Case Report: Typhoid Fever Complicated by Ileal Perforation in an Urban Slum of Dhaka, Bangladesh.

Intestinal perforation is one of the most dangerous complications of typhoid fever and demands urgent hospitalization, diagnosis, and surgical management to reduce morbidity and prevent mortality. Here, we report a case of typhoidal intestinal perforation in a 19 year-old young man detected by passive surveillance during a cluster-randomized trial with Vi-tetanus toxoid conjugate vaccine (Typhoid Vaccine Acceleration Consortium: TyVAC) in an urban slum area in Mirpur, Dhaka, Bangladesh. The patient presented with a high-grade fever, lower abdominal pain, and vomiting and was admitted to a healthcare facility. Physical examination and preoperative investigations of the patient suggested a presumptive diagnosis of intestinal perforation, and the patient was transferred to a tertiary-level hospital for surgical management. A positive blood culture, intraoperative findings, and histopathology of an intestinal biopsy confirmed ileal perforation due to typhoid fever. This case report highlights the need for prompt diagnosis and appropriate pre- and postoperative management of patients who appear with the symptoms of typhoidal intestinal perforation. This report further demonstrates the importance of systematic surveillance and proper evaluation to determine the true incidence rate of typhoid fever and intestinal perforation in Bangladesh.

A new global strategy for the elimination of schistosomiasis.

Mass drug administration utilising a single oral dose of 40mg/kg of praziquantel (PZQ) has been endorsed and advocated by the World Health Organisation (WHO) for the global control and elimination of schistosomiasis. However, this strategy is failing primarily because the drugs are not getting to the people who need them the most. The current global coverage is 20%, the drug compliance rate is less than 50%, and the drug efficacy is approximately 50%. Thus in reality, only about 5% of the reservoir human population is actually receiving intermittent chemotherapy. Despite claims that more of the drug will soon be made available the current strategy is inherently flawed and will not lead to disease elimination. We discuss the many practical issues related to this global strategy, and advocate for an integrated control strategy targeting the life cycle and the most at-risk. Moreover, we discuss how an integrated control package for schistosomiasis should fit within a larger integrated health package for rural and remote villages in the developing world. A holistic health system approach is required to achieve sustainable control and ultimately disease elimination.

Biennial versus annual treatment for schistosomiasis and its impact on liver morbidity.

OBJECTIVE: This study assessed the impact of annual versus biennial praziquantel treatment regimens on the prevalence, intensity of infection, and liver fibrosis dynamics of Asiatic schistosomiasis (caused by Schistosoma japonicum) among individuals residing in 18 endemic barangays in Northern Samar, Philippines. METHODS: Five hundred and sixty-five subjects who reported symptoms of gastrointestinal illness and/or were believed to have clinical morbidity based on physical examination were selected for cohort follow-up. RESULTS: The mean prevalence of schistosomiasis was 34% and the mean intensity of infection was 123.1 eggs per gram. Moderate to severe hepatic fibrosis (grade II/III) was demonstrated in approximately 25% of the study population. As expected, a greater reduction in both the prevalence and intensity of infection was documented with two treatment rounds versus one. Overall, hepatic fibrosis (grades I-III) regressed in only 24.3% of those who received a single treatment and in only 19.3% of those who received two doses. The prevalence of grade II-III fibrosis at baseline (25.2%) remained unchanged 2 years after treatment. CONCLUSIONS: These findings suggest that in order to reverse moderate to severe liver fibrosis due to schistosomiasis and improve clinical outcomes, a higher clinical dosage of praziquantel (i.e., 60-80mg/kg) may be required over an extended duration.

Mass drug administration and the global control of schistosomiasis: successes, limitations and clinical outcomes.

PURPOSE OF REVIEW: Preventive chemotherapy is advocated for the global control and elimination of schistosomiasis. Despite the well known short-term benefits of treating patients for schistosomiasis, the impact of mass drug administration (MDA) campaigns to control the disease in the long term remains unresolved. RECENT FINDINGS: Many studies have advocated the success of MDA programs in order to attract donor funds for elimination efforts but such successes are often short-lived given the drug does not alter the life cycle of the organism or prevent reinfection. Within a matter of months to years after halting treatment, the prevalence, intensity of infection and morbidity of disease return to baseline levels. Other mitigating factors contribute to the failings of MDA campaigns namely: poverty, poor drug coverage, poor drug compliance, and, in the case of Asiatic schistosomiasis, zoonotic transmission. Genetic and innate and acquired immunologic mechanisms complicate the epidemiologic picture of schistosomiasis globally, and may contribute indirectly to MDA shortcomings. The possibility of drug resistance is an ever present concern because of the sole reliance on one drug, praziquantel. SUMMARY: Preventive chemotherapy is advocated for the global control and elimination of schistosomiasis. The short-term benefits of MDA campaigns are well documented but the long-term benefits are questionable.

