Assessing the Effects of One-Time Praziquantel Treatment on Urogenital Lesions Detected by Ultrasound in Schistosoma haematobium-Infected Individuals in Chad.

The objective was to determine the impact of a single dose of praziquantel on urogenital lesions caused by Schistosoma haematobium. Ultrasound (US) was performed on three age groups of subjects with a positive test for hematuria, with the first examination performed in November 2017 and a follow-up visit 7 months later. None of the subjects had previously received treatment. The participants were categorized into three distinct age groups: group 1 = 1-15 years, group 2 = 15-30 years, and group 3 = ≥ 30 years. A total of 250 people from these three groups underwent screening: 99 in group 1, 90 in group 2, and 61 in group 3, among whom 131 (52.4%) had at least one detectable lesion of the urogenital tract on US. Follow-up US after 7 months was possible in 60%, 67%, and 77% of the respective groups (with lesions). The anomalies disappeared in 80% of individuals in group 1, 76% of those in group 2, and 65% in group 3. With the exception of calcifications, most visible anomalies had been resolved. The total number of anomalies is low. Severe obstructive uropathy was not detected. We can conclude that single treatment with praziquantel is able to cure visible anomalies, with the exception of calcifications. The low rate of anomalies, compared with levels in the literature, is speculated to be due to undetected death by obstructive uropathy caused by S. haematobium. This requires further investigation.

A 14-year follow-up of ultrasound-detected urinary tract pathology associated with urogenital schistosomiasis in women living in the Msambweni region of coastal Kenya.

BACKGROUND: Complications of urogenital schistosomiasis include acute inflammatory and chronic fibrotic changes within the urogenital tract. Disease burden of this neglected tropical disease is often underestimated, as only active, urine egg-patent Schistosoma infection is formally considered. Previous studies have focussed on short-term effects of praziquantel treatment on urinary tract pathology, demonstrating that acute inflammation is reversible. However, the reversibility of chronic changes is less well studied. METHODS: Our study compared, at two time points 14 y apart, urine egg-patent infection and urinary tract pathology in a cohort of women living in a highly endemic area having intermittent praziquantel treatment(s). In 2014 we matched 93 women to their findings in a previous study in 2000. RESULTS: Between 2000 and 2014 the rate of egg-patent infection decreased from 34% (95% confidence interval [CI] 25 to 44) to 9% (95% CI 3 to 14). However, urinary tract pathology increased from 15% (95% CI 8 to 22) to 19% (95% CI 11 to 27), with the greatest increase seen in bladder thickening and shape abnormality. CONCLUSIONS: Despite praziquantel treatment, fibrosis from chronic schistosomiasis outlasts the presence of active infection, continuing to cause lasting morbidity. We suggest that future efforts to eliminate persistent morbidity attributable to schistosomiasis should include intensified disease management.

Ultrasound aspects and risk factors associated with urogenital schistosomiasis among primary school children in Mali.

BACKGROUND: Urogenital schistosomiasis is endemic in Mali and is a major cause of serious morbidity in large parts of the world. This disease is responsible for many socio-economic and public health issues. The aim of this study was to investigate the impact of the disease on morbidity and to describe demographic and socioeconomic factors in relation to the status of children with urogenital schistosomiasis in Mali. METHODS: We conducted a cross-sectional study in November 2021 of 971 children aged 6 to 14 years selected at random from six schools in three districts in the Kayes Region of Mali. Demographic and socioeconomic data were collected on survey forms. Clinical data were collected following a medical consultation. Hematuria was systematically searched for through the use of strips. The search for Schistosoma haematobium eggs in urine was done via the filtration method. The urinary tract was examined by ultrasound. Associations between each of these variables and disease infection were tested using multivariate logistic regression. RESULTS: The overall prevalence of urinary schistosomiasis detected was 50.2%. The average intensity of infection was 36 eggs/10 ml of urine. The associated risk factors for urogenital schistosomiasis showed that children who bathed, used the river/pond as a domestic water source, and who habitually urinated in the river/pond were more affected (P < 0.05). Children with farming parents were most affected (P = 0.032). The collection of clinical signs revealed that boys had more pollakiuria (58.6%) and dysuria (46.4%) than girls. Ultrasound data showed that focal lesion rates were recorded in all villages with the lowest rate in Diakalel (56.1%). Ultrasound and parasitological findings showed that irregularity and thickening were strongly associated with urinary schistosomiasis (P < 0.0001). CONCLUSIONS: Schistosoma haematobium infection was still endemic in the study site despite more than a decade of mass treatment with praziquantel. However, the high percentage of symptoms associated with high intensity reinforces the idea that further studies in terms of schistosomiasis-related morbidity are still needed.

