An ultrasonographic study of liver fibrosis in patients infected with Schistosoma mansoni in north-east Brazil

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.

New index for the diagnosis of liver fibrosis in Schistosomiasis mansoni

BACKGROUND

- Periportal fibrosis is the major pathological consequence of the Schistosoma mansoni infection.

OBJECTIVE

- To evaluate the accuracy of serum markers and to construct an index to assess fibrosis.

METHODS

- Patients (n=116) with schistosomiasis were evaluated by ultrasound scan and measurements of serum levels of aminotransferases, γ-glutamyl transferase, alkaline phosphatase, hyaluronic acid, cytokines and platelets. Ultrasound images were used to evaluate the fibrosis using Niamey's classification and identified 19 patients without periportal fibrosis (patterns A and B), 48 with mild to moderate fibrosis (C and D) and 49 with advanced fibrosis (E and F).

RESULTS

- Using multivariate analysis, a model was created, which involved alkaline phosphatase and platelets and could separate patients with different patterns of fibrosis. This index showed a better performance in separating patients without fibrosis from with advanced periportal fibrosis. The biological index showed an area under the ROC curve of 1.000. Using values below the lowest or above the highest cut-off point, the presence or absence of advanced fibrosis could be predicted in all patients.

CONCLUSION

- The index constructed can be used to separate patients with different patterns of periportal fibrosis, specially to predict advanced fibrosis in schistosomiasis patients.

Pulmonary shunts in severe hepatosplenic schistosomiasis: Diagnosis by contrast echocardiography and their relationship with abdominal ultrasound findings

Background

Schistosomiasis is endemic to several parts of the world. Among the species that affect humans, Schistosoma mansoni is one of the most common causes of illness. In regions where schistosomiasis mansoni is endemic, reinfection is responsible for the emergence of hepatosplenic schistosomiasis (HSS) with portal hypertension in about 10% of infected individuals. Regardless of its etiology, portal hypertension may bring about the formation of arteriovenous fistulas and pulmonary vascular dilation, thus constituting a pulmonary shunt and its presence has been associated with the occurrence of neurological complications. The objective of this study was to identify pulmonary shunt using TTCE in patients with HSS and esophageal varices, and to compare the abdominal ultrasound and endoscopy findings among patients with and without pulmonary shunt.

Methodology/Principal findings

In this case series, a total of 461 patients with schistosomiasis mansoni were prospectively evaluated using abdominal ultrasound and endoscopy and 71 presented with HSS with esophageal varices. Fifty seven patients remained in the final analysis. The mean age of the patients was 55 ± 14 years, and 65% were female. Pulmonary shunts were observed in 19 (33.3%) patients. On comparing the groups with and without pulmonary shunt, no significant differences were observed in relation to the abdominal ultrasound and endoscopic findings. When comparing the two subgroups with pulmonary shunts (grade 1 vs grades 2 and 3), it was observed that the subgroup with shunt grades 2 and 3 presented with a significantly higher frequency of an enlarged splenic vein diameter (>0.9 cm), and an advanced pattern of periportal hepatic fibrosis (P = 0.041 and P = 0.005, respectively). None of the patients with pulmonary shunts had severe neurological complications.

Conclusions/Significance

Our findings suggest that in HSS with esophageal varices the pulmonary shunts may be present in higher grades and that in this condition it was associated with ultrasound findings compatible with advanced HSS.

Among the species of Schistosoma that infect humans Schistosoma mansoni is one of the most common causes of illness. In the areas where schistosomiasis mansoni is endemic, around 10% of infected individuals develop hepatosplenic schistosomiasis (HSS) with portal hypertension. Portal hypertension may promotes an imbalance in the hepatic production of vasoactive substances, which may act on the lungs promoting the formation of arteriovenous fistulas and pulmonary vascular dilation, a condition that is called a pulmonary shunt. When the pulmonary shunt is of higher grades, small thrombus or septic emboli that would normally be filtered through the pulmonary capillaries reach the left heart and the systemic circulation, which can lead to neurological complications. We found pulmonary shunts in patients with HSS and esophageal varices and we also found that patients with higher grades of pulmonary shunts presented with a significantly higher frequency of advanced periportal fibrosis and an enlarged splenic vein diameter. No neurological complications were observed. Our findings suggest that pulmonary shunts may be present in patients with HSS and esophageal varices. The abdominal ultrasound findings compatible with advanced HSS could be used as screening to investigate pulmonary shunt.

Morbidity of mansoni schistosomiasis in Pernambuco-Brazil: Analysis on the temporal evolution of deaths, hospital admissions and severe clinical forms (1999-2014)

BACKGROUND

Current scientific information reported that due to successive treatments of schistosomiasis cases in endemic areas of Brazil in the last 30 years, there has been a decrease in severe clinical form (hepatosplenic) and mortality from upper gastrointestinal bleeding due to this disease. Against this information, literature data show that the state of Pernambuco presents significant percentage of deaths and hospitalizations due to schistosomiasis, and occurrence of severe clinical forms as schistosomiasis myeloradiculopathy and persistence of localities with high parasite loads. This scenario justified this research which seeking to update the morbidity and mortality of schistosomiasis in Pernambuco.

OBJECTIVE

To conduct a temporal analysis on the evolution of deaths, hospital admissions and severe forms of Manson's schistosomiasis over the last 16 years in Pernambuco, Brazil.

METHODS

It was performed a gathering secondary data on schistosomiasis, from healthcare information systems and from the records of Hospital das Clínicas, Federal University of Pernambuco (HC-UFPE), covering the period from 1999 to 2014.

