Greater Washington Infectious Greater Washington Infectious Diseases Society ConferenceDiseases Society Conference

October 20, 2008October 20, 2008

Temujin T. Chavez, MDTemujin T. Chavez, MDLCDR MC USNLCDR MC USN

National Capitol ConsortiumNational Capitol Consortium

CaseCase CCCC

• Diarrhea and abdominal painDiarrhea and abdominal pain HPI HPI

• Insidious onset of intermittent, sharp, crescendo-Insidious onset of intermittent, sharp, crescendo-decrescendo, non-radiating right flank pain since Spring decrescendo, non-radiating right flank pain since Spring 20052005

• Melena June 2005Melena June 2005 EGD with EGD with Helicobacter pylori Helicobacter pylori gastritisgastritis

• CT A/P October 2006CT A/P October 2006 NormalNormal

• Fall 2007, pain worsensFall 2007, pain worsens• Diarrhea with occasional rectal bleedingDiarrhea with occasional rectal bleeding• Gastroenterology evaluation February 2008Gastroenterology evaluation February 2008

Case

PMHxPMHx• Latent Latent Mycobacterium Mycobacterium

tuberculosis tuberculosis Oct 2007Oct 2007• Helicobacter pylori Helicobacter pylori

gastritis 2006gastritis 2006

FamHxFamHx• Brother deceased from

cerebral malaria

SurgHxSurgHx• Pilonidal cyst I&D May Pilonidal cyst I&D May

20062006• Colonoscopy Feb 2008Colonoscopy Feb 2008

NKDANKDA

MedicationsMedications• Isoniazid 300 mg po dailyIsoniazid 300 mg po daily• Pyridoxine 50 mg po dailyPyridoxine 50 mg po daily

Travel HistoryTravel History

Born Monrovia, LiberiaBorn Monrovia, Liberia

Lofa county 1-16 yo Lofa county 1-16 yo

Bong county 17-18 yoBong county 17-18 yo

Wologisi mountains during Wologisi mountains during Liberian civil warLiberian civil war

Immigrated to US 2001Immigrated to US 2001

Philadelphia, PA until 2004 Philadelphia, PA until 2004 when enlisted in USMCwhen enlisted in USMC

CaseCase

T=97.4, BP=120/72, P=71, R=16T=97.4, BP=120/72, P=71, R=16

Gen: Gen: NAD. Non-cachectic NAD. Non-cachectic Heent: Heent: Sclera anictericSclera anicteric Lymph: Lymph: NormalNormal CV: CV: NormalNormal Pulm: Pulm: NormalNormal Abd: Abd: NABS. Soft. Non-tender. No NABS. Soft. Non-tender. No

hepatosplenomegalyhepatosplenomegaly Derm: Derm: No hypopigmentation / nodulesNo hypopigmentation / nodules

CaseCase

LabsLabs

• WBC=4.4 (42% PMN, 46% Lymph, 3.6% Eos), Hgb=16 WBC=4.4 (42% PMN, 46% Lymph, 3.6% Eos), Hgb=16

(MCV=89), PLT=180 (MCV=89), PLT=180

• Na=143, K=4.3, Cl=106, Co2=31, BUN=19, Cr=1.3Na=143, K=4.3, Cl=106, Co2=31, BUN=19, Cr=1.3

• Alb=4.6, AlkPhos=64, AST=26, ALT=21, TB=0.9Alb=4.6, AlkPhos=64, AST=26, ALT=21, TB=0.9

• Amylase=147, Lipase=30Amylase=147, Lipase=30

• UA=NormalUA=Normal

• HBsAg & HBsAb= non reactive, HBcAb= reactiveHBsAg & HBsAb= non reactive, HBcAb= reactive