Cervical lesion proportion measure using a digital gridded imaging technique to assess cervical pathology in women with genital schistosomiasis.

Female genital schistosomiasis (FGS) is characterized by a pattern of lesions which manifest at the cervix and the vagina, such as homogeneous and grainy sandy patches, rubbery papules in addition to neovascularization. A tool for quantification of the lesions is needed to improve FGS research and control programs. Hitherto, no tools are available to quantify clinical pathology at the cervix in a standardized and reproducible manner. This study aimed to develop and validate a cervical lesion proportion (CLP) measure for quantification of cervical pathology in FGS. A digital imaging technique was applied in which a grid containing 424 identical squares was positioned on high resolution digital images from the cervix of 70 women with FGS. CLP was measured for each image by observers counting the total number of squares containing at least one type of FGS associated lesion. For assessment of inter- and intra-observer reliability, three different observers measured CLP independently. In addition, a rubbery papule count (RPC) was determined in a similar manner. The intraclass correlation coefficient was 0.94 (excellent) for the CLP inter-rater reliability and 0.90 (good) for intra-rater reliability and the coefficients for the RPC were 0.88 and 0.80 (good), respectively. The CLP facilitated a reliable and reproducible quantification of FGS associated lesions of the cervix. In the future, grading of cervical pathology by CLP may provide insight into the natural course of schistosome egg-induced pathology of the cervix and may have a role in assessing praziquantel treatment efficacy against FGS. Trial Registration: ClinicalTrials.gov, trial number NCT04115072; trial URL https://clinicaltrials.gov/ct2/show/NCT04115072?term=Female+genital+schistosomiasis+AND+Madagascar&draw=2&rank=1.

Prospective cohort study using ultrasonography of Schistosoma haematobium-infected migrants.

BACKGROUND: Chronic infection with Schistosoma haematobium may lead to serious complications, including bladder carcinoma. Although it is recommended that only bladder masses not regressing within 6 months after praziquantel intake should be investigated invasively, cystoendoscopy is still often performed at diagnosis even in the absence of further signs of concern. No prospective study so far evaluated the evolution of bladder lesions after treatment in case of no risk of reinfection, which could inform case management. METHODS: Adult African migrants with active S. haematobium infection, as assessed by positive urine PCR or microscopy for eggs in urine or bladder biopsy, underwent urinary tract ultrasound at enrolment and at 1, 3, 6, 12 and 24 months after praziquantel treatment. Patients in advanced pregnancy or with known Schistosoma-unrelated chronic pathology of the urinary tract were excluded. RESULTS: Twenty-one patients, aged 18-29 years, participated in the study; ten (47.6%) had bladder masses on ultrasound. Follow-up ≥6 months was completed by 16 (76.2%) patients; ≥12 months by 14 (66.7%) and 24 months by 11 (52.4%). All patients with bladder lesions on enrolment completed a follow-up of ≥6 months. Lesions resolved completely by 6 months in all cases and no new development/re-appearance was observed. CONCLUSIONS: This is the first prospective, long-term follow-up study with ultrasound of patients with urinary schistosomiasis outside endemic areas. Mucosal masses in young patients regressed after treatment without recurrence, supporting the recommendation that invasive procedures should be avoided unless lesions or other symptoms/signs of concern persist for > 6 months. Further studies should assess the evolution of bladder lesions after treatment in larger populations, including older age groups, and, ideally, with parallel assessment of other biomarkers of urinary pathology and of residual S. haematobium active infection.

Macroscopic and microscopic imaging modalities for diagnosis and monitoring of urogenital schistosomiasis.

