Carcinoma of the uterine cervix associated with schistosomiasis and induced by human papillomaviruses

Schistosomiasis presenting as ruptured ectopic pregnancy

A woman from sub-Saharan Africa living in the Middle East, presented with acute abdominal pain and COVID-19 infection. She underwent a laparotomy and left salpingectomy for a left tubal ruptured ectopic pregnancy. The histopathology report revealed the presence of tubal schistosomiasis in addition to the ectopic sac. The report emphasises the importance of considering female genital schistosomiasis as a potential cause of ectopic pregnancy and the need for collaboration between obstetricians and infectious disease physicians in the definitive treatment of the disease to reduce reproductive morbidity. This case report highlights the possibility of female genital schistosomiasis as a cause of ectopic pregnancy in women from endemic regions.

Female genital schistosomiasis is a neglected public health problem in Tanzania: Evidence from a scoping review

Schistosoma haematobium, the parasite that causes urogenital schistosomiasis, is widely prevalent in Tanzania. In addition to well-known effects on the urinary tract, S. haematobium also causes clinically- evident damage to the reproductive tract in approximately half of infected women, which is known as female genital schistosomiasis (FGS). FGS has major gynecologic and social consequences on women's reproductive health, yet little information is available regarding FGS in Tanzania. To cover that gap, we conducted the present scoping review to examine the epidemiology of FGS in Tanzania (both in the mainland and Zanzibar island) and to make recommendations for future work in this area. The available evidence from community-based and hospital-based retrospective studies indicates that FGS is a significant health problem in the country. Very few community-based studies have been reported from mainland Tanzania, and Zanzibar. Our review highlights the scarcity of efforts to address FGS in Tanzania and the need for additional community-based studies. The studies will help us understand the true burden of the disease nationwide, to assess the impact of praziquantel on FGS lesions, and to address social and mental health in relation to FGS. This review emphasizes integration of delivery of FGS related services in primary health care systems through the reproductive health clinics which covers sexually transmitted infections, HIV and cervical cancer screening. These actions are essential if this neglected gynecological disease is to be addressed in Tanzania.

Population risk factors for late-stage presentation of cervical cancer in sub-Saharan Africa

BACKGROUND

Cervical cancer is the most prevalent malignancy in sub-Saharan Africa (SSA) with many women only seeking professional help when they are experiencing symptoms, implying late-stage malignancy and higher mortality rates. This ecological study assesses population-level exposures of SSA women to the numerous risk factors for HPV infection and cervical cancer, against late-stage presentation of cervical cancer.

MATERIALS AND METHOD

A literature review revealed the relevant risk factors in SSA. Open-access databases were mined for variables closely representing each risk factor. A proxy for late-stage presentation was used (ratio of incidence-to-mortality, IMR), and gathered from IARC's GLOBOCAN 2012 database. Variables showing significant correlation to the IMR were used in stepwise multiple regression to quantify their effect on the IMR.

RESULTS

Countries with high cervical cancer mortality rates relative to their incidence have an IMR nearer one, suggesting a larger proportion of late-stage presentation. Western Africa had the lowest median IMR (1.463), followed by Eastern Africa (IMR = 1.595) and Central Africa (IMR = 1.675), whereas Southern Africa had the highest median IMR (1.761). Variables selected for the final model explain 65.2% of changes seen in the IMR. Significant predictors of IMR were GDP (coefficient = 2.189 × 10^-6, p = 0.064), HIV infection (-1.936 × 10^-3, p = 0.095), not using a condom (-1.347 × 10^-3, p = 0.013), high parity (-1.744 × 10^-2, p = 0.008), and no formal education (-1.311 × 10^-3, p < 0.001).

CONCLUSION

Using an IMR enables identification of factors predicting late-stage cervical cancer in SSA including: GDP, HIV infection, not using a condom, high parity and no formal education.

