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Ultrasound assessment of schistosomiasis
Abstract
In 2000, the World Health Organization (WHO) issued an ultrasound field protocol for assessing the morbidity due to Schistosoma (S.) haematobium and S. mansoni. The experience with this classification has recently been reviewed systematically. The WHO protocol was well accepted worldwide. Here we review the use of ultrasound to assess the morbidity due to schistosomiasis with emphasis on easy, quick, and reproducible ways that can be used in the field. Findings obtained with high-end ultrasound scanners in the hospital setting that might eventually have applications in the field are also described.
© Georg Thieme Verlag KG Stuttgart · New York.
... Chronic intestinal schistosomiasis can lead to periportal liver fibrosis in approximately 4%-8% of patients with disease [1,5,6]. Also known as Symmer's clay pipestem fibrosis, this long-term complication manifests initially as hepatomegaly, leading to portal hypertension, varices, and splenomegaly [1]. ...
... Synthetic function of the liver is preserved until late stages of disease [1] thus basic liver blood tests will underestimate the incidence of hepatic schistosomiasis. Thus, ultrasound assessment of the liver is recommended [1] which can detect early signs and degree of hepatic schistosomiasis [5]. In genitourinary schistosomiasis, on the other hand, hematuria is an early sign that can be detected within 3 months of exposure [3,5], and if present, should trigger referral to urology. ...
... Thus, ultrasound assessment of the liver is recommended [1] which can detect early signs and degree of hepatic schistosomiasis [5]. In genitourinary schistosomiasis, on the other hand, hematuria is an early sign that can be detected within 3 months of exposure [3,5], and if present, should trigger referral to urology. Risk stratification with abdominal ultrasonography in patients with confirmed schistosomiasis, and bladder ultrasound and urinalysis in those with schistosomiasis from Africa should be undertaken to reduce risk of long-term sequelae. ...
... The diagnosis can be confirmed through the demonstration of the eggs in the urine [12]. Treatment of urogenital schistosomiasis is based on the use of praziquantel, which may be able to reverse, completely or partially, urogenital lesions within 3 to 6 months [13][14][15]. ...
... The use of ultrasound (US) examination in the diagnosis of Schistosoma infection is accepted worldwide [13,16,17]. US exam plays a central role in the diagnosis and follow-up of this infection and its complications, allowing to assess the presence and degree of organ involvement. ...
... The role of US is undoubtedly in detecting early bladder alterations, such as the increase in parietal thickness and the formation of endoluminal protrusions (in particular, trigone hypertrophy) which create an exophytic mass between the two orifices, even if these findings are then analysed by cystoscopy with a possible biopsy intervention (Figs. 1, 2, 3, 4, 5) [7]. The Niamey protocol also provides a quantization of the post-voiding residue, although multiple studies have confirmed that the sense of incomplete emptying is a better indicator of the presence of schistosome infection compared with the residue [13][14][15][18][19][20][21]. The calcification of the bladder wall is classically compared with the 'foetal head in the pelvis', which is actually better appreciated using radiological images and particularly computed tomography (CT) 6,7,8,9). ...
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.
... Whereas, for confirming significant PPF, the best cutoff value was >1.39 m/s, with specificity of 86.1% and positive predictive value of 92.0%. PLOS Introduction Schistosomiasis is considered a public health problem in many parts of the world and one of the most frequent causes of liver fibrosis worldwide [1]. In Brazil, schistosomiasis mansoni infection affects 1.5 millions of people, particularly in the Northeastern region [2]. ...
... Furthermore, liver biopsy is invasive, usually unsuitable for long-term follow-up and not applicable in the field, indicating that there is no gold standard for schistosomal portal fibrosis available [7]. Therefore, imaging techniques, such as ultrasound (US) scan, have been proven valuable for liver morbidity assessment and its complications in endemic areas [1,8,9]. ...
... For the assessment of PPF, and consequently schistosomiasis-related morbidity, US is one of the most important means for this purpose, especially with the formulation of a standardized WHO Niamey-Belo Horizonte protocol. [1,12]. The WHO Niamey-Belo Horizonte protocol shows practical usefulness it is considered satisfactory in terms of reproducibility, assessment of evolution of pathology, and comparability between different settings, even though physician expertise is required [7,13]. ...
Background
ARFI elastrography has been used as a noninvasive method to assess the severity of liver fibrosis in viral hepatitis, although with few studies in schistosomiasis mansoni. We aimed to evaluate the performance of point shear wave elastography (pSWE) for predicting significant periportal fibrosis (PPF) in schistosomotic patients and to determine its best cutoff point.
Methodology/principal findings
This cross-sectional study included 358 adult schistosomotic patients subjected to US and pSWE on the right lobe. Two hundred two patients (62.0%) were women, with a median age of 54 (ranging 18–92) years. The pSWE measurements were compared to the US patterns of PPF, as gold standard, according to the Niamey classification. The performance of pSWE was calculated as the area under the ROC curve (AUC). Patients were further classified into two groups: 86 patients with mild PPF and 272 patients with significant PPF. The median pSWE of the significant fibrosis group was higher (1.40 m/s) than that of mild fibrosis group (1.14 m/s, p<0.001). AUC was 0.719 with ≤1.11 m/s as the best cutoff value for excluding significant PPF. Sensitivity and negative predictive values were 80.5% and 40.5%, respectively. Whereas, for confirming significant PPF, the best cutoff value was >1.39 m/s, with specificity of 86.1% and positive predictive value of 92.0%.