• HIV-1 Ab=negativeHIV-1 Ab=negative

Differential DiagnosisDifferential Diagnosis

Immunocompetent native Immunocompetent native

Liberian male h/o latent MTb Liberian male h/o latent MTb

with 2 year history of chronic with 2 year history of chronic

abdominal pain with diarrheaabdominal pain with diarrhea

Differential DiagnosisDifferential Diagnosis

InfectiousInfectious• GiardiasisGiardiasis• StrongyloidiasisStrongyloidiasis• Entamoeba histolyticaEntamoeba histolytica• Tropical SprueTropical Sprue• Mycobacterium Mycobacterium

tuberculosis tuberculosis enteritisenteritis• SchistosomiasisSchistosomiasis

Non-infectiousNon-infectious• Inflammatory bowel Inflammatory bowel

diseasedisease• Eosinophilic enteritisEosinophilic enteritis• PancreatitisPancreatitis• AmyloidosisAmyloidosis• LymphomaLymphoma• Acute intermittent Acute intermittent

porphyriaporphyria

Human SchistosomiasisHuman Schistosomiasis Trematode parasitic Trematode parasitic

infectioninfection Species affecting Species affecting

humanshumans• S. mansoniS. mansoni• S. japonicumS. japonicum• S. mekongiS. mekongi• S. intercalatumS. intercalatum• S. haematobium S. haematobium

Geographic Geographic distribution limited to distribution limited to areas with fresh areas with fresh water snailswater snails

Schistosomiasis – Schistosomiasis – Geographic distributionGeographic distribution

Schistosomiasis – Schistosomiasis – Global disease burdenGlobal disease burden

Infects more than 200 million peopleInfects more than 200 million people

WHO World Health Report 2002WHO World Health Report 2002

Schistosomiasis - LiberiaSchistosomiasis - Liberia

S. mansoni S. mansoni half as prevalent half as prevalent as as S. haematobiumS. haematobium

S. mansoni S. mansoni with prevalence with prevalence of 24.8% (Bong County)of 24.8% (Bong County)

Rates of infection vary with Rates of infection vary with seasonseason• Higher during dry season Higher during dry season

(Dec-Feb)(Dec-Feb) Age groups (Bong county)Age groups (Bong county)

• S. mansoni S. mansoni similar similar prevalence across age prevalence across age groupsgroups

• S. haematobium S. haematobium with with disproportionate disproportionate prevalence ages 0-15 yoprevalence ages 0-15 yo

Acta Trop 1983;40:205-209Acta Trop 1983;40:205-209Acta Trop 1980;37:53-62Acta Trop 1980;37:53-62

Schistosomiasis mansoni –Schistosomiasis mansoni –Clinical spectrumClinical spectrum

AcuteAcute• Cercarial dermatitisCercarial dermatitis• Katayama feverKatayama fever

ChronicChronic• IntestinalIntestinal

Large bowelLarge bowel• Chronic or intermittent abdominal painChronic or intermittent abdominal pain• Diarrhea in 3-55%Diarrhea in 3-55%• Bloody diarrhea in 11-50%Bloody diarrhea in 11-50%

• HepatosplenicHepatosplenic• GlomerulonephritisGlomerulonephritis• NeuroschistosomiasisNeuroschistosomiasis

Lancet 2006;368:1106-1118Lancet 2006;368:1106-1118

Intestinal Intestinal Schistosomiasis Schistosomiasis mansonimansoni

Parasitologic, clinical and anamnestic data over 2 Parasitologic, clinical and anamnestic data over 2 years in Burundiyears in Burundi

Two endemic areas in Burundi sampledTwo endemic areas in Burundi sampled• Cohoha Lake (21%) & Rusizi Plain (33%)Cohoha Lake (21%) & Rusizi Plain (33%)

Parasitologic examParasitologic exam• Eggs per gram of fecesEggs per gram of feces

Clinical examClinical exam• Abdominal palpation in supine positionAbdominal palpation in supine position

Clinical historyClinical history• Diarrhea, bloody diarrhea, abdominal pain, Diarrhea, bloody diarrhea, abdominal pain,

fatigue, and weaknessfatigue, and weakness

Am J Trop Med Hyg 1995;53(6):660-667Am J Trop Med Hyg 1995;53(6):660-667

Intestinal schistosomiasis –Intestinal schistosomiasis –Clinical featuresClinical features

Area 5-9 10-19 >/=20 All

Bloody diarrheaBloody diarrhea Cohoha Lake 4.1 5.0 1.1 2.2

Rusizi Plain 3.4 2.8 2.0 2.3

Left liver enlargementLeft liver enlargement Cohoha Lake 1.2 6.4 1.0 1.9

Rusizi Plain 1.1 1.6 0.8 0.9

Spleen enlargementSpleen enlargement Cohoha Lake 0 3.4 0.4 0.9

Rusizi Plain 0.9 1.3 1.8 1.5

DiarrheaDiarrhea Cohoha Lake 5.1 5.7 0.8 2.5

Rusizi Plain 3.1 2.9 1.9 2.0

Prevalence (%) of morbidity attributable to Prevalence (%) of morbidity attributable to S. mansoni S. mansoni in two in two areas of Burundiareas of Burundi

