GrandRound Discussion

1. PerPetual Succour HoSPital
Department of Family
&
Community Medicine
GRANDROUND PRESENTATION
BY:
LIZA D. MARIPOSQUE, M.D.
2nd Year Famed Resident
February 2010

2. OBJECTIVES
 To present a case of a 67 yrs old farmer with
Schistosoma.
 To discuss Schistosoma haematobium specie.
 Epidemiology & Etiology
 Pathophysiology
 Diagnostic tools
 Treatment & Preventions

3. B.A., 67 y.o., male, married, farmer from
Bukidnon, presently residing in Cabancalan,
Mandaue City admitted due to hypogastric
pain and inability to urinate.
Travel History: Agusan del Sur in 1987 as a
farmer then to Bukidnon.

4. PAST MEDICAL HISTORY
 HPN – uncontrolled
 (-) DM 2, Bronchial asthma
 PREVIOUS HOSPITALIZATION:
 2006 – Herniorrhaphy L (Kidapawan City)
 Smoker x 20 pack yrs
 Alcohol beverage drinker
 No Food & Drug allergies

5. HISTORY OF PRESENT ILLNESS
 1 yr PTA-Difficulty voiding
 4 days PTA- difficulty in urination
 2 days PTA - sought consult
- Advised UTZ - KUB
-Rx Rowatinex

6. On Admission

7. PHYSICAL EXAMINATION
BP: 200/120 mmHg HR: 84 bpm RR: 20 cpm
160/90 mmHg T: 37.6 Wt: 50 kg
Skin: Senile, dry, warm
HEENT: Ecteric Sclerae, pinkish palpebral conjunctivae.
NECK: No lymphadenopathy, no neck vein engorgement
C/L: ECE, decrease breath sound LLF, rales LLLF
CVS: DHS, NRRR, no murmur

8. ABDOMEN: Flat, hyperactive bowel sound, no
hepatomegaly, soft, nontender, no mass palpated.
GUT: post-op infraumbilical scar, enlarged R scrotum, no
erythema, nontender; tenderness hypogastric area
(+) KPS
EXTRIMITIES: No edema, strong pulses.
CNS: within normal limit
DRE: No skin tags, tight sphincter tone, no mass, prostate
gland not enlarged, (+) fecal material on rectal vault, (-)
blood on the examining finger.

9. ADMITTING IMPRESSION
 Nephrolithiasis
 Hypertensive Urgency
 Pneumonia
 Inguinal Hernia, R

10. Admitting Orders:
 Soft , low salt, low fat diet.
 IVF PNSS @ 30 gtt/min.
 Labs:
 CBC SGPT
 U/A Uric acid
 Na+, K++ Creatinine
 Lipid panel ECG
 CXR-PA UTZ abdomen

11.  Straight catheterization.
 Medications:
 Cefuroxime 750 mg IVTT q 8H ANST.
 Salbutamol Nebulization 1 neb q 8H.
 Paracetamol 500mg 1 tab q 4H prn for T>38C.
 Amlodepine 10 mg 1 tab now then OD.
 Captopril 25mg 1 tab SL now then prn for BP
>140/90 mmHg.
 Ranitidine 50mg IVTT q 8H.
 Nicardipine drip 10mg + 90ml D5W @ 10cc/hr.

12.  Fluid challenge.
 I & O monitored q shift.
 v/s monitored q 2H.

14. CBC
 WBC 12.20 (4.10-10.9)  Hb 14.6 (13.5-17.5)
 N 83 ( 47-80)  Hct 42.4 (41-53)
 L 9 (13-40)  RBC 4.7 (4.5-5.9)
 M 8 (2-11)  MCV 89.4 (80-100)
 E 0 (0-5)
 B 0 (0-2)
 RCDW 14.1 (11.6)
 Plt 143 (140-440)

15. Urinalysis
Color: yellow
Glucose: Negative Leukocyte (-)
Protein: Negative RBC 3-5
pH: 6 WBC 0-2
Sp. Gravity: 1.010 Epithelial cells: rare
Bilirubin (-) Mucus threads: rare
Urine Ketone (-) Amorphous: rare
Nitrite (-) Bacteria: rare
Blood: ++

16.  Na 136 mmol/L  Crea 10.35 mg/dl
(n.v. 133-146) (n.v. 0.60-1.50)
 K 4.27 mmol/L
(n.v. 3.4-5.2)
 Uric Acid 12.23 mg/dl Crea Clearance: 4.84
(n.v. 3-80)
 SGPT 30 (n.v. 5-50)
 CBS: 135 mg/dl

17. LIPID PANEL
Cholesterol: 144.13 mg/dl
(n.v. 100-200)
TG: 66.93 mg/dl
(n.v. 60-200)
HDL: 48.69 mg/dl
(n.v. 35-65)
LDL: 82 mg/dl (n.v. 0-200)
Glucose: 105.66 mg/dl
(n.v. 76-110)

18. UTZ Whole Abdomen
 Echogenic lace-like pattern of the liver consistent
with Schistosomiasis.
 Gallbladder, common duct, pancreas, spleen –
negative.
 KUB – negative.
 NORMAL SIZE Prostate gland, 1.0cm cyst in the
L lobe.
 Aorta – normal in course & caliber.