Conclusions/significance
pSWE was able to differentiate significant from mild PPF, with better performance to predict significant PPF.
... Schistosomiasis is considered a public health problem in many parts of the world and one of the most frequent causes of liver fibrosis worldwide [1]. In Brazil, schistosomiasis mansoni infection affects 1.5 millions of people, particularly in the Northeastern region [2]. ...
... Furthermore, liver biopsy is invasive, usually unsuitable for long-term follow-up and not applicable in the field, indicating that there is no gold standard for schistosomal portal fibrosis available [7]. Therefore, imaging techniques, such as ultrasound (US) scan, have been proven valuable for liver morbidity assessment and its complications in endemic areas [1,8,9]. ...
... For the assessment of PPF, and consequently schistosomiasis-related morbidity, US is one of the most important means for this purpose, especially with the formulation of a standardized WHO Niamey-Belo Horizonte protocol. [1,12]. The WHO Niamey-Belo Horizonte protocol shows practical usefulness it is considered satisfactory in terms of reproducibility, assessment of evolution of pathology, and comparability between different settings, even though physician expertise is required [7,13]. ...
Background
ARFI elastrography has been used as a noninvasive method to assess the severity of liver fibrosis in viral hepatitis, although with few studies in schistosomiasis mansoni. We aimed to evaluate the performance of point shear wave elastography (pSWE) for predicting significant periportal fibrosis (PPF) in schistosomotic patients and to determine its best cutoff point.
Methodology/Principal findings
This cross-sectional study included 358 adult schistosomotic patients subjected to US and pSWE on the right lobe. Two hundred two patients (62.0%) were women, with a median age of 54 (ranging 18-92) years. The pSWE measurements were compared to the US patterns of PPF, as gold standard, according to the Niamey classification. The performance of pSWE was calculated as the area under the ROC curve (AUC). Patients were further classified into two groups: 86 patients with mild PPF and 272 patients with significant PPF. The median pSWE of the significant fibrosis group was higher (1.40 m/s) than that of mild fibrosis group (1.14 m/s, p<0.001). AUC was 0.719 with ≤1.11 m/s as the best cutoff value for excluding significant PPF. Sensitivity and negative predictive values were 80.5% and 40.5%, respectively. Whereas, for confirming significant PPF, the best cutoff value was >1.39 m/s, with specificity of 86.1% and positive predictive value of 92.0%.
Conclusions/Significance
pSWE was able to differentiate significant from mild PPF, with better performance to predict significant PPF.
Author summary
In the developing world, over 207 million people are infected with parasitic Schistosoma worms. Among the species of Schistosoma that infect humans Schistosoma mansoni is one of the most common causes of illness. Here, we investigated the performance of point shear wave elastography (pSWE) for predicting significant periportal fibrosis (PPF) in schistosomotic patients and to determine its best cutoff point. We examined 358 people from northeast of Brazil for Schistosoma infections. The present study showed that pSWE was able to differentiate significant from mild PPF, with better performance to predict significant PPF.
... Evidence summary According to recent reviews, abdominal US is the most widely used imaging method for the initial evaluation of both hepato-intestinal and urinary chronic schistosomiasis [100]. ...
... Whereas initial hepatic fibrosis and splenomegaly can regress after PZQ therapy in young patients, among adults advanced alterations do not improve even after repeated therapeutic courses [100,157]. The evolution to advanced stage of the disease is strictly dependent on complications' onset and related treatment and no single follow-up scheme suitable for all patients can be recommended [137]. ...
... In recent years, conventional ultrasound (US) and CEUS features of less common FLL have been described in detail. The currently published papers with gold standard histology include hemangioma [6], focal nodular hyperplasia [7,8], hepatocellular adenoma [7][8][9], cholangiocellular adenoma [10], peliosis [11][12][13], cystadenoma and cystadenocarcinoma [14], hemangioendothelioma [15,16], metastases [4][5][6][7][8][9][10][11][12], hepatocellular carcinoma (HCC) in the non-cirrhotic liver [17,18], HCC [13][14][15][16][17][18][19], cholangiocellular carcinoma (CCC) [20][21][22][23][24]. Several of these are from multicenter trials [4,[7][8][9][10]12], guidelines (EFSUMB) [13,14,[25][26][27][28][29][30][31][32][33][34][35][36] and comments to these guidelines [20,21,[37][38][39][40][41][42][43]. ...
... There are also several papers and reports on the more uncommon hepatic lesions. These include characterization of fibrolamellar hepatocellular carcinoma (fHCC) [19,20], very small HCC (HCC, sHCC <10 mm) [21], mixed HCC and CCC (mHCC/CCC) [22], nodular regenerative hyperplasia [23], sarcoma [24], inflammatory pseudotumour [25], sarcoidosis [26][27][28][29], tuberculosis [30,31], hydatid cysts [32][33][34][35], alveolar echinococcosis [33], schistosomiasis [36,37], ascariasis [38,39], fasciolosis [40], clonorchis and opisthorchis [41], toxocariasis [42], bacillary angiomatosis [43], amyloidosis with spontaneous hemorrhage [44], as well as rare FLL in pediatric patients [45,46]. ...
In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of bacterial infections are discussed. Improved detection and characterization of common focal liver lesions (FLL) are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper on infectious (bacterial) focal liver lesions is on their appearance on B-mode and Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.
... During acute schistosomiasis, non-specific hepatosplenomegaly with enlargement of the hilar lymph nodes can be observed. These can show an unusual structure, with a hypoechoic halo surrounding a moderately hyperechoic center [93,94]. Ultrasound readily detects portal fibrosis and thickening of the walls of portal branches (▶ Fig. 10), splenomegaly, and portal hypertension in chronic hepatosplenic schistosomiasis. ...
