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Gelape FA, Couto CA, Cançado GGL. β-Blockers in Hepatosplenic Schistosomiasis: A Narrative Review. Am J Trop Med Hyg 2023; 109:1213-1219. [PMID: 37931294 DOI: 10.4269/ajtmh.23-0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/24/2023] [Indexed: 11/08/2023] Open
Abstract
Hepatosplenic schistosomiasis (HSS) is a serious complication of chronic schistosomiasis that can result in portal hypertension and variceal bleeding. β-blockers, a class of medications commonly used to treat hypertension and other cardiovascular conditions, have been investigated for their potential use in preventing variceal bleeding in HSS. Several studies have shown that β-blockers can reduce portal pressure and prevent variceal bleeding effectively in these patients. However, there are limited data on the long-term efficacy and safety of β-blockers in this setting, and further research is needed to determine the optimal use of these medications. This review summarizes the evidence supporting current recommendations of β-blocker use in patients with HSS.
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Affiliation(s)
| | - Claudia Alves Couto
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Guilherme Grossi Lopes Cançado
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Nordmann T, Schlabe S, Feldt T, Gobbi F, Krieg A, Bode JG, Fuchs A, Kraef C, Praktiknjo M, Trebicka J, Ramharter M, Addo MM, Strassburg C, Lohse AW, Luedde T, Schmiedel S, Orth HM. TIPS and splenorenal shunt for complications of portal hypertension in chronic hepatosplenic schistosomiasis-A case series and review of the literature. PLoS Negl Trop Dis 2021; 15:e0010065. [PMID: 34932562 PMCID: PMC8726476 DOI: 10.1371/journal.pntd.0010065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 01/04/2022] [Accepted: 12/06/2021] [Indexed: 02/07/2023] Open
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) and shunt surgery are established treatment options for portal hypertension, but have not been systematically evaluated in patients with portal hypertension due to hepatosplenic schistosomiasis (HSS), one of the neglected tropical diseases with major impact on morbidity and mortality in endemic areas. Methods In this retrospective case study, patients with chronic portal hypertension due to schistosomiasis treated with those therapeutic approaches in four tertiary referral hospitals in Germany and Italy between 2012 and 2020 were included. We have summarized pre-interventional clinical data, indication, technical aspects of the interventions and clinical outcome. Findings Overall, 13 patients with confirmed HSS were included. 11 patients received TIPS for primary or secondary prophylaxis of variceal bleeding due to advanced portal hypertension and failure of conservative management. In two patients with contraindications for TIPS or technically unsuccessful TIPS procedure, proximal splenorenal shunt surgery in combination with splenectomy was conducted. During follow-up (mean follow-up 23 months, cumulative follow-up time 31 patient years) no bleeding events were documented. In five patients, moderate and transient episodes of overt hepatic encephalopathy were observed. In one patient each, liver failure, portal vein thrombosis and catheter associated sepsis occurred after TIPS insertion. All complications were well manageable and had favorable outcomes. Conclusions TIPS implantation and shunt surgery are safe and effective treatment options for patients with advanced HSS and sequelae of portal hypertension in experienced centers, but require careful patient selection. Hepatosplenic schistosomiasis is a severe form of chronic infection with various trematodes of the genus Schistosoma, characterized by portal venous fibrosis, splenomegaly with hypersplenism, and portal hypertension with subsequent life-threatening bleeding events. While effective anthelminthic treatment is available, portal fibrosis is only partially reversible. Portal hypertension with subsequent bleeding events as a complication is hitherto insufficiently addressed. Surgical techniques are currently the best established treatment option for HSS, despite their inherent complication risk and irreversibility. Interventional procedures like TIPS have rarely been assessed in HSS with mixed results. In a series of 13 cases with follow-up periods up to 99 months and a cumulative follow-up of 30.9 years, we demonstrate excellent bleeding prophylaxis and a low adverse event rate of TIPS and–if TIPS proves infeasible–splenorenal shunt surgery. Main complications of TIPS comprise transient hepatic encephalopathy and increase of liver enzymes, especially in patients with hepatic comorbidities. Due to necessary infrastructure and skills, TIPS implantation is currently limited to specialized centers. However, we think that our study can support the establishment and development of new treatment options for schistosomiasis and, in the medium term, also improve the prognosis of this neglected tropical disease in endemic regions.
