Genital manifestations of schistosomiasis mansoni in women: important but neglected

Female Genital Schistosomiasis: A Neglected among the Neglected Tropical Diseases

Schistosomiasis is a neglected parasitic disease linked to water, posing a global public health concern with a significant burden in sub-Saharan Africa. It is transmitted by Schistosoma spp., causing both acute and chronic effects affecting the urogenital or the hepato-intestinal system. Through granuloma formation, chronic schistosomiasis weakens host immunity, heightening susceptibility to coinfections. Notably, female genital schistosomiasis (FGS), a disregarded gynecological condition, adversely affects girls' and women's reproductive health and increases vulnerability to HIV. This review explores the intricate interplay between schistosomiasis and HIV, considering their geographical overlap. We delve into the clinical features of this coinfection, underlying mutual influences on transmission, diagnostic challenges, and therapeutic approaches. Understanding the dynamics of FGS and HIV coinfection is pivotal for integrated healthcare strategies in regions with co-endemicity, aiming to mitigate the impact of the two infections on vulnerable populations.

Schistosoma mansoni Infection Is Associated With Increased Monocytes and Fewer Natural Killer T Cells in the Female Genital Tract

Schistosoma mansoni infection may impair genital mucosal antiviral immunity, but immune cell populations have not been well characterized. We characterized mononuclear cells from cervical brushings of women with and without S mansoni infection. We observed lower frequencies of natural killer T cells and higher frequencies of CD14⁺ monocytes in infected women.

An update on female and male genital schistosomiasis and a call to integrate efforts to escalate diagnosis, treatment and awareness in endemic and non-endemic settings: The time is now

The last decades have brought important insight and updates in the diagnosis, management and immunopathology of female genital schistosomiasis (FGS) and male genital schistosomiasis (MGS). Despite sharing a common parasitic aetiological agent, FGS and MGS have typically been studied separately. Infection with Schistosoma haematobium manifests with gender-specific clinical manifestations and consequences of infection, albeit having a similar pathogenesis within the human genital tract. Schistosoma haematobium is a known urinary bladder carcinogen, but its potential causative role in other types of neoplasia, such as cervical cancer, is not fully understood. Furthermore, the impact of praziquantel treatment on clinical outcomes remains largely underexplored, as is the interplay of FGS/MGS with relevant reproductive tract infections such as HIV and Human Papillomavirus. In non-endemic settings, travel and immigrant health clinics need better guidance to correctly identify and treat FGS and MGS. Our review outlines the latest advances and remaining knowledge gaps in FGS and MGS research. We aim to pave a way forward to formulate more effective control measures and discuss elimination targets. With a growing community awareness in health practitioners, scientists and epidemiologists, alongside the sufferers from these diseases, we aspire to witness a new generation of young women and men free from the downstream disabling manifestations of disease.

Schistosome migration in the definitive host

Schistosomes are parasitic blood flukes that infect >200 million people around the world. Free-swimming larval stages penetrate the skin, invade a blood vessel, and migrate through the heart and lungs to the vasculature of the liver, where maturation and mating occurs. From here, the parasite couples migrate to their preferred egg laying sites. Here, we compare and contrast what is known about the migration patterns within the definitive host of the three major species of human schistosome: Schistosoma mansoni, S. japonicum, and S. haematobium. We conclude that intravascular schistosomes are inexorable colonizers whose migration and egg laying strategy is profligate; all three species (and their eggs) can be found throughout the mesenteric venules, the rectal venous plexus, and, to a greater or lesser extent, the urogenital venous plexuses. In addition, it is common for parasite eggs to be deposited in locations that lack easy access to the exterior, further demonstrating the relentless exploratory nature of these intravascular worms.

Impact of Endemic Infections on HIV Susceptibility in Sub-Saharan Africa

Human immunodeficiency virus (HIV) remains a leading cause of global morbidity with the highest burden in Sub-Saharan Africa (SSA). For reasons that are incompletely understood, the likelihood of HIV transmission is several fold higher in SSA than in higher income countries, and most of these infections are acquired by young women. Residents of SSA are also exposed to a variety of endemic infections, such as malaria and various helminthiases that could influence mucosal and systemic immunology. Since these immune parameters are important determinants of HIV acquisition and progression, this review explores the possible effects of endemic infections on HIV susceptibility and summarizes current knowledge of the epidemiology and underlying immunological mechanisms by which endemic infections could impact HIV acquisition. A better understanding of the interaction between endemic infections and HIV may enhance HIV prevention programs in SSA.