19. COURSE IN THE
WARDS

20. P: hypogastric pain, inability to
urinate, BP
S: hypogastric pain, slightly dyspnic
O: conscious, coherent & not in respiratory distress.
BP: 130/70-160/70 mmHg PR: 72-85 bpm
RR: 19-20 cpm T: 36-37 0C
Total Fluid Intake: 300 UO: 1,050 cc

21. Assessment:
 Schistosomiasis (S. haematobium)
 ARF 2ndary to Hypertensive Nephrosclerosis vs.
Uric Acid Nephropathy
 HPN
 CAP, Moderate Risk

22. Plan:
 Cefuroxime 750 mg IVTT OD.
 Allopurinol 100 mg 1 tab OD.
 Dolcet 1tab TID.
 All other meds continued.
 Foley Bag Catheter inserted.
 Referred to Nephrologist for co-mgt.
 Additional labs requested …..

23.  Ca 7.85 mg/dl
(n.v.8.4-10.3)
 BUN 104 mg/dl
(n.v. 7-18)
 Phosphorus 6.30 mg/dl (2.5-4.7)

24.  O2 inhalation @ 2 Lpm.
 IVF changed into D5 0.3% NaCl @ 10 gtt/min.
 I & O q hourly.
 Hold Allopurinol & Captopril.

25. P: hypogastric pain, inability to
urinate, BP, dyspnea, crea
S: w/ mild hypogastric pain, no dyspnea
O: conscious, coherent & not in respiratory distress.
BP: 130/70-150/90 mmHg PR: 68-74 bpm
RR: 19-20 cpm T: 36-36.8 0C
Total Fluid Intake: 2590 cc UO: 2,705 cc

26. Assessment:
 Schistosomiasis (S. haematobium)
 ARF 2ndary to Hypertensive
Nephrosclerosis vs. Uric Acid
Nephropathy
 HCVD
 CAP, Moderate Risk

27. Plan:
 CaCO3 (Tums) 500mg 1tab TID.
 NaHCO3 Gr. X 650mg 2tabs TID.
 Ranitidine IV shifted to P.O 150mg 1tab OD.
 Hold Nicardipine drip.
 Cefuroxime IV shifted to P.O 250mg 1tab OD.
 Increase IVF rate to 20gtt/min.

28.  Repeat Crea on 12/31/09.
 PSA determination requested.
 For infectious consult…

29. Infectious Consult
A: Schistosoma probably due to S. hematobium
P: > Rectal Imprint
> Praziquantel 25mg/kg in 2 divided doses
at 4 hours interval.
> Referral to DOH.

30. Plan: crea, BP,
S: No complaints
O: conscious, coherent & not in respiratory distress.
BP: 130/80-140/80 mmHg PR: 60-65 bpm
RR: 20-21 cpm T: 36.2-36.5 0C
Total Fluid Intake: 1660 cc UO: 480cc

31. Assessment:
 Schistosomiasis (S. haematobium)
 ARF 2ndary to Uric Acid Nephropathy
 HCVD
 CAP, Moderate Risk

32. Plan:
 Discharge against medical advised.
 Take home meds:
 Cefuroxime 250 mg 1tab OD x 7 days.
 NaHCO3 Gr. X 2tabs TID x 1 month.
 CaCa3 (Tums) 500mg 1tab TID.
 Amlodepine 10mg 1tab OD as maintenance.
 Advised and referred to DOH
 Ff-up with APs.

34.  What is Schistosomiasis?
 Schistosomiasis or bilharzia or Snail Fever
 It is a parasitic disease common among farmers,
fishermen and their families in Africa & certain parts
of the Philippines.
 parasitic disease that leads to chronic ill-health.
 caused by trematode flatworms of the genus
Schistosoma.

35.  Parasitic disease carried by fresh water snails
infected with one of the five varieties of the
parasite Schistosoma.
 Urinary schistosomiasis - caused by Schistosoma
haematobium
 Intestinal schistosomiasis - S. intercalatum, S. mansoni,
S. japonicum, and S. mekongi.