Urogenital schistosomiasis remains a major global challenge. Optimal management of this infection depends upon imaging-based assessment of sequelae. Although established imaging modalities such as ultrasonography, plain radiography, magnetic resonance imaging (MRI), narrow band imaging, and computerized tomography (CT) have been used to determine tissue involvement by urogenital schistosomiasis, newer refinements in associated technologies may lead to improvements in patient care. Moreover, application of investigational imaging methods such as confocal laser endomicroscopy and two-photon microscopy in animal models of urogenital schistosomiasis are likely to contribute to our understanding of this infection's pathogenesis. This review discusses prior use of imaging in patients with urogenital schistosomiasis and experimentally infected animals, the advantages and limitations of these modalities, the latest radiologic developments relevant to this infection, and a proposed future diagnostic standard of care for management of afflicted patients.

Usefulness of ultrasound in sub-Saharan patients with a serological diagnosis of schistosomiasis.

OBJECTIVE: To evaluate the usefulness of ultrasound examination in patients with just a serological diagnosis of schistosomiasis but no other evidence of active infection. METHODS: 346 sub-Saharan patients with possible schistosomiasis that presented at a Tropical Medicine Unit between 2008 and 2019 were retrospectively selected. Possible schistosomiasis was considered in those patients with a positive serology for schistosomasis in the absence of direct microbiological isolates, hematuria and/or eosinophilia. Data from ultrasound examinations before and after treatment with praziquantel were collected and categorized following the World Health Organization-Niamey score to standardize the use of ultrasonography for the assessment of schistosomiasis-related morbidity. RESULTS: Ultrasound examinations were abnormal in only ten patients (2.89%). Main findings were focal thickening of the bladder wall (n = 6), ureteral dilatation (n = 3) and grade I hydronephrosis (n = 1). No malignant lesions, hepatic lesions nor hepatobiliary related disorders were found. After treatment, the S. haematobium global score (5 vs 3.4, p = 0.06) and the urinary bladder score (2 vs 1, p = 0.059) showed a trend towards improvement after treatment. In three patients the score after treatment dropped to 0, and in another three it remained the same although with signs of improvement. No worsening of the score was observed in any case. CONCLUSION: For those patients with a diagnosis of schistosomiasis based solely in a positive serology, the ultrasound examination could safely be spared due to the low prevalence of pathological findings and its response to treatment anyway.

Ultrasound findings in urogenital schistosomiasis: a pictorial essay.

Urogenital schistosomiasis is a parasitic disease caused by S. haematobium which is endemic in tropical and sub-tropical areas but is increasingly diagnosed in temperate non-endemic countries due to migration and international travels. Early identification and treatment of the disease are fundamental to avoid associated severe sequelae such as bladder carcinoma, hydronephrosis leading to kidney failure and reproductive complications. Radiologic imaging, especially through ultrasound examination, has a fundamental role in the assessment of organ damage and follow-up after treatment. Imaging findings of urinary tract schistosomiasis are observed mainly in the ureters and bladder. The kidneys usually appear normal until a late stage of the disease.

Focused Assessment with Sonography for Urinary Schistosomiasis (FASUS)-pilot evaluation of a simple point-of-care ultrasound protocol and short training program for detecting urinary tract morbidity in highly endemic settings.

BACKGROUND: Urogenital schistosomiasis (UGS) causes inflammation and fibrosis of the urinary tract. In resource-limited settings, affordable tools for morbidity assessment in clinical care are needed. Point-of-care ultrasound has not yet been validated for UGS-related pathology. METHODS: We developed a protocol for Focused Assessment with Sonography for Urinary Schistosomiasis (FASUS), assessing pathology of the bladder wall, ureters and kidneys. Following standardized training, two clinicians performed FASUS on children and adults with hematuria in Lambaréné, Gabon. Recorded ultrasound clips were remotely reviewed by two ultrasound experts as a diagnostic reference. RESULTS: In 2015 and 2016, scans were performed in 118 patients. The image quality was sufficient in 90% of bladder views and more than 97% of kidney views. UGS-compatible pathology was detected in 51/118 (43%) by the operator and in 46/107 (43%) by the experts among baseline scans of sufficient quality. Inter-rater agreement between operators and experts was very good (κ > 0.8) for hydronephrosis and good (κ > 0.6) for bladder wall thickening. CONCLUSIONS: FASUS is a promising clinical, point-of-care tool for detecting UGS-related urinary tract morbidity in symptomatic patients. Based on larger validation studies, appropriate diagnostic and therapeutic algorithms for the use of FASUS should be established.

Restaging Pulmonary Schistosomiasis.