RESULTS

From 1999 to 2013 were registred 2578 deaths due to schistosomiasis and between 2008 and 2014 were recorded 473 hospitalizations for this disease. Among 1999-2014 were identified 1943 cases of schistosomiasis treated at the Hospital das Clínicas of Pernambuco. Among these cases, 72.6% (n. 1411) of the individuals presented the hepatosplenic clinical form (HE), 60.8% (n. 858) were at the age group 30-59 years (adults) and 58% were female. Among the HE cases, 4.6% (n. 58) had ascites, 43.2% (n. 556) had upper gastrointestinal bleeding and 39.1% (n. 489) had collateral circulation. The pattern of fibrosis in the liver E/EC (advanced fibrosis) and F/FC (very advanced fibrosis) occurred in 65.5% (n. 793) of cases. Between 1999-2014 the evolution curve of severe clinical forms of schistosomiasis remained stable, showing a tendency to decline from 2012.

CONCLUSION

When compared to other states of Brazil, Pernambuco shows high numbers of deaths and hospital admissions due to schistosomiasis. The actions of the Schistosomiasis Control Program (PCE) have been developed in a disintegrated, disjointed and discontinuous way, which may explain the magnitude of deaths, hospitalizations and severe forms of the disease in Pernambuco, showing a lack of control and the maintenance of severe frame morbidity of schistosomiasis in this state.

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.

Relationship between splenomegaly and hematologic findings in patients with hepatosplenic schistosomiasis

Background

Schistosomiasis is a tropical disease. Patients who develop hepatosplenic schistosomiasis have clinical findings including periportal fibrosis, portal hypertension, cytopenia, splenomegaly and gastrointestinal hemorrhage.

Objective

The aim of this study was to analyze the hemostatic and hematologic findings of patients with schistosomiasis and correlate these to the size of the spleen.

Methods

Fifty-five adults with hepatosplenic schistosomiasis and 30 healthy subjects were selected through a history of contact with contaminated water, physical examination and ultrasound characteristics such as periportal fibrosis and splenomegaly in the Gastroenterology Service of the Universidade Federal de Pernambuco. Blood samples were collected to determine liver function, blood counts, prothrombin (international normalized ratio), partial thromboplastin time and fibrinogen and D-Dimer levels using the Pentra 120 hematological analyzer (HORIBA/ABX), Density Plus (test photo-optical Trinity Biotech, Ireland) and COBAS analyzer 6000 (Roche). Furthermore, the longitudinal size of the spleen was measured by ultrasound (Acuson X analyzer 150, Siemens). The Student t-test, the Fisher test and Pearson's correlation were used to analyze the results with statistical significance being set for a p-value < 0.05.

Results

The mean age was higher for the Study Group than for the Control Group (54 ± 13.9 vs. 38 ± 12.7 years). The average longitudinal diameter of the spleen was 16.9 cm (Range: 12.3-26.3 cm). Anemia is a common finding in patients with schistosomiasis (36.3%). The mean platelet and leukocyte counts of patients were lower than for the Control Group (p-value < 0.001). Moreover, the international normalized ratio (1.42 vs. 1.04), partial thromboplastin time (37.9 vs. 30.5 seconds) and D-Dimer concentration (393 vs. 86.5 ng/mL) were higher for the Study Group compared to the Control Group.

Conclusion

This study suggests that hematological and hemostatic abnormalities are associated with splenomegaly, hypersplenism and portal hypertension.

Correlation between platelet count and both liver fibrosis and spleen diameter in patients with schistosomiasis mansoni

CONTEXT

Studies have described the correlation between platelet count and the stages of fibrosis in chronic viral hepatitis, but few publications have studied this correlation in Schistosomiasis mansoni.

OBJECTIVES

Therefore, this study aimed to correlate platelet count with both the periportal fibrosis pattern and spleen diameter evaluated by ultrasound exam in patients with Schistosomiasis mansoni.

METHODS

Patients with Schistosomiasis mansoni were evaluated by abdominal ultrasound by a single examiner for the determination of periportal fibrosis pattern (Niamey classification) and spleen diameter. Platelet counts were performed in an automated cell counter.

RESULTS

One hundred eighty-seven patients with Schistosomiasis mansoni (mean age: 50.2 years) were included in the study, 114 of whom (61%) were women. Based on the Niamey classification, the ultrasound analysis revealed that 37, 64, 64 and 22 patients exhibited patterns C, D, E and F, respectively. In these four groups, the mean number of platelets was 264, 196, 127 and 103 x 109/L and mean spleen diameter was 9.2, 11.9, 14.9 and 16.2 centimeters, respectively. A reduction in platelet count was significantly associated with both the progression of the periportal fibrosis and the increase in spleen size.

CONCLUSIONS

Platelet count in patients with Schistosomiasis mansoni was inversely correlated with the severity of periportal fibrosis and spleen diameter.