Concurrent Schistosoma mansoni and Schistosoma haematobium infections in a peri-urban community along the Weija dam in Ghana: A wake up call for effective National Control Programme

Globally over 200 million people are infected with schistosomiasis, and approximately 80% are caused by just two of five species, Schistosoma haematobium and Schitosoma mansoni that are broadly distributed, and often overlap across sub-Saharan Africa. Like most neglected tropical diseases, mortality is low (an estimated 200,000 deaths annually) and morbidity is considerably high and probably underestimated. Surprisingly, little attention has been given to co-infection with these two species. We have studied co-infection with S. mansoni and S. haematobium in a peri-urban community in Ghana, one of the most highly endemic countries for schistosomiasis. We collected and examined snails of the two intermediate host species from the reservoir adjacent to the community. We also used microscopical examination of stool and urine samples to determine the level of concurrent S. mansoni and S. haematobium infections in school and administered questionnaires to assess water contact activities that predispose pupils to infections Examination of the snail hosts revealed that 0.7% (7/896) of Bulinus truncatus and 1.7% (14/780) of Biomphalaria pfeifferi snails were found to be hosting cercariae morphologically consistent with that of S. haematobium and S. mansoni respectively. The overall prevalence values for urogenital and intestinal schistosomiasis were 66.8% (135/202) and 90.1% (163/181) respectively. Only 50 of 181 schistosome-infected pupils had single-species infections and the remaining 131 pupils presented concurrent infections. Among the 131 infected with both species were 50 individuals having only S. mansoni eggs in stool and S. haematobium eggs in urine (conventional presentation). Eighty-one children (81) had eggs of both species in either urine and/or stool (ectopic presentation). From these 81, 63 had eggs of both species in urine, 6 had both species in stool, and 12 had eggs of both species present in both urine and stool. A comparatively large number of individuals from the concurrent infected group presented high and moderate infection intensities than the single infected groups. The overwhelmingly high prevalence of concurrent infections indicates further study of co-infection is needed, and points to a need call for a holistic disease control plan so Ghana can be part of nations to achieve the WHO roadmap target for schistosomiasis control by 2020.

Ectopic forms of schistosomiasis mansoni in the second macroregion of Alagoas: case series report and review of the literature

INTRODUCTION

Ectopic forms of schistosomiasis are those in which the parasitic element is localized outside the portal system, the natural habitat of the helminth. Although the prevalence rates of schistosomiasis are high in Brazil, clinical and epidemiological data on ectopic forms of the disease are still scarce.

METHODS

Cross-sectional, retrospective and descriptive epidemiological study in which cases with a confirmed histopathological diagnosis of an ectopic form of schistosomiasis were analyzed. The cases were selected from a database of the anatomic pathology files of a referral center.

RESULTS

Of the 21 cases identified, seven affected the female genital tract and five the male genital tract; four cases were identified in the peritoneum; two cases involved lymph nodes and two involved adipose tissue; and renal involvement was detected in one case.

CONCLUSIONS

The lack of knowledge of the clinical presentation of ectopic forms of schistosomiasis makes the early identification and treatment of this form difficult, with direct implications in the reduction of morbidity and mortality in endemic areas.

Ruptured Tubal Gestation: An Unusual Presentation of Schistosoma Haematobium Infection of the Fallopian Tube

An unusual mode of presentation of schistosomiasis in the form of a ruptured tubal pregnancy in a previously asymptomatic 23-year-old woman is described. Histological examination of the salpingectomy specimens demonstrated Schistosoma haematobium ova.

