Schistosomal myelopathy: urologic manifestations and urodynamic findings

Beyond schistosomiasis: unraveling co-infections and altered immunity

Schistosomiasis is a neglected tropical disease caused by the helminth Schistosoma spp. and has the second highest global impact of all parasites. Schistosoma are transmitted through contact with contaminated fresh water predominantly in Africa, Asia, the Middle East, and South America. Due to the widespread prevalence of Schistosoma, co-infection with other infectious agents is common but often poorly described. Herein, we review recent literature describing the impact of Schistosoma co-infection between species and Schistosoma co-infection with blood-borne protozoa, soil-transmitted helminths, various intestinal protozoa, Mycobacterium, Salmonella, various urinary tract infection-causing agents, and viral pathogens. In each case, disease severity and, of particular interest, the immune landscape, are altered as a consequence of co-infection. Understanding the impact of schistosomiasis co-infections will be important when considering treatment strategies and vaccine development moving forward.

WITHDRAWN: Anticholinergics for urinary symptoms in multiple sclerosis

This review has been withdrawn for the following reasons:

‐ a review author contravenes Cochrane's Commercial Sponsorship Policy. This policy ensures the independence of Cochrane reviews by making sure that there is no bias associated with commercial conflicts of interest in the conduct of Cochrane reviews. The author was employed by the biopharmaceutical company AstraZeneca and cannot say with certainty that the company did not produce or have any financial interest in the interventions in this review

‐ the review is substantially out of date

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The contribution made bySchistosomainfection to non-traumatic disorders of the spinal cord in Malawi

In Malawi, although schistosomal myelopathy has been reported in visitors from overseas who have swum in Lake Malawi, the incidence of this disorder in local residents has never been investigated. Consecutive patients with non-traumatic disorders of the spinal cord were therefore recruited in a hospital and a rehabilitation centre in Blantyre. Of the 33 patients investigated, 16 were presumed to be cases of schistosomal myelopathy as they had the markers of past or current schistosomiasis and apparently no other conditions that could explain their clinical features. There was microscopical and/or immunodiagnostic evidence indicating that eight of these presumptive cases had active schistosomiasis. All 16 presumptive cases had symptoms that were similar to those of 177 presumptive or proven cases of neuroschistosomiasis described in the scientific literature. Following antihelminthic treatment, eight of the presumptive cases showed marked improvement. Schistosomal myelopathy seems to occur relatively frequently in Malawi. Early treatment with praziquantel is strongly recommended for all patients with unexplained myelopathy and a history of exposure to schistosome cercariae.

Anticholinergics for urinary symptoms in multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS) is the commonest physically disabling chronic neurological disease affecting young people. Urinary symptoms are present in about 68% of people with MS but their basis has a number of potential aetiologies that can change with time.

OBJECTIVES

To assess the absolute and comparative efficacy, tolerability and safety of anticholinergic agents in MS patients.

SEARCH STRATEGY

We searched the Cochrane Multiple Sclerosis Group Specialised Trials Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue1), MEDLINE (January 1966 to January 2008), EMBASE (January 1974 to January 2008), supplemented with search of reference lists, personal communication with authors and relevant drug manufacturers.

SELECTION CRITERIA

Randomised trials and cross-over trials (blinded and unblinded) that are either placebo-controlled or comparing two or more treatments.