Associating portal congestive gastropathy and hepatic fibrosis in hepatosplenic mansoni schistosomiasis

Upper digestive bleeding is one of the most serious complications of mansoni schistosomiasis, and portal congestive gastropathy (PCG) is responsible for 25-30% of the cases of bleeding instead of bleeding due to esophageal varices. This study aimed to investigate the association between PCG with parameters of portal hypertension and the intensity of periportal fibrosis assessed by ultrasonography, in patients with mansoni schistosomiasis. A prospective study was made of 71 patients whether or not they had a history of upper digestive bleeding, and who had not been previously treated for portal hypertension (splenectomy, use of beta blockers or endoscopic treatment). Patients with other liver diseases were excluded. After signing a form of consent, the patients underwent endoscopy, as well as ultrasonography of the abdomen, and hematological, biochemical and viral markers tests. Chi-square and Fischer's exact tests were used in the statistical analysis. The mean age of the 71 patients was 50 ± 14.5 years of whom 59.2% were women. 45.1% had antecedents of upper digestive bleeding. PCG was observed in 39 patients (54.9%): severe in 8.5%, and mild in 46.5%. A positive association was observed between PCG and the grade of esophageal varices (p=0.017); and the pattern of periportal fibrosis (p=0.041). A negative association was observed between PCG and red spots on the varices (p=0.024). PCG in patients with mansoni schistosomiasis not submitted to treatment for portal hypertension is associated with the sonographic pattern of hepatic fibrosis, as well as with the grade of esophageal varices.

Aspectos ultrassonográficos associados à morbidade de formas clínicas crônicas de esquistossomose mansônica, utilizando-se protocolo proposto pela Organização Mundial da Saúde

OBJETIVO: Avaliar aspectos ultrassonográficos associados à morbidade em pacientes com formas clínicas crônicas de esquistossomose mansônica, utilizando-se protocolo proposto pela Organização Mundial da Saúde (OMS). MATERIAIS E MÉTODOS: Foram avaliadas duas populações distintas: a) área endêmica e b) institucional terciária, com histopatológico confirmando fibrose. Critérios de inclusão: diagnóstico confirmado por parasitológico de fezes para Schistosoma mansoni (método Kato-Katz). Critérios de exclusão: sorologia positiva para HIV, HTLV-1, VHB ou VHC. Foi utilizado protocolo ultrassonográfico de Niamey, proposto pela OMS. RESULTADOS: Avaliando-se isoladamente as medidas dos espaços periportais, estas se mostraram sem alterações em 21% dos indivíduos com doença avançada da instituição terciária. Utilizando-se todos os parâmetros do protocolo, 100% dos indivíduos da instituição terciária, com forma grave da doença, apresentaram fibrose periportal avançada. Em pacientes hepatoesplênicos da área endêmica não se identificou fibrose à ultrassonografia. CONCLUSÃO: O protocolo ultrassonográfico proposto pela OMS detecta fibrose periportal avançada nos pacientes com forma grave da doença, com maior sensibilidade do que a medida do espaço periportal isoladamente. A complexidade de identificação das fases iniciais da fibrose periportal, em áreas endêmicas, pela ultrassonografia, pode suscitar o campo da complementação diagnóstica e a continuidade do aprimoramento dos protocolos ultrassonográficos nestas áreas.

Cytokine and Chemokine Profile in Individuals with Different Degrees of Periportal Fibrosis due to Schistosoma mansoni Infection

Periportal fibrosis in schistosomiasis has been associated to the host immune response to parasite antigens. We evaluated the immune response in S. mansoni infected individuals with different degrees of periportal fibrosis. Cytokine and chemokines were measured in serum and in supernatants of PBMC cultures stimulated with the soluble adult worm (SWAP) or egg (SEA) antigens, using a sandwich ELISA. The levels of IL-5 in response to SEA were higher in individuals with moderate to severe fibrosis (310.9 pg/mL) compared to individuals without fibrosis (36.8 pg/mL; P = 0.0418). There was also a higher production of TNF-α in cultures stimulated with SWAP in patients with insipient fibrosis (1446 pg/mL) compared to those without fibrosis (756.1 pg/mL; P = 0.0319). The serum levels of IL-13 and MIP-1α were higher in subjects without fibrosis than in those with moderate to severe fibrosis. However a positive association between serum levels of IL-13, TNF-α, MIP-1α, and RANTES and S. mansoni parasite burden was found. From these data we conclude that IL-5 and TNF-α may participate in liver pathology in schistosomiasis. The positive association between IL-13, TNF-α, MIP-1α, and RANTES with parasite burden, however, might predict the development of liver pathology.

Schistosomiasis mansoni: ultrasound-evaluated hepatic fibrosis and serum concentrations of hyaluronic acid

Schistosomiasis mansoni is a fibrogenic liver disease that constitutes a major health problem in north-eastern Brazil. Although one common manifestation of the disease, periportal fibrosis (PPF), can be assessed by ultrasonography by well-trained physicians, the necessary equipment and personnel are not always readily available. Serum markers, including hyaluronic acid (HA), have been used as alternative means of measuring fibrosis. Recently serum concentrations of HA have been evaluated in 77 Brazilians (61 cases of schistosomiasis mansoni and 16 healthy controls) and compared against the ultrasound-evaluated PPF in the same subjects. The HA was measured using a non-competitive fluorescence-based assay, while the PPF was explored using a portable ultrasound scanner (SSD-500; Aloka, Tokyo) and graded, as patterns A-F, according to the World Health Organization's 'Niamey protocol'. In general, the serum concentrations of HA were found to be positively correlated with the severity of the PPF. The mean concentration of HA in the sera of the 16 controls was significantly lower than that recorded in the schistosomiasis cases who showed PPF of patterns D or E (P<0·001 for each). The cases who showed pattern-C PPF also had significantly less HA in their sera than the cases with PPF of patterns D or E (P<0·001 for each), and the cases with pattern-D fibrosis had significantly lower HA concentrations in their sera than the cases with PPF of pattern E (P<0·001). In an analysis based on a receiver-operating-characteristic (ROC) curve, an HA concentration of 20·2 μg/litre of serum was identified as a threshold that could be used to distinguish moderate cases of PPF (i.e. patterns C or D) from the more advanced cases (i.e. patterns E or F), with a sensitivity of 60% and specificity of 65%. In conclusion, it appears that serum concentrations of hyaluronic acid could be used as markers for periportal fibrosis in patients with schistosomiasis mansoni.