Genital Schistosomiasis: A Report on Two Cases of Ovarian Carcinomas Containing Viable Eggs of Schistosoma mansoni

Schistosomiasis is a parasitic infection that is highly prevalent worldwide, with a variety of species being responsible for causing the disease. In Brazil, however, the only identified species is Schistosoma mansoni. The adult parasites inhabit the blood vessels of the hepatic portal system of the main host. The disease may range from being asymptomatic to provoking liver damage or portal hypertension. Furthermore, ectopic schistosomiasis may develop, and several hypotheses have been raised to explain the occurrence of the disease. This paper describes two cases, one in a 39-year-old woman and the other in a 47-year-old woman. Both had similar symptoms of pain and abdominal distension caused by a large abdominal/pelvic mass. Histopathology of the ovary showed a mucinous cystadenocarcinoma of the intestinal type in the first patient and a papillary serous carcinoma in the second, with both tumors containing viable eggs of Schistosoma mansoni. The neoplasms probably serve as a migratory route for the adult parasites and the embolization of eggs. Nevertheless, there is insufficient evidence to confirm the malignization of a benign lesion due to the presence of Schistosoma mansoni. Few cases have been reported in the international literature on the association between ovarian schistosomiasis and neoplasms.

Bilateral tubal gestation associated with schistosomiasis in an african woman

Background. The incidence of tubal ectopic gestation caused by schistosomiasis induced tubal pathology is undocumented in this environment, which may be due to rarity of this pathology. Bilateral tubal gestation is common in patients that have undergone in vitro fertilization. We report a hitherto undocumented case of spontaneous bilateral ectopic gestation following tubal schistosomiasis. Case Report. Mrs. OB was a 32-year-old G4P3⁺⁰ (3 alive) woman who complained of abdominal pain and bleeding per vaginam of 4 and 2 days' duration respectively following 8 weeks of amenorrhea. A clinical impression of ruptured ectopic gestation was confirmed by ultrasound scanning. She had bilateral salpingectomy with histology of specimens showing bilateral ectopic gestation with Schistosoma haematobium induced salpingitis (findings of Schistosoma haematobium ova noted on slide). Conclusion. Schistosoma induced salpingitis is a rare but possible cause of bilateral tubal gestation.

Revisiting the concept of hepatosplenic schistosomiasis and its challenges using traditional and new tools

Different aspects of hepatosplenic schistosomiasis are revisited here. Manson's schistosomiasis causes periportal fibrosis and portal hypertension in approximately 6% of infected subjects, usually with preservation of their hepatic function. The assessment of liver involvement is of major importance in determining the prognosis and risk of complications from schistosomiasis, such as upper digestive bleeding secondary to variceal rupture. For many years, the diagnosis of hepatosplenic schistosomiasis and liver fibrosis was made by abdominal palpation and the finding of liver and/or spleen enlargement. However, there is no consensus regarding the clinical parameters of the liver and spleen to be considered in this physical evaluation. For the last three decades, abdominal ultrasound (US) has become the best imaging technique to evaluate liver fibrosis caused by schistosomiasis mansoni. However, US is a subjective procedure and is therefore examiner-dependent. Magnetic resonance imaging (MRI) findings have provided valuable information in addition to ultrasound and clinical examination. The combination of a comprehensive history and physical examination, basic laboratory tests (a stool examination for Schistosoma mansoni eggs and a blood cell count), biomarkers for liver fibrosis/portal hypertension and imaging methods seem to offer the best approach for evaluating patients with this disease. In situations where research is involved or in patients with severe disease, MRI may be considered.