Female genital schistosomiasis (FGS): from case reports to a call for concerted action against this neglected gynaecological disease

In recent years, control of neglected tropical diseases has been increasingly gaining momentum and interventions against schistosomiasis are being progressively scaled-up through expansion of donated praziquantel and preventive chemotherapy campaigns. However, the public health importance of female genital schistosomiasis is not fully recognised nor its control is adequately addressed. Taking a clinical and anatomopathological perspective, we evaluated the available literature to highlight the importance of female genital schistosomiasis and its connections with two sexually transmitted infections of global importance, Human Immunodeficiency Virus (HIV) and Human Papilloma Virus. Outside the long list of clinical descriptive reports beginning in 1899, there is presently a shocking gap in epidemiological assessment and a significant underestimation of the burden of FGS remains. The scarcity of integrated approaches to address female genital schistosomiasis calls for more concerted action in its detection, treatment and prevention alongside other concomitant women's health issues, otherwise female genital schistosomiasis will remain a neglected gynaecological disease.

Getting the basic rights - the role of water, sanitation and hygiene in maternal and reproductive health: a conceptual framework

OBJECTIVE

To explore linkages between water, sanitation and hygiene (WASH) and maternal and perinatal health via a conceptual approach and a scoping review.

METHODS

We developed a conceptual framework iteratively, amalgamating three literature-based lenses. We then searched literature and identified risk factors potentially linked to maternal and perinatal health. We conducted a systematic scoping review for all chemical and biological WASH risk factors identified using text and MeSH terms, limiting results to systematic reviews or meta-analyses. The remaining 10 complex behavioural associations were not reviewed systematically.

RESULTS

The main ways poor WASH could lead to adverse outcomes are via two non-exclusive categories: 1. 'In-water' associations: (a) Inorganic contaminants, and (b) 'water-system' related infections, (c) 'water-based' infections, and (d) 'water borne' infections. 2. 'Behaviour' associations: (e) Behaviours leading to water-washed infections, (f) Water-related insect-vector infections, and (g-i) Behaviours leading to non-infectious diseases/conditions. We added a gender inequality and a life course lens to the above framework to identify whether WASH affected health of mothers in particular, and acted beyond the immediate effects. This framework led us to identifying 77 risk mechanisms (67 chemical or biological factors and 10 complex behavioural factors) linking WASH to maternal and perinatal health outcomes.

CONCLUSION

WASH affects the risk of adverse maternal and perinatal health outcomes; these exposures are multiple and overlapping and may be distant from the immediate health outcome. Much of the evidence is weak, based on observational studies and anecdotal evidence, with relatively few systematic reviews. New systematic reviews are required to assess the quality of existing evidence more rigorously, and primary research is required to investigate the magnitude of effects of particular WASH exposures on specific maternal and perinatal outcomes. Whilst major gaps exist, the evidence strongly suggests that poor WASH influences maternal and reproductive health outcomes to the extent that it should be considered in global and national strategies.

Placental Schistosoma haematobium infection in a German returnee from Malawi

Schistosomiasis is a widespread helminthic infection which sometimes may affect travelers to endemic areas. We report on a case of urogenital and placental schistosomiasis in a 28-year-old German woman who had been exposed to schistosomiasis in Lake Malawi one year earlier. She experienced painless macrohaematuria in her 21st week of pregnancy. Cystoscopy revealed vesical lesions typical for urogenital schistosomiasis. Histopathology confirmed ova of Schistosoma (S.) haematobium. The patient was treated with praziquantel 40 mg/kg/body weight/day for 3 days. After 285 days of gestation and 18 weeks post treatment, the patient delivered a healthy girl. Histopathology of placenta revealed eggs of S. haematobium in placental stroma. The infant proved negative for anti-Schistosoma spp. antibodies at the age of 15 months. This is the first report on placental schistosomiasis since 1980 and the first case occurring in a traveler.

Genital schistosomiasis as a cause of female sterility and acute abdomen

OBJECTIVE

To report the case of a Nigerian patient who suffered from sterility and underwent abdominal laparotomy to remove an adnexal tumor. Histologic analysis revealed Schistosoma haematobium ova.