... Portal fibrosis, also named "Symmer's pipe-stem fibrosis", can be classified into 6 progressive patterns [93,94,95,96]. CEUS does not add specific information to this fibrosis development, and CEUS has not been included in the schistosomiasis classification systems. ...
Zusammenfassung
Infektiöse fokale Leberläsionen (FLL) treten in der klinischen Praxis häufig auf, wobei bakterielle Leberabszesse die Hälfte ausmachen. Eine genaue Diagnose der FLL ist für die Auswahl der am besten geeigneten Therapie und zur Vorbeugung von Komplikationen unerlässlich. Ziel der aktuellen Arbeit ist es, den Nutzen von Ultraschall und kontrastmittelverstärktem Ultraschall (CEUS) zur Erkennung und Charakterisierung infektiöser Leberläsionen zu beschreiben.
... 3 In the pathogenesis of S. mansoni, the liver is the main organ affected and the disease is one of the most frequent causes of liver fibrosis in the world. 4 Chronic infection and the granulomatous inflammatory process around the eggs lead to excess deposition of collagen and other extracellular matrix components in the intrahepatic terminal branches of the portal vein, thereby producing periportal fibrosis (PPF). 5 The progression of PPF causes obstruction of the blood flow that is associated with splenic vein hyperflow due to splenomegaly, which results in non-cirrhotic portal hypertension and its consequences, such as gastroesophageal varices and digestive hemorrhage. ...
... 6 Examination by ultrasound is often used to diagnose morbidity in S. mansoni infection, especially in the study of liver damage, imaging being the technique of choice, either in hospital or in the field because of its greater availability, the ease of examination and its low cost compared with that of other techniques. 4 However, there are limitations: the examination requires the availability of the ultrasound device and the need for an expert examiner, being an examiner-dependent procedure. In fact, it is not accessible in all health centers, in particular primary care units in endemic areas. ...
Background
Periportal fibrosis (PPF) is the major pathological consequence of Schistosoma mansoni infection. The Coutinho index—the alkaline phosphatase (ALP) to platelet ratio ([ALP/upper limit of normality {ULN}]/platelet count [106/L] x 100)—was validated. Validation consisted of modest laboratory tests to predict advanced PPF.
Methods
A total of 378 individuals from an endemic area of Brazil with a previous history of the disease and/or a positive parasitological examination were evaluated. We used ultrasound examination as the gold standard for classification of the PPF pattern and measured the biological markers of the index.
Results
Forty-one individuals (10.8%) without PPF, 291 (77%) with moderate PPF and 46 (12.2%) with advanced PPF, were identified. ALP and platelet count were used for the index. The cut-off point ≥0.228 predicted the presence of fibrosis with an area under the receiver operating characteristic curve (AUROC) of 0.56, sensitivity of 68.6% and specificity of 46.3%. There was an absence of PPF in 46.3% of individuals without fibrosis and the presence of PPF in 68.5% of cases with moderate and advanced ultrasound fibrosis. The identification of advanced fibrosis with a cut-off point ≥0.316 revealed an AUROC curve of 0.70, sensitivity of 67.4% and specificity of 68.3%, thus confirming the advanced phase in 65.2% of cases compared with ultrasound.
Conclusion
The Coutinho index was able to predict advanced PPF in most individuals. It is valid as a new tool, uses routine laboratory tests and therefore is more accessible for screening patients with a severe form of the disease in endemic areas.
... US is one of the most important tools for PPF assessment through classification by a standardized World Health Organization Niamey protocol (Richter et al. 2001). However, the US scan requires an experienced examiner, not often available in more remote and endemic areas for schistosomiasis (Leite et al. 2015;Richter et al. 2016). Also, US is an operator-dependent examination. ...
... All patients included had an abdominal US after an 8 h fast and were examined by the same experienced operator (A.L.C.D.). During the US, the PPF was evaluated by the Niamey classification according to intensity and the location in the liver parenchyma (Richter et al. 2001;el Scheich et al. 2014;Richter et al. 2016). A comparison was made with a pictorial image pattern: pattern C (peripheral fibrosis), D (central), E (advanced) and F (very advanced). ...
In patients with Mansoni schistosomiasis, it is fundamental to evaluate the disease morbidity, which is reflected by the severity of periportal fibrosis (PPF) and parameters of portal hypertension, as analyzed by ultrasonography (US). This study aimed to evaluate the morbidity of schistosomiasis by hepatic and splenic point shear-wave elastography (pSWE) and relate this to US parameters. The PPF pattern, the diameter of the portal and splenic veins and the size of the spleen were evaluated by US. Then, liver and spleen pSWEs were assessed in 74 patients using the same equipment. As the PPF pattern progressed, the splenic pSWE values significantly increased. Significant correlations between splenic pSWE, the longitudinal and transverse lengths of the spleen and the diameters of the portal and splenic veins were observed. These findings, however, were not observed through hepatic pSWE. In conclusion, the splenic pSWE has the potential for assessing morbidity in schistosomiasis mansoni.
... Parasitic diseases are rarely encountered in Western Europe and the clinical and imaging features are generally not well known. In the era of worldwide migration and refugees, knowledge of such diseases has gained importance as illustrated by multiple recently published reports about other parasitic diseases including hydatid diseases [1 -5], ascariasis [6], schistosomiasis [7,8], fasciolosis [9], and the other liver flukes clonorchis and opisthorchis [10]. ...