Distribution and characterization of Heterobilharzia americana in dogs in Texas

Heterobilharzia americana is a trematode parasite (family Schistosomatidae) that infects a wide range of wild mammalian hosts. Canine cases have been reported in the Gulf coast and south Atlantic states, Kansas, and Oklahoma. A total of 238 canine H. americana cases in Texas were retrospectively collected for a period of approximately 22 years from case records at the Texas Veterinary Medical Diagnostic Laboratory and the Veterinary Medical Teaching Hospital pathology service, diagnostic parasitology service, and Gastrointestinal Laboratory at Texas A&M University College of Veterinary Medicine. Of these cases, 26 patients had 1-2 repeat positive tests for a total of 268 positive tests (26 biopsies, 39 necropsies, 160 fecal examinations, and 43 PCR). Multiple dogs were infected in 12 households. Cases were distributed primarily in the eastern region of Texas in 42 of 254 counties. Cases were seen as far west as Kerr county and in counties bordering Oklahoma, Louisiana, Mexico, and the Gulf of Mexico. The median dog age was 5.6 years (2.7 months to 17.2 years) and the median weight was 20.5 kg (1-61.6 kg). All American Kennel Club (AKC) breed groups were represented (n=186): crossbred (20%), herding (17.8%), sporting (16.1%), toy (10.8%), hounds (10.8%), working (10.1%), terrier (8.5%), non-sporting (4.9%), and miscellaneous (1%). No seasonal pattern of diagnosis was apparent. Clinical signs reported (n=90) were diarrhea (67%), weight loss (38%), anorexia/hyporexia (27%), vomiting (22%), hematochezia (20%), lethargy (17%), polyuria/polydipsia (6%), and collapse (3%). In 39 necropsy cases, trematode eggs were identified by histopathology in the small intestine (84%), liver (84%), large intestine (39%), pancreas (35%), lung (9%), lymph node (8%), spleen (4%), and stomach (3%). Adult parasites were identified histologically in four cases. Granulomatous inflammation associated with the eggs was the most commonly reported histopathologic change. Other changes reported were fibrosis, pigment in macrophages, and organ mineralization. Glomerulonephritis was identified in four cases. Of 20 necropsy cases where death was attributable to H. americana infection, only one case was diagnosed ante mortem. Eleven of these dogs were examined by a veterinarian but H. americana was included as a differential diagnosis in only two cases. Reported differential diagnoses included ethylene glycol toxicity, cholecalciferol toxicity, lymphoma, and pancreatitis. These data indicate that this parasite is more widely distributed and more common than is generally recognized. Increased awareness may aid in more diagnoses and timely therapy.

Absence of cervical schistosomiasis among women from two areas of north–eastern Brazil with endemicSchistosoma mansoni

Genital manifestations in schistosomiasis haematobium are common and are associated with considerable morbidity. Although Schistosoma mansoni may also cause genital disease, the frequency of this complication is not known. Cervical biopsies (N=401) and Pap smears (N=981) were therefore collected from women living in two S. mansoni-endemic areas (in the states of Alagoas and Ceará, in north-eastern Brazil). The women were screened for the presence of sexually transmitted diseases and for the presence, in their cervical smears and/or biopsies, of S. mansoni eggs. Attempts at schistosomiasis control, which began in both study areas in 1977, have led to generally low intensities of infection (<30 eggs/g faeces in 99% of infections) and community prevalences of infection that range between 1% and 52%. As no schistosome ova were detected in any of the biopsies or smears, it appears that the risk, among women, of genital manifestations of S. mansoni infection is small in areas where the parasite load in the population is low (as the result of interventions to control intestinal schistosomiasis).

A survey of female genital schistosomiasis of the lower reproductive tract in the volta basin of Ghana

OBJECTIVE

To determine the prevalence of female genital schistosomiasis in riparian communities in the Volta basin of Ghana,

DESIGN

The study was a cross-sectional study conducted among women 15-49 years in the Volta Basin. Urinary schistosomiasis prevalence was determined using microscopy. A structured questionnaire was also administered to collect information on the demography, obstetric history and reproductive health experiences. Cervical punch biopsy was collected from women who consented to be screened for FGS. Descriptive statistics was used to determine frequency of occurrence, chi squared and logistic regression to identify associated variables

RESULTS

Urinary schistosomiasis prevalence among the women was 24.8% while 10.6% of them diagnosed with FGS. More FGS diagnosed women (57.7%, p value =0.04%) were observed to report copious discharge, vaginal itch (80.8%, p=0.042) and lower abdominal pain (66.7%, p= 0.041) compared to FGS negative women. The predominant abnormal observation of the lower genital tract made was erythematous cervix (18.8%).

CONCLUSION

The study confirms the reproductive health symptoms associated with FGS and recommends awareness creation on FGS among women in endemic communities to facilitate early treatment.