Ultrasound in schistosomiasis mansoni

We reviewed ultrasound features in patients with schistosomiasis mansoni. The alterations that we observed in acute and hepatosplenic schistosomiasis are described. The advantages and disadvantages of using ultrasound patterns in the evaluation of liver fibrosis are discussed. Other diseases that are important in the differential diagnosis of schistosomal liver fibrosis are presented. Ultrasound is an effective and flexible diagnostic tool in the evaluation of a variety of diseases. It presents no harmful effects to patients, allowing non-invasive studies in hospitalized patients and in other facilities.

Use of the platelet count/spleen diameter ratio for the noninvasive diagnosis of esophageal varices in patients with schistosomiasis

BACKGROUND/AIM

In patients with liver cirrhosis, the platelet count/spleen diameter ratio has been validated as a parameter for the noninvasive diagnosis of esophageal varices. Schistosoma infection is a frequent cause of portal hypertension in Middle Eastern countries, and is associated with the development of esophageal varices. In this study we aimed to evaluate the platelet count/spleen diameter ratio as a noninvasive tool for the prediction of the presence of esophageal varices in patients with schistosoma-related chronic liver disease.

PATIENTS AND METHODS

Forty-three patients with hepatosplenic schistosomiasis underwent upper digestive endoscopy to check for the presence of esophageal varices. Furthermore, all patients underwent abdominal ultrasonography, and maximum spleen diameter (in mm) was measured. The platelet count/spleen diameter ratio was calculated in all patients.

RESULTS

Esophageal varices were found in 31 patients (72%). Age and gender were not significantly different between patients with and without varices. In patients with varices, median platelet count (82,000/μL versus 172,000/μL, P < 0.0001) and platelet count/spleen diameter ratio (571 versus 1651, P < 0.0001) were significantly lower, while spleen diameter (147 mm versus 109 mm, P = 0.0006) was significantly larger. In multivariate analysis, the platelet count/spleen diameter ratio was the only parameter independently associated with the presence of varices (P < 0.0001).

CONCLUSIONS

In this study we have validated the use of the platelet count/spleen diameter ratio for the noninvasive diagnosis of esophageal varices in patients with portal hypertension caused by schistosoma infection. In these patients, the platelet count/spleen diameter ratio might be used to allow better rationalization of medical resources and use of endoscopy.

[Serum globulin levels and intensity of hepatic fibrosis in patients with mansonic schistosomiasis]

BACKGROUND

A correlation between the levels of serum globulins and the hepatic fibrosis degree in chronic hepatitis was described, but reports in schistosomiasis mansoni have not been found.

OBJECTIVE

To evaluate the serum globulins and IgG levels, and periportal fibrosis intensity measured by ultrasound in patients with schistosomiasis mansoni.

METHODS

Between November, 2006 and February 2007, 41 patients which were eligible, filled them a questionnaire and had their levels of serum IgG measured by immunoturbidimetry and globulins indirectly measured by the Biuret method. The ultrasound was carried out by a single researcher, according to the Cairo and Niamey protocols.

RESULTS

The average age was 41 years old and 25 female patients (61%). Ten patients (24%) from 41 showed serum globulins levels raised and 21 (51%) presented elevated IgG levels. According to the Cairo classification, 21 patients showed grade I of fibrosis, 18 grade II and 2 grade III; and by the Niamey classification 8 showed standard C, 20 D, and 13 E. Those with grade II or III of fibrosis had higher IgG levels than the ones with grade I (P = 0.047), as well as those who showed standards D and E as compared to C (P = 0.011). There was no association between the globulins levels and the intensity of fibrosis.

CONCLUSION

In patients with schistosomiasis mansoni, an increase of the IgG serum levels was observed according to the progression from periportal fibrosis intensity, but the same was not founded with globulins levels.

Duplex sonography study in schistosomiasis portal hypertension: characterization of patients with and without a history of variceal bleeding

BACKGROUND

Presinusoidal portal hypertension with frequent episodes of upper gastrointestinal variceal bleeding are hallmarks of hepatosplenic Mansons schistosomiasis; a clinical form that affects about 5% of Brazilians who are infected by Schistosoma mansoni.

AIMS

To evaluate duplex sonography findings in patients with hepatosplenic Mansons schistosomiasis with and without upper gastrointestinal variceal hemorrhage.

METHODS

A cross-sectional study was performed whereby 27 consecutive patients with hepatosplenic Mansons schistosomiasis were divided into two groups: group I (six men and six women; mean age 48.7 years) with a past history of bleeding and group II (four men and eight women; mean age 44.7 years) without a past history of upper gastrointestinal bleeding, underwent duplex sonography examination. All patients underwent the same upper gastrointestinal endoscopy and laboratory examinations. Those with signs of mixed chronic liver disease or portal vein thrombosis (three cases) were excluded.

RESULTS

Group I showed significantly higher mean portal vein flow velocity than group II (26.36 cm/s vs 17.15 cm/sec). Although, as a whole it was not significant in all forms of collateral vessels (83% vs 100%), there was a significantly higher frequency of splenorenal collateral circulation type in group II compared with group I (17% vs 67%). The congestion index of the portal vein was significantly lower in group I than in group II (0.057 cm vs 0.073 cm/sec).