... Allergic bronchopul-b monary aspergillosis may have similar symptoms but takes a more chronic disease. In the case of hepatic involvement with periportal fibrosis and eosinophilia, schistosomiasis should be considered; we refer to recently published reviews [7,8]. ...
Zusammenfassung
Parasitäre Erkrankungen werden in Europa relativ selten diagnostiziert und behandelt. Somit sind auch klinische Besonderheiten und bildgebende Merkmale weniger bekannt. In den heutigen Zeiten von Migration und weltweiter Flüchtlingsströme ist die Kenntnis parasitärer Infektionen zunehmend von Bedeutung. Anhand von klinischen Beschreibungen der Echinokokkose, Schistosomiasis, Fasciolosis und Ascariasis wurden entsprechende Berichte in der Zeitschrift für Gastroenterologie publiziert. In der hier präsentierten Veröffentlichung werden klinische Besonderheiten und Bildgebungsmerkmale der Toxocariasis diskutiert.
... The diagnosis of UGS should be suspected in patients with compatible symptoms (such as haematuria), and/or history of exposure in endemic countries, and should be confirmed by serological, parasitological, radiological and/ or histopathological exams [16]. Ultrasonography is a wellestablished tool to assess advanced schistosomiasis-related morbidity [17][18][19]. ...
... In most cases, subjects with UGS and ultrasound-detectable urinary trait alterations at baseline do not need to undergo any bioptic procedure and may be strictly followed-up with ultrasound after PZQ treatment to assess the improvement of the alterations. In case of worsening or not satisfying improvement of bladder lesions 6 months after antihelmintic treatment, an invasive diagnostic procedure such as a biopsy is advisable to exclude the presence of S. haematobium-associated bladder cancer, as suggested by other authors [18]. ...
Objectives
To evaluate ultrasound and praziquantel to, respectively, assess and reduce urogenital schistosomiasis (UGS)-associated morbidity in migrants from Sub-Saharan Africa (SSA).
Methods
Migrants from SSA with UGS attending three Italian centres for tropical diseases during 2011–2016 were retrospectively enrolled. Data on clinical symptoms, routine laboratory, parasitological tests, and ultrasound reported as per the WHO–Niamey protocol were collected at baseline and at available follow-up visits after treatment with praziquantel 40 mg/kg/day for 3 days.
Results
One hundred and seventy patients with UGS were enrolled and treated with praziquantel. Baseline ultrasonography showed urinary tract abnormalities in 115/169 patients (68%); the mean global Schistosoma haematobium score was 2.29 (SD 2.84, IQR 0–2), the mean urinary bladder intermediate score 1.75 (SD 1.73, IQR 0–2), and the mean upper urinary tract intermediate score 0.54 (SD 2.37, IQR 1–10). Abnormalities were more common among the 111 (65%) who were symptomatic (p < 0.02; OR 2.53; 95% CI 1.19–5.35). Symptoms started in 94/111 (85%) before arriving (median 63 months, IQR 12–119). At follow-up, we observed a significant reduction in the prevalence of UGS-related symptoms, blood, urine, and ultrasound abnormalities.
Conclusions
Our study results support the use of ultrasound and praziquantel for assessing and reducing UGS-associated morbidity in migrants. Health-seeking behaviour, diagnostic, and treatment delays contribute to the advanced pathology and qualified treatment success. To ensure earlier treatment, based on our findings, clinical experience, and available literature, we propose an algorithm for the diagnosis and clinical management of UGS. Multicentre studies are needed to improve the management of subjects with UGS in non-endemic countries.
... Numerous papers and reports have been published on these rare and specialized hepatic lesions. These encompass the characterization of fibrolamellar hepatocellular carcinoma [13,14], very small HCC (<10 mm) [15], mixed HCC and cholangiocellular carcinoma [16], nodular regenerative hyperplasia [17], sarcoma [18], inflammatory pseudotumour [19], sarcoidosis [20][21][22][23], tuberculosis [24,25], hydatid cysts [26][27][28][29], alveolar echinococcosis [27], schistosomiasis [30,31], ascariasis [32,33], fasciolosis [34], clonorchis and opisthorchis [35], toxocariasis [36], bacillary angiomatosis [37], and amyloidosis with spontaneous hemorrhage [38], as well as rare FLLs in pediatric patients [39,40]. More recently rare bacterial [41], parasitic [42], and autoimmune focal liver lesions [43], bile duct lesions [44], other benign FLL [45,46], and FLL other than HCC in the cirrhotic liver [47,48] have been featured as well [41][42][43]49]. ...
The diagnosis or rare, non-hematologic malignant lesions of the liver may be a challenge owing to the rarity of the disease, and is usually made by histological confirmation. Ultrasound with color Doppler and contrast-enhanced, if required, taking into account the clinical background of the patient, may help to focus the differential diagnosis. In this review, we describe the pathological and ultrasound features of rare malignant neuroendocrine and predominantly epithelioid liver lesions including primary neuroendocrine tumor of the liver, Invasive mucinous cystic neoplasm of the liver, and also hepatoblastoma.
