Schistosomiasis

• (also known as bilharzia, bilharziosis or snail fever) is a parasitic disease caused

by several species of trematodes (platyhelminth infection, or "flukes"), a parasitic
worm of the genus Schistosoma.
• Although it has a low mortality rate, schistosomiasis often is a chronic illness that
can damage internal organs and, in children, impair growth and cognitive
development. The urinary form of schistosomiasis is associated with increased
risks for bladder cancer in adults. Schistosomiasis is the second most
socioeconomically devastating parasitic disease after malaria.
• This disease is most commonly found in Asia, Africa, and South America,
especially in areas where the water contains numerous freshwater snails, which
may carry the parasite.
• The disease affects many people in developing countries, particularly children
who may acquire the disease by swimming or playing in infected water.
• Second most prevalent tropical parasitic disease in the world (behind Malaria
only)

Signs and symptoms

• Abdominal pain
• Cough
• Diarrhea
• Fever
• Fatigue
• Hepatosplenomegaly — the enlargement of both the liver and the spleen.
• Genital sores —
• Skin symptoms: At the start of infection, mild itching and a papular dermatitis of
the feet and other parts after swimming in polluted streams containing cercariae.
• Colonic polyposis with bloody diarrhea
• Portal hypertension with hematemesis and splenomegaly
• Cystitis and ureteritis (S. haematobium) with hematuria, which can progress to
bladder cancer;
• Pulmonary hypertension
• Glomerulonephritis; and central nervous system lesions.

• Bladder cancer diagnosis and mortality are generally elevated in affected areas.

Pathophysiology

Snails
• parasite eggs are released into the environment from infected individuals,
hatching on contact with fresh water to release the free-swimming miracidium.
• Miracidia infect fresh-water snails by penetrating the snail's foot.
 • After infection, close to the site of penetration, the miracidium transforms into a
primary (mother) sporocyst. Germ cells within the primary sporocyst will then
begin dividing to produce secondary (daughter) sporocysts, which migrate to the
snail's hepatopancreas.
• germ cells within the secondary sporocyst begin to divide again, this time
producing thousands of new parasites, known as cercariae, which are the larvae
capable of infecting mammals.
• Cercariae emerge daily from the snail host in a circadian rhythm, dependent on
ambient temperature and light. Young cercariae are highly mobile, alternating
between vigorous upward movement and sinking to maintain their position in the
water. Cercarial activity is particularly stimulated by water turbulence, by
shadows and by chemicals found on human skin.

Humans

• Penetration of the human skin occurs after the cercaria have attached to and
explored the skin. The parasite secretes enzymes that break down the skin's
protein to enable penetration of the cercarial head through the skin. As the
cercaria penetrates the skin it transforms into a migrating schistosomulum stage.
• schistosomulum may remain in the skin for 2 days before locating a post-capillary
venule; from here the schistosomulum travels to the lungs where it undergoes
further developmental changes necessary for subsequent migration to the liver.
Eight to ten days after penetration of the skin, the parasite migrates to the liver
sinusoids. S. japonicum migrates more quickly than S. mansoni, and usually
reaches the liver within 8 days of penetration. Juvenile S. mansoni and S.
japonicum worms develop an oral sucker after arriving at the liver, and it is
during this period that the parasite begins to feed on red blood cells.
• The nearly-mature worms pair, with the longer female worm residing in the
gynaecophoric channel of the shorter male. Adult worms are about 10 mm long.
Worm pairs of S. mansoni and S. japonicum relocate to the mesenteric or rectal
veins. S. haematobium schistosomula ultimately migrate from the liver to the
perivesical venous plexus of the bladder, ureters, and kidneys through the
hemorrhoidal plexus.
• Parasites reach maturity in six to eight weeks, at which time they begin to produce
eggs. Adult S. mansoni pairs residing in the mesenteric vessels may produce up to
300 eggs per day during their reproductive lives. S. japonicum may produce up to
3000 eggs per day.

Preferred definitive host of Schistosome sp. in the wild

S. mansoni Group
S. haematobium Group
(Restricted to Africa. Only exception:
(Africa, the Mediterranean area and the
S. mansoni is also prevalent in South
Middle East)
America)
S.
Parasites humans S. mansoni Parasites humans.
haematobium
S. Parasites rodents and
Parasites humans S. rodhaini
intercalatum carnivores
Parasites cattle sheep andS.
S. bovis Parasites ruminants
goats, rarely Man edwardiense
Parasites primates andS. Parasites the
S. mattheei
ruminants, rarely Man hippopotami hippopotamus
S. curassoni Parasites ruminants
S.
Parasites ruminants
margrebowiei
S. leiperi Parasites ruminants
S. japonicum Group S. indicum Group
(East Asia) (Asia)
Parasites humans and other
S. japonicum S. indicum Parasites ruminants
animals
Parasites humans and some Parasites ruminants and
S. mekongi S. spindale
other animals dogs
Parasites humans (rarely)
S. malayensis S. nasale Parasites ruminants
and other animals
S. Parasites rodents,
S. sinensum Parasites rodents
incognitum carnivores and ruminants

Treatment and control

• Treatment: praziquantel and oxamniquine
• Reinfection rate is very high.
• Vaccine strategy: not expected to be available soon
• Control strategy: massive populational screening and treatment. Increase access
to treated water.