DESIGN

Case report.

SETTING

Multidisciplinary group practice and teaching hospital.

PATIENTS

One patient who underwent an abdominal laparotomy to remove an adnexal tumor.

INTERVENTION(S)

In vitro fertilization and adnexal tumor resection via laparotomy.

MAIN OUTCOME MEASURE(S)

Treatment of the adnexal tumor affecting the reproductive health.

RESULT(S)

Histologic analysis performed on the tissue removed at surgery revealed fibrous patches around aggregates of calcified Schistosoma haematobium eggs in the fallopian tube wall.

CONCLUSION(S)

Schistosomiasis needs to be considered as a differential diagnosis of female infertility and sterility.

Prevalence of cervical neoplastic lesions and Human Papilloma Virus infection in Egypt: National Cervical Cancer Screening Project

Background

Data from Egyptian studies provide widely varying estimates on the prevalence of pre-malignant and malignant cervical abnormalities and human papilloma virus (HPVs) infection. To define the prevalence and risk factors of pre-invasive and invasive cervical cancer (cacx), a community based full-scale cross sectional, household survey including 5453 women aged between 35 and 60 years was conducted.

Methods

The study period was between February 2000 and December 2002. Initially, conventional Papanicolaou (Pap) smears were evaluated using the Bethesda system (TBS), followed by colposcopic guided biopsy (CGB) for all epithelial abnormalities (EA). In a third step, HPV was tested on all EA by in-situ hybridization (ISH) using first the broad spectrum HPV probe recognizing HPVs 6, 11, 16, 18, 30, 31, 35, 45, 51 and 52 followed by subtyping with probes 6/11, 16/18 and 31/33. Lastly, unequivocal cases were immunostained for herpes simplex type-2 (HSV-2), cytomegalovirus (CMV), and human immunodeficiency virus (HIV).

Results

EA representing 7.8% (424/5453), were categorized into atypical squamous cell of undetermined significance (ASCUS) (34.4%), atypical glandular cell of undetermined significance (AGCUS) (15.3%), combined ASCUS and AGCUS (3.1%), low grade squamous intraepithelial lesions (SIL) (41.0%), high grade SIL (5.2%) and invasive lesions (1%). CGB of EA (n = 281) showed non neoplastic lesions (12.8%), atypical squamous metaplasia (ASM) (19.2%), cervical intraepithelial neoplasia I (CIN) (44.4%), CIN II (4.4%), CINIII (2.8%), endocervical lesions (5.2%), combined squamous and endocervical lesions (10.0%), invasive squamous cell carcinoma (SCC) (0.02%) and extranodal marginal zone B cell lymphoma (MZBCL) (0.02%). The overall predictive value of cytology was 87% while the predictive value for high grade lesions was 80%. On histological basis, HPVs were present in 94.3% of squamous lesions while it was difficult to be identified in endocervical ones. ISH revealed positivity for pan HPV in 65.9% of the studied biopsies (n = 217), with incorporation of the viral genome HPV 6/11, 16/18 and 31/33 in 11.1%, 33.3% and 17.1% respectively. Multiple HPVs infections were identified in 0.02%.

Conclusion

Pre-invasive high grade lesions and invasive cervical carcinoma represent 0.5% and 0.04% respectively in Egyptian women. HPV mostly 16/18 as a risk factor (p < 0.001), was frequently associated with mixed infections (p < 0.001) and bilharzial infestation (p < 0.001).

Female genital schistosomiasis as an evidence of a neglected cause for reproductive ill-health: a retrospective histopathological study from Tanzania

Background

Schistosomiasis affects the reproductive health of women. Described sequelae are ectopic pregnancy, infertility, abortion, and cervical lesions and symptoms mimicking cervical cancer and STIs. There are indications that cervical schistosomiasis lesions could become co-factors for viral infection such as HIV and HPV.

Methods

In a retrospective descriptive histopathological study clinical specimens sent between 1999 and 2005 to the pathology department of a consultant hospital in Tanzania were reviewed to analyse the occurrence and features of schistosomiasis in female genital organs.