CONCLUSION

Our duplex sonography findings in hepatosplenic Mansons schistosomiasis support the idea that schistosomotic portal hypertension is strongly influenced by overflow status, and that collateral circulation seems to play an important role in hemodynamic behavior.

Reprodutibilidade da classificação ultra-sonográfica de Niamey na avaliação da fibrose periportal na esquistossomose mansônica

OBJETIVO: Medir a concordância intra- e interobservador da classificação ultra-sonográfica qualitativa para graduar a fibrose periportal adotada no encontro de Niamey em 1996. MATERIAIS E MÉTODOS: No período de fevereiro de 2005 a março de 2006 foi realizado estudo prospectivo, observacional e transversal em 30 pacientes esquistossomóticos, sem outras hepatopatias associadas, submetidos a ultra-sonografia abdominal e classificados segundo os critérios de Niamey. Os exames foram realizados por dois radiologistas de forma independente em diferentes momentos: durante o exame dinâmico (primeiro momento) e 30 e 90 dias depois (segundo e terceiro momentos) do exame, por meio da documentação fotográfica analisada em estação de trabalho. A concordância intra- e interobservador foi avaliada pelo teste kappa. RESULTADOS: A concordância intra-observador medida pelo teste kappa foi 0,43 para o observador 1 e 0,57 para o observador 2. A concordância interobservador durante o estudo dinâmico e na avaliação fotográfica foi, respectivamente, de 0,46 e 0,71. CONCLUSÃO: O uso do ultra-som para classificar a fibrose periportal segundo o protocolo de Niamey apresentou uma reprodutibilidade que variou de moderada a substancial.

High serum laminin and type IV collagen levels in schistosomiasis mansoni

BACKGROUND: Fibrosis is the process of excessive deposition of collagen and other extra cellular matrix components and large amounts of these components have been shown in periovular schistosomal granulomas, especially in the liver. Laminin and type IV collagen have been investigated in various hepatic disorders but their accuracy in fibrosis detection and in the evaluation of its progression in schistosomiasis have not been fully explained. AIM: To measure the serum levels of two markers of fibrosis, laminin and type IV collagen in schistosomiasis. PATIENTS AND METHODS: Sixty-four patients with different clinical forms of schistosomiasis mansoni: intestinal (group I), hepatointestinal (group II), compensated (group III) and decompensated hepatosplenic (group IV) and 18 healthy volunteers were included. RESULTS: Serum type IV collagen and laminin levels were significantly increased in patients compared to controls. At about clinical forms, serum type IV collagen was increased in groups II and IV, compared to controls and was significantly higher in group IV than in group I. Serum laminin was significantly increased in groups II, III and IV and was significantly higher in group IV than in group II. Serum type IV collagen was closely correlated with serum laminin in groups II and IV. CONCLUSIONS: Connective tissue marker levels did not correlate with periportal thickness. In schistosomiasis mansoni there is an increase of type IV collagen and laminin levels at the initial stage of the disease, as well as in advanced forms. We also suggest that these markers may be a useful predictor of disease progression.

The influence of periportal (pipestem) fibrosis on long term results of surgical treatment for schistosomotic portal hypertension

AIM

To evaluate the degree of influence that periportal fibrosis has on clinical development and the long term results of surgical treatment on patients with hepatic-splenic schistosomiasis with previous gastrointestinal hemorrhages.

METHODS

During the period of 1992-1998, 111 patients underwent surgical treatment for the treatment of hepatic-splenic schistosomiasis with previous gastrointestinal hemorrhages. The degree of fibrosis was classified as: degree I - the portal spaces show a rich increase of young connective cells, a slight collagen production and a varying presence of inflammatory infiltrate. The periportal blade unchangeable (29/111); degree II - there is an expansion of the connective tissue with the emission of radial collagen septa, producing a star shaped aspect (38/111); degree III - the connective septa form bridges with other portal spaces or with the vein, with evident angiomatoid neo-formation (44/111).

CONCLUSION

The patients with periportal fibrosis degree I present recurrent hemorrhages statistically less than patients with periportal fibrosis degrees II and III, and that the intensity of the periportal fibrosis is not the only pathophysiological factor of the esophageal varices, gastric varices, prevalence of post-operative portal vein thrombosis and hematological and biochemical alterations of the patients with pure mansoni schistosomiasis.

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.

Measuring morbidity in schistosomiasis mansoni: relationship between image pattern, portal vein diameter and portal branch thickness in large-scale surveys using new WHO coding guidelines for ultrasound in schistosomiasis

OBJECTIVE

World Health Organization consensus meetings on 'Ultrasound in Schistosomiasis' in 1996 and 1997 anticipated further challenges in the global implementation of a standardized protocol for morbidity assessment in schistosomiasis mansoni. We evaluated the performance of the qualitative and quantitative components of the new Niamey criteria.

METHOD

Use of the Niamey protocol among 3954 subjects in two linked, cross-sectional ultrasound surveys of Schistosoma mansoni-endemic populations in Egypt and Kenya.

RESULTS

There were significant differences between Egyptian and Kenyan sites in prevalence and age distribution of S. mansoni-related hepatic fibrosis (36%vs. 3%, P < 0.001). Protocol image pattern scoring could be performed quickly and was stable to interobserver variation. However, there were unintended but systematic differences between study sites in the measurement of portal vein diameter (PVD) and wall thickness. By Niamey criteria, a high prevalence of portal dilation was scored for normal Egyptian subjects, which reduced the predictive value of image pattern for portal hypertension. Using alternative height-indexing of PVD, image pattern plus PVD findings predicted 15% of Egyptians and 2.5% of Kenyans were at risk for variceal bleeding, whereas locally derived PVD norms estimated 25% of Egyptians and 12% of Kenyans to be at possible risk.