Management

Intestinal Intestinal Schistosomiasis mansoniSchistosomiasis mansoni• Praziquantel 40 mg/kg poPraziquantel 40 mg/kg po• Repeat treatment in 4 to 6 weeksRepeat treatment in 4 to 6 weeks• Review CT A/PReview CT A/P• CounselingCounseling

Avoid fresh waterAvoid fresh water Water used for washing heated to 50 Water used for washing heated to 50

degrees Celsius or let stand 2 daysdegrees Celsius or let stand 2 days

DiscussionDiscussion

Schistosomiasis has a high global prevalence and a large burden of disease in sub-Saharan Africa

S. mansoni should be suspected in immigrants of endemic areas who present with lower GI symptoms

Visualization of S. mansoni eggs on microscopy or histopathology is important diagnostically

Schistosomiasis – Schistosomiasis – Transmission cycleTransmission cycle

NEJM 2002;346:1212-1220NEJM 2002;346:1212-1220

Schistosomiasis mansoni Schistosomiasis mansoni – – Global disease burdenGlobal disease burden

WHO World Health Report 2002WHO World Health Report 2002

Schistosomiasis mansoni – Schistosomiasis mansoni – HepatosplenicHepatosplenic

Assessed utility of abdominal palpationAssessed utility of abdominal palpation Two rural communities in BrazilTwo rural communities in Brazil

• Highly endemic (66.3% prevalence)Highly endemic (66.3% prevalence)• NonenemicNonenemic

Two physicians performed abdominal palpationTwo physicians performed abdominal palpation All aged > 5 yo examined by USAll aged > 5 yo examined by US Exam and eggs in stools unable to adequately detect in Exam and eggs in stools unable to adequately detect in

endemic communityendemic community• Severe peri-portal thickening, portal hypertension and spleen not Severe peri-portal thickening, portal hypertension and spleen not

palpablepalpable• Normal liver with palpable spleenNormal liver with palpable spleen

Acta Tropica 2000;77:101-109Acta Tropica 2000;77:101-109

Schistosomiasis mansoniSchistosomiasis mansoni - - HepatosplenicHepatosplenic

Two distinct syndromes of early inflammation and Two distinct syndromes of early inflammation and late fibrotic diseaselate fibrotic disease

Inflammatory hepatic schistosomiasis is an early Inflammatory hepatic schistosomiasis is an early rxn to trapped ova in pre-sinusoidal periportal rxn to trapped ova in pre-sinusoidal periportal spacesspaces• Left lobe enlargement and nodular Left lobe enlargement and nodular

splenomegalysplenomegaly• Most cases w/o signs of functional diseaseMost cases w/o signs of functional disease

Fibrotic or chronic hepatic schistosomiasis Fibrotic or chronic hepatic schistosomiasis develops in long-standing intense infectiondevelops in long-standing intense infection• Periportal pipestem fibrosisPeriportal pipestem fibrosis• Gastro-esophageal variceal bleedingGastro-esophageal variceal bleeding

Lancet 2006;368:1106-1118Lancet 2006;368:1106-1118

Schistosomiasis mansoniSchistosomiasis mansoni - - TreatmentTreatment

Furoxan – an oxadiazole & possible alternative to Furoxan – an oxadiazole & possible alternative to praziquantelpraziquantel

Lancet Inf Dis 2007;7:218-224Lancet Inf Dis 2007;7:218-224Nature 2008;452:296Nature 2008;452:296

Intestinal schistosomiasis –Intestinal schistosomiasis –Clinical featuresClinical features

Individuals with Individuals with higher infection higher infection intensity at greater intensity at greater risk of morbidity risk of morbidity (right)(right)

Highest risk indicator Highest risk indicator was bloody stoolswas bloody stools

Trop Med Int Health 1996;1:646-54Trop Med Int Health 1996;1:646-54