... There are also several papers and reports on the uncommon and esoteric hepatic lesions. These include characterization of fibrolamellar hepato-cellular carcinoma [12,13], very small HCC (<10 mm) [14], mixed HCC and cholangiocellular carcinoma [15], nodular regenerative hyperplasia [16], sarcoma [17], inflammatory pseudotumour [18], sarcoidosis [19][20][21][22], tuberculosis [23,24], hydatid cysts [25][26][27][28], alveolar echinococcosis [26], schistosomiasis [29,30], ascariasis [31,32], fasciolosis [33], clonorchis and opisthorchis [34], toxocariasis [35], bacillary angiomatosis [36], and amyloidosis with spontaneous hemorrhage [37], as well as rare FLLs in pediatric patients [38,39] and further published comments and illustrations of the WFUMB CEUS guidelines [40][41][42][43][44][45][46]. ...
The diagnosis or rare mesenchymal malignant lesions of the liver may be a challenge owing to the rarity of the disease and is usually made by histological confirmation. An ultrasound examination with, if required, color Doppler sonography and contrast-enhanced ultrasound, taking into account the clinical background of the patient, may help to focus the differential diagnosis. In this review, we describe the pathological and ultrasound features of several rare mesenchymal malignant liver lesions which include undifferentiated sarcoma of the liver, leiomyosarcoma, angiosarcoma, fibrosarcoma, liposarcoma, and epithelioid hemangioendothelioma.
... However, there is now a wide range of data on rare focal liver lesions, which are only mentioned here as examples. These are of benign [6][7][8] and malignant [4,[9][10][11] origin, mesenchymal [12], vascular [13][14][15], autoimmune [16], sarcoidosis [17][18][19], infectious/parasitic pathogenesis [20][21][22][23][24][25][26][27][28][29], mucinous cystic neoplasms [30], lesions in liver cirrhosis [31,32], hepatic manifestations of amyloidosis [33], hematological diseases [34,35] and in pediatric patients [36]. ...
In this series of articles with comments and illustrations on the World Federation for Medicine and Biology (WFUMB) guidelines on contrast-enhanced ultrasound (CEUS) the topics of very rare focal liver lesions (FLL) are discussed. Improving the detection and characterization of the most common FLL are the main topics of these guidelines. The focus of this review is on the many manifestations of cystic fibrosis-related liver disease (CFLD). These include focal biliary fibrosis, liver cirrhosis, vascular manifestations with nodular regenerative hyperplasia and portal hypertension with or without cirrhosis. This article describes the diverse changes of liver involvement in cystic fibrosis and their appearance on ultrasound, duplex sonography, and contrast enhanced ultrasonography. This knowledge and the imaging should help to recognize liver manifestations in time and enable a correct interpretation of ultrasound images in CF in the corresponding clinical situation.
... For a large number of rare focal liver lesions (FLL), data already exist. Examples are nodular regenerative hyperplasia [6], inflammatory pseudotumour [7], peliosis [8][9][10], sarcoidosis [11][12][13][14], cholangiocellular adenoma [15], cystadenoma and cystadenocarcinoma [16], hemangioendothelioma [17,18], hepatocellular carcinoma (HCC) in the non-cirrhotic liver [19], fibrolamellar hepatocellular carcinoma [20,21], mixed HCC and cholangiocellular carcinoma [22], very small HCC (<10 mm) [23], sarcoma [24], tuberculosis [25,26], hydatid cysts [27][28][29][30], alveolar echinococcosis [28], schistosomiasis [31,32], ascariasis [33,34], fasciolosis [35], clonorchis and opisthorchis [36], toxocariasis [37], bacillary angiomatosis [38], amyloidosis with spontaneous hemorrhage [39], as well as rare FLLs in pediatric patients [40,41]. ...
In this series of articles on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast-enhanced ultrasound (CEUS), the topics on very rare focal liver lesions (FLL) are discussed. This article describes the diverse changes of focal liver lesions in peliosis hepatis and the typical changes in porphyria. Although the focus is on the appearance on ultrasound and CEUS, the clinical context is always considered. While peliosis may be a surprising finding on puncture, lesions in porphyria cutanea tarda may be typical visual diagnoses that obviate the need for biopsy. If only you knew. This article aims to sharpen the clinician’s eye. It provides knowledge of the clinical presentation and US and CEUS imaging of peliosis hepatis and porphyria.
... There are also several papers and reports on the uncommon and more esoteric hepatic lesions. These include characterization of fibrolamellar hepatocellular carcinoma [16,31], very small HCC (<10 mm) [32], mixed HCC and cholangiocellular carcinoma [33], nodular regenerative hyperplasia [34], sarcoma [35], inflammatory pseudotumour [36], sarcoidosis [37][38][39][40], tuberculosis [41,42], hydatid cysts [43][44][45][46], alveolar echinococcosis [44], schistosomiasis [47,48], ascariasis [49,50], fasciolosis [51], clonorchis and opisthorchis [52], toxocariasis [53], bacillary angiomatosis [54], amyloidosis with spontaneous hemorrhage [55], and portal venous gas accumulation [20] as well as rare FLLs in pediatric patients [56,57]. ...
It is important to be familiar with the typical imaging features of the uncommon or even extremely rare focal liver lesions (FLL). Current guidelines of the World Federation for Ultrasound in Medicine and Biology (WFUMB) is aimed at assessing the usefulness of contrast enhanced ultrasound (CEUS) in the management of various FLL. In this review, we aim to summarize the ultrasound and CEUS characteristics with literature review of some extremely rare benign FLL, which might be helpful for improving diagnostic efficiency clinically
... There are also several papers reporting on the rare and more esoteric hepatic lesions. These papers include characterization of fibrolamellar hepatocellular carcinoma [16,31], very small HCC (<10 mm) [32], mixed HCC and cholangiocellular carcinoma [33], nodular regenerative hyperplasia [34], sarcoma [35], inflammatory pseudotumour [36], sarcoidosis [37][38][39][40], tuberculosis [41,42], hydatid cysts [43][44][45][46], alveolar echinococcosis [44], schistosomiasis [47,48], ascariasis [49,50], fasciolosis [51], clonorchis and opisthorchis [52], toxocariasis [53], bacillary angiomatosis [54], amyloidosis with spontaneous hemorrhage [55], and portal venous gas accumulation [20] and rare FLLs in pediatric patients [56,57]. ...