CONCLUSION

Niamey scoring criteria performed acceptably as a relative grading system for disease in schistosomiasis mansoni, but failed to account fully for site-to-site variation in test performance and morbidity prevalence. Consequently, standardized image pattern scoring appears to provide the most useful tool for detection and comparison of S. mansoni-associated morbidity in large-scale surveys.

Enhanced interleukin-12 and CD40 ligand activities but reduced Staphylococcus aureus Cowan 1-induced responses suggest a generalized and progressively impaired type 1 cytokine pattern for human schistosomiasis

Whole-blood-cell cultures from schistosomiasis patients were stimulated with a variety of T-cell-dependent and T-cell-independent stimuli to determine whether the defect in type 1 cytokine expression observed following helminth infection is associated with alterations in interleukin-12 (IL-12) or CD40 ligand (CD40L) responsiveness. Cultures from uninfected individuals produced abundant gamma interferon in response to Staphylococcus aureus Cowan 1 (SAC), while patients with intestinal and hepatosplenic disease displayed intermediate and weak responses, respectively. Importantly, the decrease in type 1 cytokine expression was not attributed to defects in IL-12- or CD40L-induced activity. Indeed, schistosomiasis patients displayed heightened responses and even produced more biologically active IL-12 when stimulated with SAC and CD40L than did uninfected controls. Finally, additional studies suggested only a partial role for IL-10, since intestinal patients were the only group that overproduced this downregulatory cytokine. Together, these studies demonstrate that the type 1 deficiency in chronic hepatosplenic schistosomiasis is not related to specific defects in IL-12, IL-10, or CD40L activity, although changes in the functional status of antigen-presenting cells appear to be involved.

Treatment by splenectomy of a portal vein aneurysm in hepatosplenic schistosomiasis

Portal vein aneurysm is a rare medical entity that can be caused by chronic hepatic diseases with portal hypertension. We describe a 45-year-old man with variceal bleeding from hepatosplenic schistosomiasis and an incidentally found intrahepatic aneurysm. Diagnosis was confirmed with non-invasive imaging exams, arteriography and liver biopsy. Following splenectomy, the aneurysm diameter decreased substantially.

Immunoglobulins anti-Anisakis simplex in patients with gastrointestinal diseases

The nematode Anisakis simplex causes anisakidiasis, a disease that often mimics other gastrointestinal diseases. Patients with digestive haemorrhaging, Crohn's disease, digestive cancer and appendicitis were analysed for antibodies to A. simplex. Antibody detection was carried out by enzyme-linked immunosorbent assay (ELISA) and immunoblotting using crude extract (CE) antigen and excretory-secretory (ES) products. Total immunoglobulin (Igs), IgG, IgM, IgA and IgE were studied. The highest percentage was obtained when Igs were tested against CE antigen. A higher percentage of positivity was observed with the appendicitis group. The Crohn's disease group showed the highest levels of IgG against the ES antigen. Using immunoblotting, 24% and 48% of sera from patients with symptoms of Crohn's disease and digestive haemorrhaging, respectively, showed a positive immunorecognition pattern of CE antigen. The prevalence of detectable antibodies against A. simplex is higher in patients with digestive disorders than in the healthy population. A linear correlation was observed between prothrombin activity and Igs-CE, IgA-CE and IgA-ES but not between IgE-CE and the other immunoglobulin levels. Specific IgA is associated with a higher activity index of Crohn's disease. Specific antibodies were observed against A. simplex in patients with appendicitis and gastrointestinal cancer, indicating a higher rate of positivity for IgA.

Hepatosplenic schistosomiasis in field-based studies: a combined clinical and sonographic definition

A combined clinical and sonographic classification of hepatosplenic schistosomiasis mansoni to be used in field-based studies is proposed herein. Seven hundred forty one individuals out of 892 (83%), living in an area endemic for schistosomiasis in Brazil, have been submitted to clinical and ultrasound examinations. Based on two stool examinations the overall prevalence for schistosomiasis in this area was 73%. Abdominal palpation was performed with patients in dorsal decubit, during deep breath, by two experienced physicians and a portable ultrasound was used for the evaluation of liver fibrosis, portal collaterals and spleen size. Four groups of individuals were identified using data obtained by abdominal palpation and ultrasound examination: (1) palpable spleen and intense periportal thickening in 9 individuals (1.2%); (2) spleen not palpable and intense periportal thickening in 15 (2%); (3) palpable spleen with light to moderate periportal thickening in 32 (4.3%), and (4) palpable spleen with a normal liver on ultrasound in 30 (4%). The definition of hepatosplenic schistosomiasis in field-based studies as the finding of Schistosoma mansoni eggs in the stools in an individual with splenomegaly is not acceptable anymore. Abdominal ultrasound should be combined with clinical examination to accurately identify hepatosplenics in endemic areas for schistosomiasis.

Preliminary results on the effects of CD40/CD40L interactions and SAC-induction on IFN-gamma expression in human schistosomiasis

In this communication the authors analyzed the pattern of expression of IFN-gamma as a surrogate type 1 response in different clinical forms of schistosomiasis in response to stimulation involving T-cell dependent and T-cell independent pathways, to investigate which pathways were functional in human schistosomiasis, and to further characterize the nature of Th1 response impairment in this parasitic disease.