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Affiliation(s)
- Tamara Nordmann
- Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine & I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Infection Research (DZIF), partner site Hamburg-Luebeck-Borstel-Riems, Germany
| | - Stefan Schlabe
- University Hospital Bonn, Department of Internal Medicine I, Bonn, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Germany
| | - Torsten Feldt
- University Hospital Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Federico Gobbi
- Department of Infectious/Tropical diseases and Microbiology, IRCSS Sacro Cuore-Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Andreas Krieg
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf
| | - Johannes G. Bode
- University Hospital Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Andre Fuchs
- Internal Medicine III–Gastroenterology and Infectious Diseases, University Hospital of Augsburg, Germany
| | - Christian Kraef
- Centre of Excellence for Health, Immunity and Infections & Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Denmark
| | - Michael Praktiknjo
- University Hospital Bonn, Department of Internal Medicine I, Bonn, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Germany
| | - Jonel Trebicka
- Department of Internal Medicine I, Goethe University Clinic Frankfurt, Germany
| | - Michael Ramharter
- Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine & I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Infection Research (DZIF), partner site Hamburg-Luebeck-Borstel-Riems, Germany
| | - Marylyn M. Addo
- German Center for Infection Research (DZIF), partner site Hamburg-Luebeck-Borstel-Riems, Germany
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Department for Clinical Immunology of Infectious Diseases, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Christian Strassburg
- University Hospital Bonn, Department of Internal Medicine I, Bonn, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Germany
| | - Ansgar W. Lohse
- German Center for Infection Research (DZIF), partner site Hamburg-Luebeck-Borstel-Riems, Germany
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Tom Luedde
- University Hospital Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Stefan Schmiedel
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Hans Martin Orth
- University Hospital Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
- * E-mail:
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Tamarozzi F, Fittipaldo VA, Orth HM, Richter J, Buonfrate D, Riccardi N, Gobbi FG. Diagnosis and clinical management of hepatosplenic schistosomiasis: A scoping review of the literature. PLoS Negl Trop Dis 2021; 15:e0009191. [PMID: 33764979 PMCID: PMC7993612 DOI: 10.1371/journal.pntd.0009191] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Francesca Tamarozzi
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Veronica A. Fittipaldo
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Hans Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, Duesseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Joachim Richter
- Institute of Tropical Medicine and International Health, Charité Universitätsmedizin, Berlin, Germany
| | - Dora Buonfrate
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Niccolò Riccardi
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Federico G. Gobbi
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
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Sibomana JP, Campeche A, Carvalho-Filho RJ, Correa RA, Duani H, Pacheco Guimaraes V, Hilton JF, Kassa B, Kumar R, Lee MH, Loureiro CMC, Mazimba S, Mickael C, Oliveira RKF, Ota-Arakaki JS, Rezende CF, Silva LCS, Sinkala E, Ahmed HY, Graham BB. Schistosomiasis Pulmonary Arterial Hypertension. Front Immunol 2020; 11:608883. [PMID: 33362796 PMCID: PMC7758287 DOI: 10.3389/fimmu.2020.608883] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/03/2020] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a disease of the lung blood vessels that results in right heart failure. PAH is thought to occur in about 5% to 10% of patients with hepatosplenic schistosomiasis, particularly due to S. mansoni. The lung blood vessel injury may result from a combination of embolization of eggs through portocaval shunts into the lungs causing localized Type 2 inflammatory response and vessel remodeling, triggering of autonomous pathology that becomes independent of the antigen, and high cardiac output as seen in portopulmonary hypertension. The condition is likely underdiagnosed as there is little systematic screening, and risk factors for developing PAH are not known. Screening is done by echocardiography, and formal diagnosis requires invasive right heart catheterization. Patients with Schistosoma-associated PAH show reduced functional capacity and can be treated with pulmonary vasodilators, which improves symptoms and may improve survival. There are animal models of this disease that might help in understanding disease pathogenesis and identify novel targets to screen and treatment. Pathogenic mechanisms include Type 2 immunity and activation and signaling in the TGF-β pathway. There are still major uncertainties regarding Schistosoma-associated PAH development, course and treatment.
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Affiliation(s)
- Jean Pierre Sibomana
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Tikur Anbessa Specialized Hospital, College of Health Sciences, University of Addis Ababa, Addis Ababa, Ethiopia
- Department of Medicine, Butare University Teaching Hospital, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Aloma Campeche
- Division of Gastroenterology, Department of Medicine, Santa Casa Hospital, Salvador, Bahia, Brazil
| | - Roberto J. Carvalho-Filho
- Division of Gastroenterology, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Ricardo Amorim Correa
- Internal Medicine/Pulmonary Division, Medical School, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Helena Duani
- Internal Medicine/Infectious Diseases Division, Medical School, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Virginia Pacheco Guimaraes
- Pulmonary Department, Hospital Júlia Kubistchek, Fundação Hospitalar of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Joan F. Hilton
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
| | - Biruk Kassa
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Rahul Kumar
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Michael H. Lee
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | | | - Sula Mazimba
- Division of Cardiology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Claudia Mickael
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Rudolf K. F. Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Jaquelina S. Ota-Arakaki
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Camila Farnese Rezende
- Pulmonary Medicine, Hospital das Clinicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Luciana C. S. Silva
- Internal Medicine Department, Medical School, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Edford Sinkala
- Hepatology Clinic, Department of Medicine, University of Zambia Teaching Hospital, Lusaka, Zambia
| | - Hanan Yusuf Ahmed
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Tikur Anbessa Specialized Hospital, College of Health Sciences, University of Addis Ababa, Addis Ababa, Ethiopia
| | - Brian B. Graham
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
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