Programs to control schistosomiasis

• Four pillars
– Mass chemotherapy (WHO guidelines)
– Molluscicides (chemical and/or biological)
– Sanitation (water and sewer treatment)
– Education
• Other factor:
– Urbanization
 Filariasis

What is lymphatic filariasis?

Filariasis is an infection with any of several round, thread-like parasitic worms.

The most common type of filariasis is infection with a parasitic worm that lives in the
human lymph system. This is called lymphatic filariasis.

What is the infectious agent that causes lymphatic filariasis?

Filariasis is caused by three types of parasitic worms: Wuchereria bancrofti,

Brugia malayi, and Brugia timori.

Where is lymphatic filariasis found?

Lymphatic filariasis is a disease of the tropics. Wuchereria bancrofti, the most

common filariasis parasite, is found in Africa, India, Southeast Asia, the Pacific islands,
the Caribbean, and South America. The Brugia malayi and Brugia timori parasites are
found in Southeast Asia.

How is lymphatic filariasis spread?

Filariasis is spread from infected persons to uninfected persons by mosquitoes.

Adult worms live in an infected person's lymph vessels. The females release large
numbers of very small worm larvae, which circulate in an infected person's bloodstream.
When the person is bitten by a mosquito, the mosquito can ingest the larvae. These
develop in the mosquito and can then be spread to other people via mosquito bites. After
a bite, the larvae pass through the skin, travel to the lymph vessels, and develop into
adults, which live about 7 years. Then the cycle begins again.

What are the signs and symptoms of lymphatic filariasis?

Most of the signs and symptoms of filariasis are caused as a consequence of the
adult worms living in the lymph system. Tissue damage caused by the worms restricts the
normal flow of lymph fluid. This results in swelling, scarring, and infections. The legs
and groin are most often affected.

How soon after exposure do symptoms appear?

Symptoms can appear 5-18 months after a mosquito bite.

How is lymphatic filariasis diagnosed?

 Filariasis larvae can sometimes be detected in blood.

Who is at risk for lymphatic filariasis?

Those most at risk are people who live in or stay for a long time in tropical areas
where the disease is common. Short-term tourists rarely get filariasis. Getting an infection
with symptoms usually requires several mosquito bites over a long period of time.

What complications can result from lymphatic filariasis?

Lymphatic filariasis is rarely fatal, but it can cause recurring infections, fevers,
severe inflammation of the lymph system, and a lung condition called tropical pulmonary
eosinophilia (TPE). In about 5% of infected persons, a condition called elephantiasis
causes the legs to become grossly swollen. This can lead to severe disfigurement,
decreased mobility, and long-term disability. Testicular hydrocele is a disfiguring
enlargement of the scrotum.

What is the treatment for lymphatic filariasis?

Treatment consists of: 1) medicine to kill circulating larvae and adult worms, 2)
soap and water and skin care to prevent secondary infections, and 3) elevation, exercises,
and, in some cases, pressure bandages to reduce swelling.

How common is lymphatic filariasis?

At least 120 million people in 73 countries worldwide are estimated to be infected

with filariasis parasites. The most widespread is Wuchereria bancrofti, which affects
about 100 million people in Africa, India, Southeast Asia, the Pacific islands, South
America, and the Caribbean. The Brugia malayi and Brugia timori parasites affect about
12 million people in Southeast Asia.

Is lymphatic filariasis an emerging infectious disease?

Yes. Lymphatic filariasis is among the world's leading causes of permanent and
long-term disability. The number of infected persons is increasing worldwide, due in
large part to unchecked urbanization in many areas where the parasite is common.

How can lymphatic filariasis be prevented?

There is no vaccine for filariasis. Prevention centers on mass treatment with anti-
filariasis drugs to prevent ingestion of larvae by mosquitoes, public health action to
control mosquitoes, and individual action to avoid mosquito bites. To avoid being bitten
by mosquitoes:

• If possible, stay inside between dusk and dark. This is when mosquitoes are most
active in their search for food.
• When outside, wear long pants and long-sleeved shirts.
• Spray exposed skin with an insect repellent.