Evolution of schistosomiasis-induced pathology after therapy and interruption of exposure to schistosomes: a review of ultrasonographic studies

Ultrasonography (US) is suitable for diagnosing schistosomiasis-related organic pathology and is particularly useful to assess its evolution after therapy and/or interruption of exposure to the Schistosoma parasites. Evolution of pathology after treatment: Regression of hepatic abnormalities in Schistosma mansoni-infected children and adolescents has been observed already from 7 months post-therapy on. This does, however, not occur in all cases: individual differences are great ranging from spontaneous regression of pathology without treatment to persistence of pathology lasting for years after therapy even without re-infection. Intensity and duration of exposure, different parasite strains, patients' age and genetic background all influence the evolution of pathology. In communities at continuous exposure to S. mansoni infection, repeated re-treatment is required to control hepatosplenic morbidity. In Schistosoma japonicum infection, changes around the portal tree may regress, but characteristic diffuse abnormalities described as 'network pattern' abnormalities do not resolve. In Schistosoma haematobium infection bladder abnormalities and urinary tract obstruction frequently resolve after treatment. Clinically relevant pathology may resurge from 1 year after therapy on if exposure continues. Subjects with more advanced pathology before therapy, appear to be at higher risk of pathology re-appearance. Evolution of pathology after interruption of exposure to schistosomiasis: Knowledge on the evolution of pathology induced by S. mansoni is limited to some reports in emigrants and to the experience of ultrasonographists working in areas, where transmission has been partially interrupted. Due to the longevity of the parasite, infection may last for many years. Even after elimination of the parasites severe pathology may persist for long. In S. haematobium infection spontaneous healing after interruption of re-exposure may occur, but cases have been reported where urogenital lesions led to complications many years after exposure. Contrary to hepatosplenic and urinary pathology, knowlegde on the evolution of other organic abnormalities is very limited: studies on the evolution of biliary abnormalities or intestinal pathology have not been published. Genital pathology may be induced by all Schistosoma spp. Post-therapy evolution of genital schistosomiasis is largely ignored. In some European travellers partial regression of prostatic fibrosis has been described. Schistosomal adnexitis leading to infertility and/or ectopic pregnancy has been reported occurring many years after interruption of exposure. Ultrasonography (US) has never been used to study the influence of schistosomiasis on pregnancy. Concluding, current knowlegde on the evolution of pathology after treatment and/or interruption of exposure is still fragmentary. Frequently, fibrosis reverses after therapy, but advanced pathology may persist for long. Therefore, the possibility of severe clinical complications has to be taken into account, even if the infection is inactive since many years. In interventions aimed at controlling schistosomiasis-related morbidity, evolution of pathology must be monitored by US in representative patient cohorts. Further systematic US-studies are needed not only on the evolution of hepatosplenic and urinary pathology but also on that of intestinal, biliary and genital pathology induced by schistosomiasis, as well as on the influence of schistosomiasis on the outcome of pregnancy.

Esquistossomose hepatoesplênica cirúrgica: histopatologia hepatica e endoscopia digestiva alta em crianças comparadas a adultos

Objetivando melhor compreender a fisiopatologia da esquistossomose grave em adultos e crianças, avaliaram-se diferenças histopatológicas do fígado e do padrão de endoscopia digestiva entre esses pacientes. Vinte e um adultos e igual número de crianças foram incluídos no estudo. Todos foram submetidos a esplenectomia e ligadura da veia gástrica esquerda. Os achados histopatológicos foram avaliados em secções de biópsia hepática. Utilizou-se videoendoscópio para endoscopia digestiva. Nos adultos foram encontradas: 1 - fibrose de Symmers, grau I, em um paciente; grau II, em sete; e grau III, em treze; 2 - atividade inflamatória mínima em cinco; leve, em sete; moderada, em seis; e intensa, em um; ausência de atividade inflamatória, em dois; 3 - mínima granulomatose, em quatro pacientes; moderada, em dois; ausência de granulomas, em quinze; 4 - pigmento esquistossomótico mínimo, em quatro pacientes; moderada, em um; ausência, em dezesseis. Nas crianças, foram encontradas: 1 - fibrose de Symmers, grau I, em um paciente; grau II, em quatro e grau III, em dezesseis; 2 - atividade inflamatória mínima, em sete pacientes; leve, em quatorze; 3 - mínima granulomatose, em seis pacientes; leve, em cinco; moderada, em dois; ausência, em oito; 4 - pigmento esquistossomótico mínimo, em seis pacientes; leve, em três; moderada, em seis; ausência, em seis. Na endoscopia digestiva alta encontrou-se nos adultos: oito (38%) com varizes de médio calibre e treze (62%), de grosso calibre. Oito pacientes (38%) tiveram varizes de fórnix gástrico e cinco (24%), da cárdia. Gastropatia da hipertensão porta foi diagnosticada em dezesseis pacientes (76%). Com relação às crianças, quatro (19%) apresentaram varizes de fino calibre, oito (38%) de médio; e nove (43%) de grosso calibre. Três (14%) tiveram varizes gástricas, sendo duas no fórnix e uma no cárdia. Nove (43%) das crianças apresentavam gastropatia de hipertensão porta. Os achados evidenciaram uma histopatologia hepática similar nos dois grupos; entretanto, as repercussões hemodinâmicas da hipertensão porta foram mais importantes nos adultos, sem, no entanto, alcançar significação estatística.

