157 participants, who completed the survey, were re-infected with no significant difference in prevalence and intensity of infection between treatment groups. Resolution of organomegaly occurred in all age groups after treatment. A novel association between Schistosoma haematobium infection and moderate portal vein enlargement was found in 35% (n: 55). Severe portal vein diameter enlargement was found in 3.2%. After two years, moderate hepatomegaly was present in 50.6%, moderate splenomegaly in 45.6% and moderate portal vein diameter enlargement in 19%. A subsequent dose of PZQ did not provide any additional long-term advantages.

The burden, pattern and factors that contribute to periportal fibrosis in HIV-infected patients in an S. mansoni endemic rural Uganda

INTRODUCTION

Both Human Immunodeficiency Virus (HIV) and S.mansoni infections are common in Uganda and can cause liver disease. No study has determined co-infection significance in Uganda. We carried out a study on the burden, pattern and factors that contribute to peri-portal fibrosis (PPF) in HIV infected patients attending a Primary healthcare setting at Pakwach.

METHODOLOGY

We conducted a cross-sectional study in the HIV clinic at Pakwach health centre IV. Data on demographics, contact with the Nile, CD4⁺ cell count, ART and alcohol use were collected. Urinary Circulating Cathodic Antigen (CCA), was done for S. Mansoni detection. Liver scan was done for presence and pattern of PPF. HBsAg testing was performed on all participants. Data was analyzed using Stata Version 10.

RESULTS

We enrolled 299 patients, median age 39 years (IQR 16), most were female, 210 (73%). Overall, 206 (68.9%) had PPF, majority 191 (92.7%) had pattern c, either alone (63 participants) or in combination with pattern d (128 participants). Age of 30-50 years was significantly associated with PPF (OR 2.28 p-value-0.003).

CONCLUSION

We found high prevalence of S. mansoni and PPF in the HIV infected population and age was a significant factor for PPF. We recommend all HIV infected patients be examined routinely for S. mansoni infection for early anti-schistosomal treatment.

Is ultrasonography useful for population studies on schistosomiasis mansoni? An evaluation based on a survey on a population from Kome Island, Tanzania

Background

Observation of characteristic alterations at liver ultrasonography in clinical schistosomiasis mansoni cases has initiated utilization of this examination method in population surveys in areas where this disease is endemic.

Purpose

To present results of liver ultrasonography and their relation to epidemiological data of a population in an area endemic for S. mansoni, to estimate the precision of classification of periportal anatomy changes known as periportal fibrosis (PPF), and to evaluate the relevance of ultrasonography in epidemiological studies on S. mansoni.

Material and Methods

A total of 459 inhabitants on Kome Island, Lake Victoria, Tanzania were examined by ultrasound with image documentation by locally trained personnel. A subsample of this population, 116 individuals, was subject to ultrasonography by two examiners independently. Separately, the images were classified for PPF according to the Managil protocol, twice for the subsample.

Results

PPF could be classified for 458 individuals; 64% and 36% were classified as I or II, respectively; none was classified as 0; only one as III. Results were similar for the subsample examined twice. Comparing the two separate classifications of all 232 sets of images of the subsample gave a Kappa (K) value of 0.50. When comparing the classifications of each of the two different examinations of the same individuals of the subsample, K values of 0.29 and 0.34 for the first and second classification, respectively, were obtained.

Conclusion

Ultrasonography does not appear to correlate well with disease stage. Presently, it should not be utilized for staging of schistosoma mansoni-related liver damage in population surveys.

Hepatitis E virus seroprevalence among schistosomiasis patients in Northeastern Brazil

Background

Hepatitis E virus (HEV) can cause chronic infection with rapid progression to liver cirrhosis in immunocompromised patients. HEV seroprevalence in patients with Schistosoma mansoni in Brazil is unknown. We evaluated the prevalence of past or present HEV infection in schistosomiasis patients in Recife, Pernambuco, Brazil. A total of 80 patients with Schistosoma mansoni were consecutively enrolled in a cross-sectional study. Serum samples were tested for the presence of anti-HEV IgG antibodies by enzyme immunoassay (Wantai anti-HEV IgG, Beijing, China) and for the presence of HEV RNA using real time reverse transcriptase-polymerase chain reaction with primers targeting the HEV ORF2 and ORF3. Clinical and laboratory tests as well as abdominal ultrasound were performed at the same day of blood collection.

Results

Anti-HEV IgG was positive in 18.8% (15/80) of patients with SM. None of the samples tested positive for anti-HEV IgM or HEV-RNA. Patients with anti-HEV IgG positive presented higher levels of alanine aminotranferase (p = 0.048) and gama-glutamil transferase (p = 0.022) when compared to patients without anti-HEV IgG antibodies.

Conclusion

This study demonstrates that the seroprevalence of HEV is high in patients with Schistosoma mansoni in Northeastern of Brazil. Past HEV infection is associated with higher frequency of liver enzymes abnormalities. HEV infection and its role on the severity of liver disease should be further investigated among patients with Schistosoma mansoni.

Application of Ultrasonography in the Diagnosis of Infectious Diseases in Resource-Limited Settings

Ultrasound (US) has vast potential in the field of infectious diseases, especially so in resource-limited settings. Recent technological advances have increased availability and access to ultrasound in low-resource settings, where the burden of infectious diseases is greatest. This paper collates the evidence for the utilization of ultrasound and evaluates its effectiveness in the diagnosis and management of a range of infectious diseases. This paper explores the role of ultrasound in population-based screening for specific diseases as well as highlights its benefits for individual patient management. We describe the common diagnostic signs seen on US for common and neglected parasitic, bacterial, and viral diseases. We proceed to document the emerging field of chest US which is proving to be a superior imaging modality for the diagnosis of specific pulmonary conditions. We conclude by discussing the efforts needed to formalize and rigorously evaluate the role of ultrasound in infectious diseases.

