Parasitic diseases of urinary and renal system

Urinary schistosomiasis

1
 Schistosomiasis
• Schistosomiasis, also known as snail fever and Bilharzia is a
disease caused by parasitic worms called schistosomes

• It belongs to the group of helminth infections

• The urinary tract or the intestines may be infected

• Symptoms include abdominal pain, diarrhea, bloody stool, or

blood in the urine

• Those who have been infected for a long time may experience
liver damage, kidney failure, or bladder cancer

2
 Epidemiology
• Schistosomiasis affected about 252 million people worldwide in 2015.
• An estimated 4,400 to 200,000 people die from it each year
• The disease is most commonly found in Africa, as well as Asia and South
America
• Around 700 million people, in more than 70 countries, live in areas
where the disease is common
• In tropical countries, schistosomiasis is second only to malaria among
parasitic diseases with the greatest economic impact
• Schistosomiasis is listed as a neglected tropical disease and even
not include in the list of tropical disease priorities in Ethiopia

3
General Characteristics of schistosomes (blood flukes)
– Males are shorter and fatter than females
– Lateral margins of males are folded ventrally to form a
gynecophoral canal in which females are received
– Eggs are non-operculated
– Eggs are fully embryonated when laid
– Embryonated eggs have a ciliated embryo called
miracidium
– Cercaria is the infective stage penetrating human skin
– Human is most significant definitive host
– Species specific freshwater snails serve as intermidate host
– No secondary intermidate host required unlike other flukes

4
 Urinary schistosomiasis
• It is caused by a digenetic trematode, S.hematobium also called
vesical/urinary (affecting urinary bladder) blood fluke

• S. haematobium was the first blood fluke discovered

• Theodor Bilharz, a German surgeon working in Cairo, identified

the parasite as a causative agent of urinary tract infection in 1851

• It is the only blood fluke that infects the urinary tract, causing
urinary schistosomiasis, and is the leading cause of bladder
cancer

5
 Urinary schistosomiasis...

• The disease is chronic in nature, with the most frequently affected

organ being the urinary bladder, where calcification of eggs
trapped in the tissues often occurs
• The disease is characterized by blood in the urine (haematuria),
hence the infection is often referred to as ‘urinary schistosomiasis'
• Cancer of the bladder is an important complication of infection
with S. haematobium.
• Eggs may be deposited in the bladder, often in high numbers, and
granuloma formation may occur

6
• Distribution: Africa, Middle East, South Europe

• In Ethiopia -Awash, Wabeshebele, Asossa

• The disease is especially common among children in developing

countries as they are more likely to play in contaminated water

• Other high risk groups include farmers, fishermen, and people

using unclean/unprotected water during daily living

7
Habitat
• Adult parasites are found in small venules around the

bladder and ureter.

• Eggs released from adult travels to the wall of the urinary

bladder causing haematuria and fibrosis of the bladder

• The bladder becomes calcified, and there is increased

pressure on ureters and kidneys (hydronephrosis)

8
Morphology:
 Adults
Cylinderial in shape

Males are shorter and fatter than females

Male has gynecophoral canal that holds the female

 The female only leaves the male for laying eggs

9
 Egg:
• Large about 112 -170µm
• Oval with one well rounded end
• Prominent terminal spine at one
end (important laboratory
diagnostic feature)
• Contains fully developed
miracidium when laid
–Embryonated when laid

10
 Transmission and life cycle
• The disease is spread by contact with water contaminated
with the parasites/cercarial stage
• Infected individuals release embryonated schistosoma eggs
into water via their urine
• After larvae hatch from these eggs, the larvae infect a very
specific type of freshwater snail (bulinus spp).
• The larvae undergo the next phase of their lifecycle within
snails, spending their time reproducing and developing in to
cercaria
• The cercaria leaves the snail and enters the water column.
• The cercaria can live in the water for only 48 hours without a
human host
11
• Once a host has been found, cercaria lose tails during penetration
and become schistosomula
• Then the schistosomula enters host’s blood vessels
• After several weeks, the schistosomula in the vessels, will
continuer its development into its adult form
• When maturity is reached, mating occurs and eggs are produced
• Eggs enter the bladder and are excreted through urine and the
process repeats
• If the eggs do not get excreted, they can become fixed in the body
tissues and cause a variety of problems such as immune reactions
and organ damage
• Uninfected humans encounter larvae of the schistosoma parasite
when they enter contaminated water while bathing, playing,
swimming, washing, fishing, or walking through the water
12
Life cycle of S.hematobium

13
Pathogenesis and clinical features
• It is the eggs and not the adult worms, which are responsible for
the pathogenesis associated with Schistosoma haematobium
infections.
• The adult worm acquire host antigen which protects them from
the host's immune response (host immune response against adult
worm is minimal)
• Adult worms lay eggs that can cause inflammatory reactions
• Eggs induce intense inflammatory reaction, leading to granuloma
formation.
• Pathology related to urinary schistosomiasis is therefore due to
the eggs

14
 Pathogenesis…
• Granuloma consists of egg at center surrounded by eosinophils ,
macrophages and lymphocytes

• Larvae inside the egg produce enzymes that aid in tissue

destruction and

• Allow the eggs to pass through the mucosa and in to lumen of

bladder to be shed

• This cause cystitis and ureteritis with Hematuria, which can

progress to bladder cancer

• The enzymes also cause an eosinophilic inflammatory reaction

when eggs get trapped in tissues
15
Eggs of S. haematobium surrounded by intense infiltrates of
eosinophils and macrophages in bladder tissue.