Results

During the study period, schistosomiasis was histopathologically diagnosed in 423 specimens from different organs (0.7% of all specimens examined in the study period), out of those 40% were specimens from female and male organs. The specimens were sent from 24 hospitals in 13 regions of mainland Tanzania. Female genital schistosomiasis was diagnosed in 125 specimens from 111 patients. The main symptoms reported were bleeding disorders (48%), ulcer (17%), tumor (20%), lower abdominal pain (11%) and infertility (7%). The majority of cases with genital schistosomiasis were diagnosed in cervical tissue (71 cases). The confirmation of cervical cancer was specifically requested for 53 women, but the diagnosis could only be verified for 13 patients (25%), in 40 cases only severe cervical schistosomiasis was diagnosed. Vulval/labial schistosomiasis was seen in specimens from young women. Infertility was reported in four patients with schistosomiasis of the Fallopian tubes.

Conclusion

Genital schistosomiasis adds to the disease burden of women in all age groups. Pathological consequences due to the involvement of different genital organs can be damaging for the affected women. Clinical unawareness of genital schistosomiasis can lead to misdiagnosis and therefore false and ineffective therapy. In endemic areas cervical schistosomiasis should be considered as differential diagnosis of cancer.

Non-neoplastic diseases of the cervix in Nigerians: a histopathological study

BACKGROUND

Diseases of the cervix are common in young sexually active women. Non-neoplastic diseases are predominantly inflammatory and are common but there are a few publications on the subject compared to neoplastic diseases of the cervix.

MATERIALS AND METHODS

The surgical day books of the Histopathology department of the Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife, Nigeria from the year 1990-1999 (Ten years) were studied for all cervical biopsies.

RESULTS

Four hundred (400) cervical surgical biopsies were received during this period. 150 (37.5%) of the cases were non-neoplastic lesions. Age range was 20-69 years with peak incidence at 40-49 years. Histological distribution showed 123 cases (82%) were chronic non-specific cervicitis. Eighteen cases (12%) were chronic cervicitis with koilocytic change pathognomonic of Human Papilloma Virus (HPV) infection, two-third (12 cases) of which occur within 40-49 years. There were five cases (3.3%) of chronic granulomatous cervicitis, three cases (2.0%) of acute cervicitis and only one case (0.7%) of microglandular endocervical hyperplasia.

CONCLUSION

All the histological types were found within the peak age incidence of 40-49 years. Chronic non-specific cervicitis was the most common non-neoplastic cervical lesion and it occurs in all age groups of women studied. In 12% of patients it is associated with cytopathic effect of HPV. This has obvious implication for the occurrence of carcinoma of the cervix in our country. We recommend routine pap smear test in this group of patients especially, as a way of reducing the occurrence of carcinoma of the cervix.

Cervical schistosomiasis and neoplasia in HIV-infected patients

We report two HIV-positive women with schistosomiasis of the uterine cervix, a disease that is being increasingly seen in developed countries. In both cases, there were no schistosoma ova in the cervical Papanicolaou smears. Both patients underwent LLETZ procedures that revealed an absence of a granulomatous response to the schistosoma ova, a finding that should alert the pathologist to the possibility of HIV infection. The absence of ova on cervical smears of HIV-infected women with schistosomiasis is probably related to the absence of granulomatous inflammation in these patients. A diligent search should be made for schistosoma ova in the cervical biopsy of patients from endemic areas. Treatment of schistosomiasis in HIV-infected patients should be prompt and complete to prevent recurrent high-risk HPV infection.

Cervical schistosomiasis, human papilloma virus (HPV), and human immunodeficiency virus (HIV): a dangerous coexistence or coincidence?

BACKGROUND

Female genitourinary schistosomiasis (FGS) is widespread in endemic areas causing significant morbidity and mortality. Recent data suggest that FGS of the cervix not only is considered a risk factor for contracting different sexually transmitted diseases (STD), but also plays a significant role in modifying the natural history and immunological response to those infections, in particular HIV and HPV.