Improved detection and characterization of common focal liver lesions (FLL) are the main topics of the World Federation for Ultrasound in Medicine and Biology (WFUMB) guidelines on the use of contrast-enhanced ultrasound (CEUS). On stateof-the-art CEUS imaging, to create a library of rare FLL, especially concerning their atypical imaging characteristics, might be helpful for improving clinical diagnostic efficiency. In this review, we aim to summarize the ultrasound and CEUS features of rare benign FLL. Currently there are limited reports and images published.
... These scores (IP, PT, and PH) are interpreted using a table that classifies the periportal fibrosis as follows: group 1 (no sign of periportal fibrosis), group 2 (incipient periportal fibrosis not excluded), group 3 (possible periportal fibrosis), group 4 (probable periportal fibrosis), group 5 (periportal fibrosis), group 6 (advanced periportal fibrosis), and group 7 (advanced periportal fibrosis + portal hypertension). This method has been used in several previous studies (19)(20)(21)(22)(23). ...
This is a case series study to evaluate immunological markers associated with schistosomiasis advanced fibrosis, including 69 patients from an endemic area from the State of Sergipe and from the Hepatology Service of the University Hospital in Sergipe, Brazil. Hepatic fibrosis was classified based on Niamey protocol for ultrasonography (US). Immune response to Schistosoma mansoni antigens was evaluated by stimulating peripheral blood mononuclear cells (PBMCs) from these patients with either adult worm (SWAP—10 μg/ml) or egg (SEA—10 μg/ml) antigens or purified protein derivative of turberculin (PPD—10 μg/ml) or phytohemagglutinin (PHA—1 μg/ml) for 72 h. The levels of IFN-γ, TNF-α, IL-5, IL-10, and IL-17 were measured in these supernatants by ELISA and IL-9 by Luminex. Single nucleotide polymorphisms in IL-17, IL10, and CD209 genes were genotyped using TaqMan probe by qPCR. Higher levels of IL-9, IL-10, and IL-17 were found in PBMC supernatants of patients with advanced hepatic fibrosis. Direct correlations were detected between IL-9 and IL-17 levels with US spleen sizes, portal vein diameters, and periportal thickening. The CD209 rs2287886 AG polymorphism patients produce higher IL-17 levels. Together, these data suggest a role of these cytokines in the immunopathogenesis of advanced fibrosis in human schistosomiasis.
... The degree of calcification depends on the number of calcified eggs in the bladder wall: therefore, late-stage chronic schistosomiasis leads to extensive bladder calcifications [39]. US is less sensitive than X-rays and CT in the detection of urinary schistosomiasis [40]; a typical pathognomonic pattern of chronic schistosomiasis may be shown with a pelvic radiograph, in which the image of a calcified bladder may resemble a fetal head in the pelvis [39]. There are also others described in the literature, represented by granular, linear, or irregular calcification, easily detectable with CT scan [39]. ...
Schistosomiasis is one of the most important parasitic diseases and it is endemic in tropical and subtropical areas. Clinical and laboratory data are fundamental for the diagnosis of schistosomiasis, but diagnostic imaging techniques such as x-rays, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT) may be helpful in the evaluation of disease severity and complications. In this context, the aim of this review is to explore the actual role of diagnostic imaging in the diagnosis of schistosomiasis, underlining advantages and drawbacks providing information about the utilization of diagnostic imaging techniques in this context. Furthermore, we aim to provide a useful guide regarding imaging features of schistosomiasis for radiology and nuclear medicine physicians of non-endemic countries: in fact, in the last years non-endemic countries have experienced important flows of migrants from endemic areas, therefore it is not uncommon to face cases of this disease in daily practice.
... On the other hand, increasing numbers of immigrants from high prevalence countries challenge clinicians to remain updated in infectious diseases. Our working group has summarized the imaging features of parasitic diseases, including hydatid cysts [1][2][3][4][5][6], schistosomiasis [7,8], fascioliasis [9] and other important intestinal diseases reported rarely in Europe which may mimic parasitic diseases [10][11][12][13][14]. Here we present the current knowledge and imaging of ascaris infection including clinical features and hot topics in ascariasis. ...
Ascariasis no longer widespread within Europe and so experience in diagnosis and treatment is limited for many specialists. On the other hand, clinicians face increasing numbers of migrants from high prevalence countries and are therefore, challenged to update in this field of infectious diseases. Here we present imaging features and current knowledge of this infection.
... Although in our environment HSS is a rare cause of chronic liver disease with pHTN, it is important to know its ultrasonographic features as they play a crucial role in its diagnosis (2,3). In addition to this, ultrasound study findings correlate with the severity of the disease and can be used to monitor the evolution of the process following antischistosomiasis therapy (3). ...
Hepatosplenic schistosomiasis (HSS) is a major cause of chronic liver disease with portal hypertension (pHTN) in Africa, Asia and America. Abdominal ultrasound is essential in its diagnosis.