36. Epidemiology:
 affects at least 200 million people worldwide,
 >700 million people live in endemic areas.
 Prevalent in 74 countries worldwide, but over half of all
documented cases are in Africa

37.  Prevalence:
 tropical areas
 sub-tropical areas
 poor communities without potable water and
adequate sanitation.

38.  Endemic in 12 regions in the Philippines.
 Affecting 28 of the 79 provinces in the country.

39.  Morbidity rate- declined from 17.5
cases/100,000 population in 1997 to
5.6/100,000 in 2000.
 Case fatality ratio has also continued to decline
from 0.9 death/100,000 population in 1980 to
0.3/100,000 in 1997 and has reached a plateau
since then.

40. PATHOPHYSIOLOGY
 Life cycle - common to all species
 sexual generation in vascular system of the
definitive host (human)
 asexual generation in the intermediate hosts
(snails).

41.  1) Embrionated eggs are discharged in
faeces and urine.
 in water miracidia hatch from the egg and
penetrate the intermediate hosts:

42. Schistosome species Snails
S.mansoni Biomphalaria spp.
S.haematobium Bulinus spp.
S.intercalatum Bulinus spp.
S.japonicum Oncomelania spp.
S.mekongi Neotricula spp.

43. 2) after penetration in the snail the miracidium
develops into sporocysts.
 4 weeks thousand of cercariae are produced
(asexual multiplication).
 infective forms.
 500 micron.

44.  3) the infection of the definitive host occurs
by penetration of the skin.

45.  During the penetration process the cercariae
lose their tail and transform into the larval
stage: the schistosomulum.
 antibody depended
cytotoxicity of schistosomulum

46. 3-4 days

47. Body: larvae adult schistosomes
(blood vessels)
feces
females EGGS Immune reaction
URINE

48. S.haematobium:
 adult schistosomes live in pairs in the pelvic
veins
(especially in the venous plexus surrounding
the bladder).
 Males = 10-15 mm in lenght by 0.8-1 mm in
diameter.
 have a ventral infolding from the ventral sucker
to the posterior end forming the gynecophoric
canal.

49.  Females = slender ( 0.25 mm in diameter)
and longer (up to 20 mm in lenght)
 Each female lays about 150 eggs per day.

50.  Schistosoma haematobium eggs
 Concentrated in the tissue of the
bladder.
 the main agent of pathology inducing
granuloma formation Hyperplasia
of the mucosa
fibrosis and calcification
polyps formation in bladder & ureter
stenosis.
Hydronephrosis Bladder Cancer

51.  Not uncommonly found in male genital
organs.
 A relationship between the presence of eggs
in seminal fluid and male infertility has not
been demonstrated.
 The damage of the seminal vescicles seems
to correlate with the degree of the
obstructive uropathy.
 Less commonly affected are the prostate, the
testes and the epididymis.

52. Manifestations:
 Initial itching and rash at infection site (“swimmer’s
itch”)
 Fever, chills and muscle aches
 Frequent, painful or bloody urine.
 Bladder, ureteral fibrosis and hydronephrosis -
advanced cases
 Bladder cancer - late-stage complications.

53. DIAGNOSTIC TOOLS
 Stool Exam
 Urinalysis – visible hematuria &/macrohematuria
 Urine filtration kit
 UTZ abdomen
 Immunodiagnostic/Serological test
 Monoclonal antibodies

54.  Diagnosis - identification of eggs in urinary
sediment.
 viable eggs contain a motile miracidium.

55.  Serological tests - useful for travellers
returning from endemic areas and in patients
with light or ectopic infection, with no
detectable eggs in the faeces, urine or
intestinal biopsies (i.e. hepatic, CNS
infections).
 (+) test may reflect previous exposure to the agent
rather than an active infection.
 a slow decrease in titer - after effective treatment

56. Treatment & Preventions
 Environmental sanitation
 Safety of supply water
 Education
 snail control with spraying
& drip feeding.
Molluscisciding
drip feeding

57.  Education – the risk of getting infected by bathing
in fresh water lakes and ponds/dams.
 Heating bathing water to 50°C (122°F) for 5
minutes or filtering water with fine-mesh filters.
 Allow bathing water to stand for 2 days because
cercariae rarely remain infective longer than 24
hrs.

58.  Swimming in adequately chlorinated pools.
 Vigorous towel drying after accidental exposure.
 Topical application of the insect repellent
DEET can block penetrating cercariae.

59.  A schistosomiasis vaccine is currently
developed by Sabin’s vaccine development team
 Praziquantel – DOC; A single dose of it has
been shown to reduce the severity of symptoms
in cases of subsequent re-infection.
 PZQ 40 mg/kg (WHO Recommendation)
 Oxamniquine has been effective in treating
infections caused by S. mansoni.
 Metrifonate & Albendazol - alternative

60.  Oxamniquine and
 Metrifonate. Albendazol also is used