CASE REPORT

A 32-year-old female from Zambia, who was recently diagnosed with HIV and high-grade dysplasia with koilocytosis on cervical Pap smear, underwent cervical conization which confirmed moderate cervical dysplasia and also revealed the presence of viable and nonviable schistosoma eggs in cervical stroma. Four different HPV types were isolated by PCR, including one "low-risk" (type 6) and three "high-risk" types (types 45,56, and 58).

CONCLUSION

The presence of HPV, HIV infection, and cervical schistosomiasis in our patient is likely more than coexistence of multiple agents in the same milieu as cervical schistosomiasis increase susceptibility for other STDs including HIV and HPV. Therefore, in patients with schistosomiasis, immediate treatment for schistosomiasis and additional testing for HIV and HPV is warranted.

Human papillomavirus, coinfection with Schistosoma hematobium, and cervical neoplasia in rural Tanzania

Cervical cancer is the most common malignant tumor among women in Tanzania and other countries in tropical Africa. Genital schistosomiasis has been proposed as a possible cofactor in the genesis of this malignant disease that might contribute to its high incidence in regions where bilharzias is endemic. One hundred nine Tanzanian patients from an area with endemic bilharzias who were transferred to a gynecologic out-patient clinic were age-matched with 109 German controls. In patients and controls, separate samples were taken for cytologic assessment and human papillomavirus (HPV) DNA detection using the Hybrid Capture 2 assay (HC2) and PCR (GP5+/6 +). Samples that tested positive for HPV DNA with general primers were re-tested with HPV type-specific primers. After application of 3% acetic acid, punch biopsies were taken from any cervical lesion. Patients were interviewed for recent symptoms or clinical history suggestive of bilharzias. Urine samples from all patients were examined for the presence of schistosoma hematobium ova. Additionally six Tanzanian patients with invasive cervical cancer were included for separate analysis. Patients and controls had an identical prevalence of HPV-DNA (21.5%) using HC2. Based on PCR results with general primers, the corresponding prevalence was 34.5% for Tanzanian cases and 26.9% for German controls. A history suggestive of bilharzias and/or active schistosomiasis were associated with a significantly increased risk for infection with high-risk HPV types. We conclude that infection with Schistosoma hematobium seems to favor persistent genital HPV infection either by traumatizing the genital epithelium and/or by local immunosuppression.

The impact of chemotherapy on morbidity due to schistosomiasis

Current knowledge on the impact of chemotherapy on schistosomiasis-related morbidity is still fragmentary. In urinary schistosomiasis, reversal of organ pathology follows cure after 6 months and resurgence takes place after at least another 6 months. Retreatment after less than 1 year is, therefore, unnecessary. Also, intestinal schistosomiasis appears to regress promptly after chemotherapy. For the reversal of hepatic morbidity, more than one chemotherapy round appears necessary at least in foci of intense transmission of schistosomiasis. The earlier chemotherapy is given, the higher the chances of reversal of schistosomal pathology, but pathology may regress to some extent also in adults. The regression and resurgence of periportal fibrosis, as detected by ultrasonography, occurs with a delay of 7 months to more than 2 years after therapy. Retreatment after less than 1 year may not permit full assessment of the impact of the first round on hepatic morbidity. Children and adolescents should be the major target population, taking into account that in many foci, children out-of-school must be covered because they are at the highest risk. Repeated treatment during childhood may prevent the development of urinary tract disease in adulthood. However, no data are available on the prevention of genital pathology. Repeated chemotherapy may have a long term effect on re-infection intensities and the development of severe morbidity, even in foci where control has been interrupted for many years. Severe hepatic fibrosis may be prevented even in foci of intense transmission provided more than two rounds of chemotherapy have been given in childhood and that chemotherapy is available on demand. Chemotherapy has an important impact on child development, physical fitness and working capacity. Its effect on growth and anemia is improved by simultaneous treatment of intestinal parasites and the provision of adequate iron supplementation. The impact of chemotherapy on many of the multifaceted manifestations of schistosomiasis has not been assessed systematically. More data are needed on gallbladder pathology, neuroschistosomiasis, endocrinologic disorders, bladder cancer and co-infections with other pathogens. In areas where control has been achieved, the overall morbidity and mortality has decreased with a delay of many years or even decades.