Schistosomiasis is traditionally classified into an acute and a chronic phase, although a precise temporal distinction between the two phases has not been established. Lung involvement can be observed in both phases. We previously reported seven cases of pulmonary lesions due to chronic schistosomiasis in African immigrants. All cases were documented with CT scans and demonstrated complete resolution after treatment with praziquantel. Moreover, another case showed spontaneous disappearance of the nodule before treatment with praziquantel. These findings are similar to those observed in the acute phase of schistosomiasis, with well-defined or ground glass nodules that resolve spontaneously. According to these findings, we postulate the presence of an "intermediate" phase of schistosomiasis involving the lungs that can be defined as an "early chronic phase," and presents analogies to the acute phase. We also hypothesize that in the "early chronic phase," the female worms transit through the lungs where they may lay eggs. These passages not only cause transient, but also radiologically visible alterations. The pathophysiology of lung lesions in the late chronic phase is probably different: the adult worms settled in the mesenteric plexuses produce eggs for years. The eggs repeatedly migrate to the perialveolar capillary beds via portal-caval shunting. Thus, in this case it is the eggs and not the adult worms that reach the lungs in a scattered way. Based on our findings, we suggest the alternative hypothesis that the pulmonary involvement is a phase of the natural evolution of the infection, both from Schistosoma mansoni and Schistosoma haematobium.

Ultrasound Evolution of Pediatric Urinary Schistosomiasis after Treatment with Praziquantel in a Highly Endemic Area.

Urinary schistosomiasis causes damage to the urological system. Ultrasound is a method that detects the burden of secondary disease, individually and in epidemiological studies. In this study, the Schistosoma haematobium-associated urinary tract pathology is analyzed before and after treatment in a short period of time. Seventy children who had previously participated in an epidemiological study on schistosomiasis in the city of Cubal, Angola, and had also performed urinary ultrasound between August 2013 and February 2014 were cited 6-8 months later to assess the possible reinfection and repeat new urinary ultrasound, analyzing changes at the level of urinary pathology. The presence of hematuria and proteinuria was also analyzed. Of the 70 children analyzed, 29 (41.4%) were girls, with an average age of 10.4 years (standard deviation 2.3). Fifty-three (75.7%) had an improvement in their bladder and/or kidney scores, whereas 12 (17.1%) had no change and five (7.1%) had progression of the disease. None of the parameters analyzed completely disappeared. After one single course of treatment with praziquantel, all the analyzed parameters showed regression. Improvement was greater in the urinary bladder than in the upper urinary tract, though these lesions also reversed; the reversion of all parameters was greater among children older than 10 years old than the younger ones. Proteinuria was the parameter with a smaller reduction. Ultrasound should be a usual tool for diagnosis and follow-up in urinary schistosomiasis, particularly in children; more accurate recommendations about follow-up in the case of children whose lesions do not reverse should be established.

Sonographic early findings in a case of bladder schistosomiasis.

Urinary schistosomiasis is a tropical infection with a high endemicity in the developing countries and is included in the list of "Neglected Tropical Diseases". It is caused by a parasitic worm, Schistosoma haematobium, and it has come into the spotlight as a major cause of urogenital disease. Furthermore, it is linked to bladder cancer and it is a predisposing factor for HIV/AIDS. In this case, we describe a bladder schistosomal disease in a young African boy with persistent macroscopic hematuria and its ultrasound diagnostic bladder imaging.

Case Report: Hemianopia: From Suspected Glioblastoma to the Diagnosis of Ectopic Schistosomiasis Haematobium Infection in a Traveler Returning from the Republic of the Congo.

Schistosomiasis due to Schistosoma haematobium is a widespread disease usually affecting the urinary tract associated with hematuria and kidney disorders. Neurological damage is rarely reported and symptoms are nonspecific and may suggest brain tumors such as glioma. We describe the first double ectopic haematobium schistosomiasis case involving the brain and intestine.

Ultrasound findings and associated factors to morbidity in Schistosoma haematobium infection in a highly endemic setting.