Schistosoma haematobium in Guinea-Bissau: unacknowledged morbidity due to a particularly neglected parasite in a particularly neglected country

Schistosomiasis is the major neglected tropical helminthic disease worldwide. Current knowledge on the epidemiology of schistosomiasis in Guinea-Bissau is scarce and regarding to the absence of Schistosoma haematobium (S.h.). Therefore, a pilot study was undertaken to assess the prevalence and morbidity due to S.h. infection in randomly selected 90 children and adolescents aged 6 to 15 years. Prevalence of S.h. infection was 20.00 % (18/90). Microhematuria was observed in 61.11 % (11/18) of S.h.-egg-excreting vs. 37.50 % (27/72) of non-S.h.-egg-excreting children p ≤ 0.01. Body mass index (BMI) was less than 15 kg/m(2) in 52/90 (57.78 %) of all children and adolescents, but this proportion increased to 66.67 % (12/18) in S.h.-infected children who were more frequently stunted and wasted than in non-infected children. The mean weight-for-age Z score (WAZ) was reduced in S.h. infected as compared to non-infected children (-1.48 ± 1.08 SD vs. -0.80 ± 1.11 SD; p ≤ 0.01). To our knowledge, this is the first epidemiologic report on S. haematobium infection in Guinea-Bissau since 22 years. Even in this relatively small study sample, it appears that S. haematobium, besides the well-known symptoms such as hematuria, leads to significant, albeit commonly unacknowledged morbidity such as stunting and wasting. These observations underscore the notion that this vulnerable but neglected population urgently needs to be targeted for implementation of measures for treatment and control.

Point-of-Care Ultrasound Assessment of Tropical Infectious Diseases--A Review of Applications and Perspectives

The development of good quality and affordable ultrasound machines has led to the establishment and implementation of numerous point-of-care ultrasound (POCUS) protocols in various medical disciplines. POCUS for major infectious diseases endemic in tropical regions has received less attention, despite its likely even more pronounced benefit for populations with limited access to imaging infrastructure. Focused assessment with sonography for HIV-associated TB (FASH) and echinococcosis (FASE) are the only two POCUS protocols for tropical infectious diseases, which have been formally investigated and which have been implemented in routine patient care today. This review collates the available evidence for FASH and FASE, and discusses sonographic experiences reported for urinary and intestinal schistosomiasis, lymphatic filariasis, viral hemorrhagic fevers, amebic liver abscess, and visceral leishmaniasis. Potential POCUS protocols are suggested and technical as well as training aspects in the context of resource-limited settings are reviewed. Using the focused approach for tropical infectious diseases will make ultrasound diagnosis available to patients who would otherwise have very limited or no access to medical imaging.

Severe liver fibrosis caused by Schistosoma mansoni: management and treatment with a transjugular intrahepatic portosystemic shunt

Liver diseases are common in inhabitants and migrants of tropical countries, where the liver can be exposed not only to toxins but also to many viral, bacterial, fungal, and parasitic infections. Schistosomiasis--a common parasitic infection that affects at least 240 million people worldwide, mostly in Africa--is regarded as the most frequent cause of liver fibrosis worldwide. We present a case of a 19-year-old male refugee from Guinea with recurrent oesophageal variceal bleeding due to schistosomal liver fibrosis refractory to endoscopic therapy. This case was an indication for portosystemic surgery, which is a highly invasive non-reversible intervention. An alternative, less invasive, reversible radiological procedure, used in liver cirrhosis, is the placement of a transjugular intrahepatic portosystemic shunt (TIPS). After thorough considerations of all therapeutic options we placed a TIPS in our patient. In more than 3 years of observation, he is clinically well apart from one episode of hepatic encephalopathy related to an acute episode of viral gastroenteritis. Bleeding from oesophageal varices has not recurred. In this Grand Round, we review the diagnostic approaches and treatment options for portal hypertension due to schistosomal liver fibrosis.

Morbidity associated with schistosomiasis before and after treatment in young children in Rusinga Island, western Kenya

Schistosoma mansoni infection is a major cause of organomegaly and ultimately liver fibrosis in adults. Morbidity in pre-school-aged children is less defined, and they are currently not included in mass drug administration (MDA) programs for schistosomiasis control. We report results of a study of the association of schistosomiasis with organomegaly in a convenience sample of 201 children under 7 years old in Rusinga, Kenya on two cross-sectional visits, before and after praziquantel treatment. Data included stool examination and serology for schistosomiasis, the Niamey ultrasound protocol to stage hepatosplenic morbidity including organomegaly, and potential confounders including malaria. Unadjusted and adjusted Poisson regressions were performed. The baseline prevalence of schistosomiasis by antibody and/or stool was 80.3%. Schistomiasis was associated with hepatomegaly (adjusted prevalence ratio [aPR] = 1.4; 95% confidence interval [CI]: 1.0-2.1) and splenomegaly (aPR = 2.1; 95% CI: 1.2-3.7). The association with hepatomegaly persisted posttreatment (aPR = 1.4; 95% CI: 1.1-1.6). Schistosomiasis was associated with morbidity in this cohort. Efforts to include young children in mass treatment campaigns should intensify.