Female genital schistosomiasis: facts and hypotheses

In this paper we summarise the parasitological, clinical and epidemiological characteristics of female genital schistosomiasis (FGS), a frequent manifestation of the infection with Schistosoma haematobium. Means to diagnose and treat lesions in the lower and upper genital tract are discussed. Based on clinical findings and available pathophysiological as well as immunological data it is conceivable that FGS of the cervix and vagina not only facilitates the infection with agents of sexually transmitted diseases, but presumably also alters the natural history of such infections. Two infectious agents are of particular concern: the Human Immunodeficiency Virus and the oncogenic Human Papilloma Viruses. Possible interactions and their consequences are discussed and research areas which should be addressed are outlined.

p53 immunohistochemical expression of Egyptian cervical carcinoma

Data concerning the expression of p53 in cervical carcinoma, one of the leading cause of death in developing countries, are still confusing. This study was designed to identify p53 in Egyptian cervical carcinoma in an attempt to evaluate its prognostic significance. Eleven chronic cervicitis and 38 invasive carcinoma (31 squamous cell carcinoma (sqcc) and 7 adenocarcinoma, ranging from stage IB to IVB), were stained with the monoclonal antibody anti p53, DO7, using the microwave for antigen retrieval. No immunoreactivity was detected in chronic cervicitis, while nuclear p53 reactivity was detected in all carcinoma and in squamous intra-epithelial lesions (SIL) overlying 8 sqcc. P53 immunohistochemical (IHC) expression was more pronounced in early clinical stages (p=0.007) and in adenocarcinoma compared to sqcc (p=0.015). A positive correlation was present between p53 and heat shock protein 70 (hsp70) expressions (p=0.005). No correlation could be found between p53 expression and tumor infiltrating lymphocytes, the presence or absence of either schistosomiasis or HPV infections. It can be concluded, that in the Egyptian population, p53 immunoreactivity appears to be an early event in cervical neoplasm, and seems to play an important role together with other cell regulatory proteins in the process of carcinogenesis, which could be different between sqcc and adenocarcinoma.

Female genital schistosomiasis due to Schistosoma haematobium. Clinical and parasitological findings in women in rural Malawi

A total of 51 women with urinary schistosomiasis haematobium were examined in order to identify diagnostic indicators for female genital schistosomiasis (FGS). Patients were selected at random from the outpatient department of the Mangochi District Hospital, Malawi. The medical histories were recorded according to a pre-designed questionnaire and the women were subjected to a thorough gynaecological examination including colposcopy and photographic documentation of lesions. Microscopy of genital biopsies revealed that 33 of the 51 women had S. haematobium ova in cervix, vagina and/or vulva in addition to the presence of ova in urine. The most sensitive diagnostic procedure was beside microscopic examination of a wet cervix biopsy crushed between two glass slides, which revealed 25 of the 33 genital infections. There was a significant correlation between the size of genital lesions and the number of ova counted per mm2 of crushed tissue. Women with FGS had significantly more tumours in the vulva than women with schistosomiasis limited to the urinary tract. Most of the observed genital pathology could easily be identified by the naked eye, but colposcopic examination yielded valuable additional information like the demonstration of neovascularisation around cervical sandy patches. Few of the symptoms previously regarded as indicators for FGS could be linked to the presence of schistosome ova in genital tissue. Husbands of infertile women with FGS had children with other women significantly more often than husbands of women who only had urinary schistosomiasis. This, together with the finding that the majority of the divorced women had FGS, indicates that the manifestation of this disease may have implications for the marital and sexual life of the affected women.