Genital schistosomiasis mansoni: tubal tumor and parietal peritoneum involvement diagnosed during laparoscopy

Female genital schistosomiasis is not uncommon in endemic areas for schistosomiasis, but there are few reports in the Brazilian medical literature. Here, we describe the case of a 31-year-old woman with lower abdominal pain who was diagnosed as presenting a fallopian tube tumor caused by Manson's schistosomiasis. The diagnosis was delayed because her symptoms were considered nonspecific. Involvement of the parietal peritoneum of the ovarian fossa was observed during laparoscopy and confirmed by histological analysis. The left tube and the tumor were excised and schistosomiasis was treated with praziquantel. She presented a full recovery and options for future reproduction are under evaluation.

Ectopic schistosomiasis: description of five cases involving skin, one ovarian case and one adrenal case

Seven cases of patients with ectopic schistosomiasis from the State of Sergipe, Brazil, are presented (five involving skin, one ovarian and one adrenal). Data were collected from surveying the clinical records and anatomopathological reports in the files of the dermatology and pathology clinics of the University Hospital of the Federal University of Sergipe, from 1995 to 2005. The patients' mean age at diagnosis was 21.1 years. In the dermatological cases, full cures were achieved after treatment with oxamniquine. In the ovarian case, there was an association with embryonic carcinoma: this patient underwent surgery with adjuvant chemotherapy and praziquantel treatment, with satisfactory evolution. The adrenal case was associated with adenoma.

Sexually transmitted infections in a female population in rural north-east Brazil: prevalence, morbidity and risk factors

OBJECTIVES

To determine the prevalence of major sexually transmitted infections (STIs) and gynaecological morbidity in women of reproductive age living in rural communities in north-east Brazil and to assess risk factors associated with the presence of STIs.

METHODS

A total of 341 women (84%) were examined gynaecologically and colposcopically. The gynaecological history was taken by means of a standardized, pre-tested questionnaire. Cervical smears were obtained and vaginal fluid was collected. Vulvovaginal candidiasis (VC), bacterial vaginosis (BV), trichomoniasis (TV) and syphilis seroreactivity were determined by standard laboratory techniques. Infections with Neisseria gonorrhoeae, Chlamydia trachomatis and human papilloma virus (HPV) were diagnosed by hybrid capture assays using vaginal lavage fluid. Odds ratios (OR) were calculated to assess risk factors associated with STIs.

RESULTS

The prevalence of HPV, BV and TV was 26%, 15% and 10%, respectively. VC as well as infections with N. gonorrhoeae and C. trachomatis were detected in 6%; syphilis seroreactivity, in 3%. Multiple infections were very common, and 51% of women had at least one STI. Vaginal discharge, the predominant morbidity (56%), was significantly associated with BV (OR = 6.3; P < 0.001), vulvovaginal itching with VC (OR = 3.5; P < 0.05) and lower abdominal pain with C. trachomatis infection (OR = 2.6; P < 0.04). Colpitis was diagnosed in 27% of women and significantly associated with TV (OR = 3.5%; P < 0.001) and VC (OR = 2.9; P < 0.05). Being unmarried was a significant risk factor for having an STI (OR = 2.4; P < 0.05). Among unmarried women, age (<20 years) was a significant risk factor (OR = 3.3; P = 0.01).

CONCLUSIONS

The STIs are highly prevalent in this female population in the rural hinterland of north-east Brazil and associated with considerable morbidity. In view of the expected spread of HIV from the urban centres at the coast to the interior there is an urgent need for providing STI-related health care and health education for adolescents and women in rural Brazil.

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.

Schistosomiasis of the female genital tract: public health aspects

In this paper Gabriele Poggensee, Hermann Feldmeier and Ingela Krantz discuss the public health relevance of female genital schistosomiasis (FGS). Some of the stated hypotheses are supported only by clinical observations and/or circumstantial evidence as valid epidemiological and immunological data of this disease entity are still very scanty. Morbidity caused by the presence of schistosome eggs in the lower and upper genital tract have been almost completely neglected during the past two decades. This has been acknowledged by the WHO and, in 1997, the Gender Task Force of the WHO's Tropical Disease Research Programme (TDR) included FGS in a list of scientific areas that deserve high research priority.