DATA COLLECTION AND ANALYSIS

All four review authors independently assessed eligibility and trial quality, and extracted data. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Our search strategy identified 33 articles of which thirty were excluded. Three single centre trials were included. No details were given regarding randomisation and blinding in the first two trials but side effects were frequent with all treatments.The first (Hebjorn 1977) was a double blind randomised crossover trial. Thirty four persons with MS received three drugs Methantheline Bromide, Flavoxate Chloride and Meladrazine Tartrate each for 14 days, washout periods were not mentioned. Median volume measurements at the first bladder contraction were statistically significant at a 5% level for Methantheline Bromide only compared to no treatment.The second (Gajewski 1986) was a prospective parallel group randomised study. Thirty four persons with MS were treated for 6-8 weeks with Oxybutynin (19 subjects) or Propantheline (15 subjects). For frequency, nocturia, urgency, and urge incontinence differences in symptom grade in favour of Oxybutynin were found. However, only for frequency the difference was statistically significant at 5% level.The third (Fader 2007) was a double blind crossover trial. Sixty four persons with MS received oral Oxybutynin or intravesical Atropine for 14 days. Details of randomisation and blinding were given. There was no significant difference between the two treatments in any efficacy outcome measure. Side effects and QOL scores showed significant differences in favour of atropine.

AUTHORS' CONCLUSIONS

From the available evidence we cannot advocate the use of anticholinergics in MS.

Neurological complications of Schistosoma infection

Schistosomiasis is a parasitic disease caused by blood flukes of the genus Schistosoma. Currently more than 200 million people worldwide are affected. Neuroschistosomiasis constitutes a severe presentation of the disease. Neurological symptoms result from the inflammatory response of the host to egg deposition in the brain and spinal cord. Neurological complications of cerebral schistosomiasis include delirium, loss of consciousness, seizures, dysphasia, visual field impairment, focal motor deficits and ataxia. Cerebral and cerebellar tumour-like neuroschistosomiasis can present with increased intracranial pressure, headache, nausea and vomiting, and seizures. Myelopathy (acute transverse myelitis and subacute myeloradiculopathy) is the most common neurological complication of Schistosoma mansoni infection. Schistosomal myelopathy tends to occur early after infection and is more likely to be symptomatic than cerebral schistosomiasis. The conus medullaris and cauda equina are the most common sites of involvement. Severe schistosomal myelopathy can provoke a complete flaccid paraplegia with areflexia, sphincter dysfunction and sensory disturbances. Schistosomicidal drugs, steroids and surgery are the currently available treatments for neuroschistosomiasis. Rehabilitation and multidisciplinary team care are needed in severely disabled patients.

Urological manifestations of chronic schistosomal myeloradiculopathy

OBJECTIVE

To describe the clinical and urodynamic features of patients with chronic voiding dysfunction secondary to schistosomal myeloradiculopathy (SM), as the clinical involvement of the spinal cord is a well recognized complication of Schistosomiasis mansoni infection.

PATIENTS AND METHODS

We reviewed the records and urodynamic studies of 26 consecutive patients (17 males and nine females, aged 8-58 years) with chronic neurological and urinary symptoms secondary to SM. The voiding function history, radiological and urodynamic findings and therapeutic approaches were reviewed. Patients with and without upper urinary tract complications were compared in terms of age, duration of voiding dysfunction and urodynamic pattern.

RESULTS

The most common urinary symptoms were difficulty in emptying the bladder (17 patients, 65%), urinary incontinence (14, 54%), and urgency and frequency (13, 50%). Laboratory and radiographic evaluation showed urinary tract infection in eight (30%) patients, bilateral hydronephrosis in five (19%) and bladder calculi in five (19%). Urodynamics showed detrusor overactivity with detrusor-external sphincter dyssynergia (DESD) in 14 patients (54%), detrusor arreflexia in six (23%), detrusor overactivity with no dyssynergia in four (15%), and detrusor underactivity in two (8%). Comparing patients with and without upper tract complications showed no differences in age and duration of urinary symptoms, but there was a significant association of detrusor overactivity with DESD and upper urinary tract complications (P = 0.04). Urological management consisted of antibiotics, clean intermittent catheterization, anticholinergic medication and stone removal, as appropriate. Conservative treatment failed in three patients and they required an injection with botulinum-A toxin into the detrusor (two) or ileocystoplasty (one).

CONCLUSION

Patients with chronic SM behave clinically like those with other causes of spinal cord disease and neurogenic bladder dysfunction requiring lifelong surveillance. The severity of illness in these patients should re-emphasize the need for early recognition and treatment of this condition, to prevent or reverse the neurological deficits.