... Abdominal ultrasound is the recommended imaging examination to rule out lesions and complications due to schistosomiasis such as abnormalities in the urinary or the hepatobiliary tracts [14][15][16][17][18]. The prevalence of such conditions is much higher in patients whose diagnosis is based on direct microbiological findings compared to those presenting with positive serology but no other data suggesting active infection [2]. ...
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.
... Parasitic diseases are rarely encountered in Europe and the clinical and imaging features are generally not well known. In the era of worldwide migration and refugees, knowledge of such diseases has gained importance as illustrated by multiple recently published reports of hydatid diseases [1][2][3][4][5], schistosomiasis [6,7], fasciolosis [8], ascariasis [9], liver flukes [10], toxocariasis and other rare intestinal diseases [11,12]. This article describes the clinical and imaging features along with current treatment strategies for filariasis. ...
Lymphatic filariasis is an infection transmitted by blood-sucking mosquitoes with filarial nematodes of the species Wuchereria bancrofti, Brugia malayi und B. timori. It is prevalent in tropical countries throughout the world, with more than 60 million people infected and more than 1 billion living in areas with the risk of transmission. Worm larvae with a length of less than 1 mm are transmitted by mosquitoes, develop in human lymphatic tissue to adult worms with a length of 7–10 cm, live in the human body for up to 10 years and produce millions of microfilariae, which can be transmitted further by mosquitoes. The adult worms can be easily observed by ultrasonography because of their size and fast movements (the so-called “filarial dance sign”), which can be differentiated from other movements (e. g., blood in venous vessels) by their characteristic movement profile in pulsed-wave Doppler mode. Therapeutic options include (combinations of) ivermectin, albendazole, diethylcarbamazine and doxycycline. The latter depletes endosymbiotic Wolbachia bacteria from the worms and thus sterilizes and later kills the adult worms (macrofilaricidal or adulticidal effect).
... b Introduction Parasitic diseases are rarely nowadays encountered in Europe and the clinical and imaging features are generally not well known. In the era of worldwide migration, knowledge of such diseases has gained importance as illustrated by multiple recently published reports of hydatid diseases [1 -3], schistosomiasis [4,5], fasciolosis [6], and ascariasis [7]. Herewith we describe the clinical and imaging features and current treatment strategies of infections by the "small liver flukes": Clonorchis sinensis (Chinese or oriental liver fluke), Opisthorchis viverrini (Southeast Asian liver fluke) and Opisthorchis felineus (cat liver fluke), and other Opisthorchis species prevalent in South Asia. ...
Parasitic diseases are relatively rarely diagnosed and treated in Europe. Therefore, European clinicians are not familiar with their clinical and imaging features. In an era of increased human migration, it is fundamental for clinicians to be able to identify such diseases. We have recently described the features of cystic echinococcosis, schistosomiasis, fascioliasis and ascariasis. Here, we report on the clinical and imaging features as well as on the current therapy options of infections by the small liver flukes: Clonorchis sinensis, Opisthorchis viverrini (Southeast Asian liver fluke) and Opisthorchis felineus (cat liver fluke) and other Opisthorchis species prevalent in South Asia.
© Georg Thieme Verlag KG Stuttgart · New York.
... Significant growth, the development of progressive symptoms, or any suspicion of neoplastic change requires a definite diagnosis and surgical intervention. Other parasitic liver manifestations occasionally need to be considered in the differential diagnosis [56][57][58]. ...
The introduction of imaging techniques in clinical practice 40 years ago changed the clinical management of many diseases, including cystic echinococcosis (CE). For the first time cysts were clearly seen before surgery. Among the available imaging techniques, ultrasound (US) has unique properties that can be used to study and manage cystic echinococcosis. It is harmless, can image almost all organs and systems, can be repeated as often as required, is portable, requires no patient preparation, is relatively inexpensive and guides diagnosis, treatment and follow-up without radiation exposure and harm to the patient. US is the only imaging technique which can be used in field settings to assess CE prevalence because it can be run even on solar power or a small generator in remote field locations. Thanks to US classifications, the concept of stage-specific treatments was introduced and because US is repeatable, the scientific community has gained a clearer understanding of the natural history of the disease. This paper reviews the scope of US in CE, describes its strengths and weaknesses compared to other imaging techniques and its relationship with serodiagnosis and discusses sonographic features that may be helpful in differential diagnosis.
... Diagnosis and management of schistosomiasis using imaging modalities have mostly been performed using ultrasound (US). The US is an effective imaging method that is frequently used to assess the morbidity associated with infection with Schistosoma mansoni and S. heamatobium and to monitor the changes of fibrosis in the liver, splenomegaly, and dilated main portal vein (PV) and splenic vein (SV) following chemotherapeutic treatment for schistosomiasis [10,11]. ...
Purpose
To assess the effect of praziquantel (PZQ) treatment on liver echotexture and diameters of the portal and splenic veins.
Materials and methods
This was a prospective study involving 86 known cases of schistosomiasis; these cases were examined via gray-scale sonography in 3-month intervals for a period of 6 months. The patients were categorized into two groups based on whether or not they were treated with PZQ. The liver, spleen, main portal vein (PV), and splenic vein (SV) were evaluated sonographically using 3.5-curvilinear transducers, according to a standard abdominal ultrasound protocol.
Results
The liver echotexture and size were significantly recovered in patients who received PZQ therapy compared to those who did not use the drug (p-values < 0.001). PZQ caused significant reduction in diameters of the PV and SV (p-value <0.001). Conclusion: Liver size and echotexture and diameters of PV and SV improved well as a result of Praziquantel therapy in patients with chronic Schistosoma infection. Treatment of Schistosomiasis is necessary to prevent liver cirrhosis and portal hypertension.