OBJECTIVE: To evaluate the usefulness of the WHO classification of ultrasound pathological changes and to establish risk factors for morbidity in a highly endemic setting. METHODS: One hundred and fifty-seven ultrasounds were performed on school-aged children previously diagnosed with urinary schistosomiasis in Cubal, Angola. The findings were analysed according to the WHO guidelines. Factors for morbidity were studied. RESULTS: Mean age of the children was 8.7 (SD 3.2) years. Pathological changes were found in 85.3% (84.7% in the bladder, 34.4% the ureter and 6.3% kidney lesions). The global score according to the WHO classification was 5.74. Male gender [OR 2.61 (1.04-6.58); P 0.043] and older age [OR 2.96 (1.17-7.46); P 0.023] were associated with a higher risk of developing any kind of urinary abnormality. Proteinuria was present in 61.7% of the children. Macroscopic haematuria [OR 2.48 (1.11-5.58); P = 0.02)] and a high level of proteinuria > 300 mg/dl [OR 5.70 (2.17-14.94); P 300 mg/dl)] were associated with abnormalities of the upper urinary tract and showed good positive and negative predictive values for the detection of pathology in the upper urinary tract (65.5% and 71.1%, respectively). CONCLUSIONS: Severe urinary tract pathology was found in a high percentage of the children in our setting. Microhaematuria and proteinuria were good markers of morbidity, proteinuria being more precise for severe alterations of the upper urinary tract. We suggest initial and evolutive ultrasound in children diagnosed with schistosomiasis, and close monitoring including periodic controls. As schistosomiasis control efforts are currently focused on reducing morbidity, tests that detect the presence or degree of morbidity are essential for targeting treatment and tracking the progress of control campaigns.

Carcinosarcoma of the bladder following local schistosomiasis infection.

A young patient from central Africa presented acute renal insufficiency due to extrinsic compression of the distal ureters by a pelvic mass. After initial medical management, a biopsy revealed poorly differentiated bladder cancer and Schistosoma haematobium eggs embedded in the bladder wall. The initial workup showed evidence of locoregional disease. Radical cystectomy with an incontinent urinary diversion was performed with no complications. Carcinosarcoma of the bladder was diagnosed by pathological analysis of the surgical specimen. After a short follow-up, the patient was readmitted presenting with lung and bone metastases. At 60 days after diagnosis, he died of respiratory insufficiency caused by pulmonary metastatic disease.

Ultrasonographic evaluation of urinary tract morbidity in school-aged and preschool-aged children infected with Schistosoma haematobium and its evolution after praziquantel treatment: A randomized controlled trial.

BACKGROUND: Schistosoma haematobium infections are responsible for significant urinary tract (UT) complications. Schistosomiasis control programs aim to reduce morbidity, yet the extent of morbidity in preschool-aged children and the impact of treatment on morbidity reduction are not well studied. METHODOLOGY: Our study was embedded in a randomized, placebo-controlled, single-blind trial in Côte d'Ivoire, which evaluated the efficacy and safety of three doses (20, 40 and 60 mg/kg) of praziquantel in school-aged (SAC) and preschool-aged (PSAC) children infected with S. haematobium. Enrolled children were invited to participate in an ultrasound examination prior and six months after treatment. At these time points 3 urine samples were collected for parasitological and clinical examinations. PRINCIPAL FINDINGS: 162 PSAC and 141 SAC participated in the ultrasound examination at baseline, of which 128 PSAC and 122 SAC were present at follow-up. At baseline 43% (70/162) of PSAC had UT morbidity, mostly at bladder level and 7% had hydronephrosis. 67% (94/141) of SAC revealed mainly moderate UT pathology, 4% presented pseudopolyps on the bladder wall, and 6% had pyelectasis. At follow up, 45% of PSAC and 58% of SAC were S. haematobium positive, mostly harboring light infection intensities (41% and 51%, respectively). Microhematuria was present in 33% of PSAC and 42% of SAC and leukocyturia in 53% and 40% of PSAC and SAC, respectively. 50% (64/128) of PSAC and 58% (71/122) of SAC presented urinary tract morbidity, which was mainly mild. A significant correlation (p<0.05) was observed between praziquantel treatment and reversal of S. haematobium induced morbidity. Progression of UT pathology decreased with increasing praziquantel dosages. A worsening of morbidity was observed among children in the placebo group. CONCLUSION/SIGNIFICANCE: Bladder morbidity is widespread among PSAC. Praziquantel treatment is significantly associated with the reversal of S. haematobium induced morbidity, which underscores the importance of preventive chemotherapy programs. These programs should be expanded to PSAC to prevent or decrease the prevalence of morbidity in young children. This trial is registered as an International Standard Randomized Controlled Trial, number ISRCTN15280205.