16
 General Pathogenesis

• The disease associated with urinary schistosomiasis is largely due

to the host’s immune response to the larvae and eggs

• Mature adult worms evade the host’s immune defenses by

antigenic mimicry and other mechanisms mediated by the
tegument, and thus contribute little to the immunopathology of
the disease.

17
 Immune evasion mechanisms
 Active shedding of worm tegument as the parasite develops

 Antigenic masking (adult worm acquires host antigens (HLA &

blood group Antigens), Immunoglobulins, on its surface)

 Tegument proteins also have the ability to recognize the Fc

receptors of host Antibody, thus immunoglobulins are directed in
wrong direction

18
 Clinical features
• Infection may be acute or chronic
• Many infections are mildly symptomatic, with anemia and
malnutrition being common in endemic areas

 The severity of disease in urinary schistosomiasis is determined

by
• Duration and intensity of the infection

• Parasite strain

• Co-infections with malaria, hepatitis viruses, HIV, and other

infections
19
 Acute manifestations (immune-complex mediated disease)

• Katayama fever/syndrome: It is an immune-complex mediated

reaction against migrating schistosomula and early egg deposition

• It may occur weeks or months after the initial infection as a systemic

reaction against migrating schistosomula

• Katayama fever is more commonly seen in people with their first

infection such as migrants and tourists

• Cercarial dermatitis (swimmer’s itch): occurs after penetration of skin

by cercaria if a patient’s immune system has been sensitized earlier

• It is a hypersensitivity reaction caused by dead or dying larvae (skin

rash)
20
 Chronic manifestations (cell mediated diseases)
• Worms of S. haematobium migrate to the veins around the
bladder and ureters to lay egg
• This can lead to blood in the urine 10 to 12 weeks after
infection and there may be pain on urination
• Hematuria from inflammation and small ulcerations in the
bladder mucosa may appear within 3 to 4 months of infection.
• Over time, fibrosis can lead to obstruction of the urinary tract
(obstructive uropathy), hydronephrosis and kidney failure
• Bladder cancer diagnosis and mortality are generally elevated
in affected areas
21
 Clinical presentations
• Hematuria : Gross Hematuria is easily identified, as it causes red or
brown discoloration of the urine

• Microscopic Hematuria is invisible to the naked eye and is often

detected on urinalysis or urine dipstick

• Pyelonephritis: kidneys can leak blood into the urine

• Cystitis and ureteritis: Urinary tract (ureters, and urinary bladder)

leak blood into the urine

• In advanced cases bladder cancer: The most common type is

transitional and squamous cell carcinoma
22
Hematuria

23
 Laboratory diagnosis
 Eggs can be found in the urine.
 Investigation of S. haematobium should also include a pelvic x-
ray as bladder wall calcificaition is highly characteristic of
chronic infection.
 Tissue biopsy (rectal and bladder biopsy) may demonstrate S.
haematobium eggs when urine examinations are negative.
 Antibody detection can be useful in both clinical management
and for epidemiologic surveys.
 Cystoscopy with tissue biopsies in advanced cases

24
Ova of S. hematobium

25
Treatment and Prevention
• Methods to prevent urinary schistosomiasis include improving
access to clean water and reducing the number of snails

• In areas where the disease is common, the medication praziquantel

may be given once a year to the entire group

• This is done to decrease the number of people infected and,

consequently, the spread of the disease

• Praziquantel is also the treatment recommended by the World

Health Organization (WHO) for those who are known to be infected

26
• In some cases, urbanization, pollution, and the consequent
destruction of snail habitat have reduced exposure, with a
subsequent decrease in new infections

• The drug praziquantel is used for prevention in high-risk

populations living in areas where the disease is common

• The CDC advises avoiding drinking or coming into contact with

contaminated water in areas where urinary schistosomiasis is
common

27
• Treatment: praziquantel

• Vaccine strategy: not expected to be available soon

• Control strategy: massive populational screening and treatment.

• Increase access to treated water

• Four pillars

– Mass chemotherapy (WHO guidelines)

– Molluscicides (chemical and/or biological)

– Sanitation of water

– Heath education

28
 Other parasitic diseases of kidney & urinary system
• Echinococcus granulosus: large amount of hydatid cyst
overcrowded in kidney and cause kidney dysfunction

• Plasmodium falciparum: complicated falciparum malaria causes

renal impairment

• Parasitized RBCs sequestered in tubules causing acute tubular

necrosis and acute renal failure

• Kidney slightly enlarged and malarial pigments found in the

glomeruli

• Trichomonas vaginalis: causes urethritis in sexually active males

29
Thank you

30