Can mass drug administration lead to the sustainable control of schistosomiasis?

BACKGROUND: In the Philippines, the current national control strategy for schistosomiasis is annual mass drug administration (MDA) with 40 mg/kg of praziquantel in all schistosomiasis-endemic villages with a prevalence ≥10%. METHODS: A cross-sectional survey of schistosomiasis was conducted in 2012 on 18 221 individuals residing in 22 schistosomiasis-endemic villages in the province of Northern Samar. The prevalence of schistosomiasis, intensity of Schistosoma infection, and morbidity of disease were assessed. RESULTS: Despite an active schistosomiasis-control program in Northern Samar for >30 years, which included a MDA campaign in the last 5 years, the mean prevalence of schistosomiasis among 10 435 evaluated subjects was 27.1% (95% confidence interval [CI], 26.3%-28.0%), and the geometric mean intensity of infection among 2832 evaluated subjects was 17.2 eggs per gram of feces (95% CI, 16.4-18.1). Ultrasonography revealed high levels of schistosomiasis-induced morbidity in the schistosomiasis-endemic communities. Left lobe liver enlargement (≥70 mm) was evident in 89.3% of subjects. Twenty-five percent of the study population had grade II/III liver parenchyma fibrosis, and 13.3% had splenomegaly (≥100 mm). CONCLUSIONS: MDA on its own was insufficient to control the prevalence of schistosomiasis, intensity of Schistosoma infection, or morbidity of the disease. Alternative control measures will be needed to complement the existing national MDA program.

Prudent care of head trauma in the elderly: a case report.

INTRODUCTION: Severe traumatic brain injury is a major public health problem that accounts for one-third of all deaths due to trauma in the United States. This case report illustrates some of the challenges faced by the elderly in accessing essential emergency services for traumatic brain injury. CASE PRESENTATION: A 74-year-old Caucasian man presented with head trauma at his local acute care hospital (level III/IV) in Canada at 2:30 PM. He was triaged at 4:00 PM and was seen by the emergency room physician at 4:50 PM. His vital signs were normal, and his Glasgow Coma Scale score was 15/15 upon admission. A computed tomography-based diagnosis of acute subdural hematoma was subsequently made by a radiologist at 5:00 PM. A neurosurgical transfer was requested to the nearby tertiary trauma center (level I/II), but was initially refused by the neurosurgical resident on call. The patient's condition slowly deteriorated until he became unconscious at 7:45 PM. The patient was intubated and transferred to the neurosurgical unit at 8:34 PM. He was seen by a consultant neurosurgeon at 9:30 PM, but surgery (craniotomy) was deemed not viable, given the patient's age and the fact that his pupils were now fixed and dilated (Glasgow Coma Scale score 3/15). The patient was taken off life support at 1:00 AM the following morning and died shortly thereafter. The patient's family made a formal complaint, but the decision by an independent medical review panel was that "the patient's care was prudent, timely and professional." CONCLUSIONS: Geriatric patients with severe head injury are less likely than their younger counterparts to be transferred to neurosurgical trauma centers. Protocol-driven care of the elderly can reduce mortality due to head trauma through the application of the Brain Trauma Foundation guidelines.

The chronic enteropathogenic disease schistosomiasis.

Schistosomiasis is a chronic enteropathogenic disease caused by blood flukes of the genus Schistosoma. The disease afflicts approximately 240 million individuals globally, causing approximately 70 million disability-adjusted life years lost. Chronic infections with morbidity and mortality occur as a result of granuloma formation in the intestine, liver, or in the case of Schistosoma haematobium, the bladder. Various methods are utilized to diagnose and evaluate liver fibrosis due to schistosomiasis. Liver biopsy is still considered the gold standard, but it is invasive. Diagnostic imaging has proven to be an invaluable method in assessing hepatic morbidity in the hospital setting, but has practical limitations in the field. The potential of non-invasive biological markers, serum antibodies, cytokines, and circulating host microRNAs to diagnose hepatic fibrosis is presently undergoing evaluation. This review provides an update on the recent advances made with respect to gastrointestinal disease associated with chronic schistosomiasis.

Utility of Diagnostic Imaging in the Diagnosis and Management of Schistosomiasis.