Severe hepatic fibrosis in Schistosoma mansoni infection is controlled by a major locus that is closely linked to the interferon-gamma receptor gene

Lethal disease due to hepatic periportal fibrosis occurs in 2%-10% of subjects infected by Schistosoma mansoni in endemic regions such as Sudan. It is unknown why few infected individuals present with severe disease, and inherited factors may play a role in fibrosis development. Schistosoma mansoni infection levels have been shown to be controlled by a locus that maps to chromosome 5q31-q33. To investigate the genetic control of severe hepatic fibrosis (assessed by ultrasound examination) causing portal hypertension, a segregation analysis was performed in 65 Sudanese pedigrees from the same village. Results provide evidence for a codominant major gene, with.16 as the estimated allele A frequency predisposing to advanced periportal fibrosis. For AA males, AA females, and Aa males a 50% penetrance is reached after, respectively, 9, 14, and 19 years of residency in the area, whereas for other subjects the penetrance remains <.02 after 20 years of exposure. Linkage analysis performed in four candidate regions shows that this major locus maps to chromosome 6q22-q23 and that it is closely linked (multipoint LOD score 3.12) to the IFN-gammaR1 gene encoding the receptor of the strongly antifibrogenic cytokine interferon-gamma. These results show that infection levels and advanced hepatic fibrosis in human schistosomiasis are controlled by distinct loci; they suggest that polymorphisms within the IFN-gammaR1 gene could determine severe hepatic disease due to S. mansoni infection and that the IFN-gammaR1 gene is a strong candidate for the control of abnormal fibrosis observed in other diseases.

Ultrasonography of the liver and spleen in Brazilian patients with hepatosplenic schistosomiasis and cirrhosis

Ultrasonography is now widely used in the diagnosis and management of patients with chronic Schistosoma mansoni infections. The present study was undertaken to evaluate the use of ultrasonography in patients with hepatosplenic schistosomiasis (HSS) with and without cirrhosis. Ninety-seven patients (52 males; median age 38 years, range 19-68 years) with HSS, 65 with well compensated (HSSC) and 32 with decompensated (HSSD) disease and cirrhosis, were systematically examined by ultrasound. Hepatic fibrosis was graded according to WHO recommendations. Typical atrophy of the right hepatic lobe accompanied by hypertrophy of the left lobe, with a rounded inferior marginal edge, was seen in 86 (88.7%) patients. Periportal fibrosis was observed in 83 (85.6%) cases and confirmed histologically in all. In 66 patients (68.0%) thickening of the gallbladder wall, associated with periportal fibrosis and extending from the branches of the porta hepatis, was noted. No evidence of biliary disease was found in these patients and gallstones were present in only 3 cases. Fourteen (43.8%) of the HSSD patients could not be classified for grade of fibrosis because of the advanced stage of cirrhosis related to hepatitis B or C viral infection. Of the remaining 18 HSSD patients, none had only grade I fibrosis (vs. 10.8% of HSSC, P = 0.054) and only 6 had grade II (vs. 67.7% of HSSC, P < 0.0005), while the frequency of grade III was significantly higher in the HSSD patients than in those with HSSC (37.5% vs. 21.5%, P = 0.049). These findings indicate that although ultrasonography is a very valid technique for assessing patients with pure HSS, and should be considered the 'gold standard', it is not reliable for assessing periportal fibrosis in patients with concomitant cirrhosis due to other causes.

Schistosoma mansoni infection in a recently exposed community in Senegal: lack of correlation between liver morphology in ultrasound and connective tissue metabolites in serum

Four hundred and seventy villagers of Ndombo, a village with recently established intensive transmission of Schistosoma mansoni in the Senegal River Basin, were enrolled in a study with the intention to assess hepatosplenic morbidity. All patients were examined parasitologically and by ultrasound. Hepatic fibrosis serum markers were determined in 153 adult patients (aminoterminal propeptide of procollagen type III, hyaluronan and laminin). By ultrasound, about 60% of the patients showed early stages of hepatic involvement, 3% of the patients unequivocally showed severe hepatosplenic pathology (grade 3 according to the Managil classification), whereas in another study performed in the same village 3 years earlier, no patients with severe hepatosplenic pathology had been found. No correlation between the aminoterminal propeptide of procollagen type III, hyaluronan or laminin and the ultrasound findings could be established. These hepatic fibrosis serum markers do not seem to be a sensitive method to detect early hepatic fibrosis in schistosomiasis.

Occurrence of a community with high morbidity associated with Schistosoma mansoni infection regardless of low infection intensity in north-east Brazil

To establish the relationship between schistosome-associated morbidity and infection intensity in northeast Brazil, a parasitological and ultrasonographical study was carried out on 484 inhabitants of 4 villages (I, II, III and IV) in São Lourenço da Mata, Pernambuco, Brazil, where schistosomiasis is endemic. Quantitative stool examination using Knight's method demonstrated a high prevalence and moderate intensity of Schistosoma mansoni infection, and also that the subjects in village IV had a significantly lower prevalence and intensity of infection than those of the other villages. By ultrasonography, periportal fibrosis (PPF) and splenomegaly were found in 52% of the 299 infected subjects and 66% of the 146 infected subjects aged over 16 years old, respectively; 32% and 31% of the 299 infected subjects had abnormally high values of total bile acid (TBA) and alkaline phosphatase (ALP) activity, respectively. Liver and spleen size, PPF, and serum level of TBA and ALP were not correlated with infection intensity. There was no significant difference in the morbidity assessed by liver and spleen size, PPF, and serum analysis between the subjects in village IV and the other villages. These findings suggest the occurrence of a community with high morbidity associated with schistosomiasis regardless of low infection intensity.