Diagnosis of schistosomiasis is made by demonstration of the parasite ova in stools, urine,and biopsy specimens from affected organs, or presence of antibodies to the different stages of the parasite or antigens circulating in body fluids by serologic techniques. DNA of schistosomes can now also be detected in serum and stool specimens by molecular technique.However, these tests are unable to determine the severity of target organ pathology and resultant complications. Accurate assessment of schistosome-induced morbidities is now made with the use of imaging techniques like ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). US has made major contributions in the diagnosis of hepatosplenic and urinary form of disease. This imaging method provides real time results, is portable (can be carried to the bed side and the field) and is lower in cost than other imaging techniques. Typical findings in hepatosplenic schistosomiasis by US include: hyperechoic fibrotic bands along the portal vessels (Symmer's fibrosis), reduction in the size of the right lobe, hypertrophy of the left lobe, splenomegaly, and ascites. More advanced ultrasound equipment like the colour Doppler ultrasound can characterize portal vein perfusion, a procedure that is critical for the prediction of disease prognosis and for treatment options for complicated portal hypertension. Although CT and MRI are more expensive, are hospital based, and require highly additional specially-trained personnel, they provide more accurate description of the pathology, not only in hepatosplenic and urinary forms of schistosomiasis, but also in the diagnosis of ectopic forms of the disease,particularly involving thebrain and spinal cord. MRI demonstrates better tissue differentiation and lack of exposure to ionizing radiation compared with CT.

Clinical management of advanced schistosomiasis: a case of portal vein thrombosis-induced splenomegaly requiring surgery.

We report for the first time in the Philippines a case of portal vein thrombosis in a 12 year old Filipino boy with advanced schistosomiasis. The boy was referred to the Research Institute for Tropical Medicine (RITM), Manila, due to a rapidly enlarging spleen post-praziquantel treatment. At RITM, liver function tests were within normal limits but complete blood examinations showed pancytopenia and abnormal coagulation times. Serum markers for hepatitis A, B and C were negative. Abdominal MRI revealed schistosome-induced periportal fibrosis. The main portal vein appeared thrombosed with characteristic cavernous transformation of the right portal vein. Varices were seen in the oesophagus, gastrohepatic ligament, and splenic hilum. The spleen was markedly enlarged, with parenchymal foci representing Gamna-Gandy bodies. The patient underwent splenectomy. Histopathologic findings in the liver showed moderate pipestem fibrosis and schistosome egg granulomas. The patient was discharged from the hospital in excellent clinical condition.

Bilharzia in the Philippines: past, present, and future.

Schistosomiasis japonica has a long history in the Philippines. In 1975, 24 endemic provinces were identified in the northern, central, and southern islands of the Philippines. More than five million people were at risk, with approximately one million infected. In 2003, new foci of infection were found in two provinces in the north and central areas. For the past 30 years, human mass drug administration (MDA), utilizing the drug praziquantel, has been the mainstay of control in the country. Recent studies have shown that the schistosomiasis prevalence ranges from 1% to 50% within different endemic zones. Severe end-organ morbidity is still present in many endemic areas, particularly in remote villages with poor treatment coverage. Moreover, subtle morbidities such as growth retardation, malnutrition, anemia, and poor cognitive function in infected children persist. There is now strong evidence that large mammals (e.g. water buffaloes, cattle) contribute significantly to disease transmission, complicating control efforts. Given the zoonotic nature of schistosomiasis in the Philippines, it is evident that the incidence, prevalence, and morbidity of the disease will not be controlled by MDA alone. There is a need for innovative cost-effective strategies to control schistosomiasis in the long term.

Bilharzia: Pathology, Diagnosis, Management and Control.

More than one billion people travel internationally each year and approximately 100 million to the tropics. Schistosomiasis is a neglected tropical disease caused by trematode blood flukes of the genus Schistosoma. It currently infects over 250 million people worldwide and results in approximately 25 million disability adjusted life years lost. Clinical manifestations depend on the affected organ. Subtle morbidities have also been documented including: growth retardation, anaemia and poor cognitive function in children. While schistosomiasis has been eradicated from Japan and significantly reduced in parts of China and Egypt, transmission in many other regions remains ongoing due to the wide-spread distribution of the intermediate snail host, poor sanitation, lack of health education and decreasing compliance to mass drug administration. Integrated control has significantly reduced the burden of disease in China but considerable financial capital is needed if similar results are to be duplicated elsewhere. Human vaccination is in various stages of development, and once found, will become an integral part of future control. This comprehensive review examines the epidemiology, pathology, diagnosis, clinical management, prevention and control of the disease.