... On the other hand, clinicians are facing an increasing number of immigrants from high-prevalence countries and are, therefore, challenged to update in this field of infectious diseases. Our working group has summarized imaging features of parasitic diseases including hydatid cysts [1 -5], schistosomiasis [6,7], fascioliasis [8], and other important intestinal diseases reported rarely in Europe, which may mimic parasitic diseases [9 -13]. ...
Ascariasis is not widespread in Europe, and the knowledge on how to diagnose and treat the disease is limited to some specialists. On the other hand, clinicians are facing an increasing number of immigrants from high-prevalence countries and are, therefore, challenged to update in this field of infectious diseases. Here we present current knowledge on this infection in 2 parts. The first part discusses clinical features and hot topics in ascariasis, and the second part presents imaging features of ascariasis as a pictorial essay.
© Georg Thieme Verlag KG Stuttgart · New York.
... This protocol was derived from the WHO's Niamey ultrasound protocol, widely used in prevalence studies, but not validated as a clinical tool for morbidity assessment in individual patients presenting with symptoms of S. haematobium infection. With the increasing availability of low-cost ultrasound in endemic areas, this approach could provide a point-of-care morbidity detection tool that could allow better definition of the risk of early childhood pathology (Belard et al. 2016;Richter et al. 2016). ...
Early in the history of schistosomiasis research, children under 5 years of age were known to be infected. Although this problem was recognized over 100 years ago, insufficient action has been taken to address this issue. Under current policy, such infected children only receive their first antiparasitic treatment (praziquantel – PZQ) upon entry into primary school as current mass drug administration programmes typically target school-aged children. For many infected children, they will wait up to 6 years before receiving their first medication and significant schistosomiasis-related morbidity may have already established. This inequity would not be accepted for other diseases. To unveil some of the reasons behind this neglect, it is paramount to understand the intricate historical relationship between schistosomiasis and British Imperial medicine, to underline its lasting influence on today's public health priorities. This review presents a perspective on the historical neglect of paediatric schistosomiasis, focusing on important gaps that persist from the early days after discovery of this parasite. Looking to end this inequity, we address several issues that need to be overcome to move forward towards the lasting success of schistosomiasis control and elimination efforts.
... In settings where control of morbidity is the main goal of public health interventions, the most widely used criteria to determine it is the measurement of egg counts and urine analyses for hematuria and proteinuria, as indirect signs of UT impairment [3,12]. However, obviously a more accurate and specific evaluation of the organ pathology should be the way to follow [12,[21][22]. Ultrasound examination allows to assess the damage of bladder wall and genito-urinary tract, which in combination with parasitological results and urine analyses are good indicators of consequences of chronic infection [4,12,13]. Ultrasonography has been applied since the '70s [21] for schistosomiasis to detect and describe the morphology of lesions. ...
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.
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; 10 (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.
Schistosomiasis is a neglected, tropical, vector-borne, water-borne disease caused by helminth parasites of the genus Schistosoma. It is globally distributed, still reported from 78 countries, and estimated to affect over 200 million people. Schistosomes have complex life cycles, entailing snail intermediate hosts; some schistosome species have animal reservoirs, which makes public health control more challenging. Humans contract the infection following contact with freshwater contaminated with larval stages of the parasite. Morbidity is mainly caused by granulomatous reactions to the parasite's eggs trapped in organ tissues and the resulting fibrosis. Two main clinical forms exist: intestinal and urinary (or urogenital) schistosomiasis. Detection of parasite eggs in the stool and urine is the gold standard for diagnosis, although a wide range of tests and diagnostic techniques have been developed and are available. The anthelminthic praziquantel is the treatment of choice against all the species of schistosomes. Its mass administration at regular intervals to populations living in endemic areas (preventive chemotherapy) is the mainstay of WHO's strategy for public health control of schistosomiasis, with over 105 million treated in 2019. Snail control, access to water and sanitation, environmental management, health education, chemoprophylaxis and treatment of animal reservoir are complementary public health interventions. No vaccine is currently available. The new road map for neglected tropical diseases 2021–30 lists schistosomiasis among the diseases targeted for elimination as a public health problem by 2030.
Schistosomiasis affects nearly 250 million individuals in the world. Hepatosplenic schistosomiasis (HSS) results in periportal fibrosis (PPF) and portal hypertension (pHTN). Ultrasound has been extensively used for the diagnosis of Schistosoma‐related PPF and a number of staging methods have been validated for this purpose such as Strickland classification and Niamey protocol. Nevertheless, the application of noninvasive techniques, particularly elastography modalities, has not been well explored. In this review, we describe the various noninvasive diagnostic tools for assessment of Schistosoma‐related PPF including US parameters, serum biomarkers, and US‐based elastography techniques. While elastography techniques have demonstrated value in the evaluation of HSS, the evidence remains limited with most studies recruiting a small number of patients. Longitudinal studies with larger sample size are required in order to devise robust criteria to accurately assess the performance of noninvasive techniques in the prediction f of both regression and progression of the degree of PPF and identify their cost‐effectiveness in community screening.
Several imaging modalities have now been employed to visualize the manifestations of larval Toxocara infection in hepatic, neurologic, ocular, renal, and other anatomical sites. This report reviews the usefulness and value of these individual imaging methods in diagnosis and follow-up of the different cases causing eosinophilic (granulomatous) infiltrations the liver, lungs, brain, heart, and eyes. Imaging provides a means of assisting in diagnosis and management in this infection where diagnosis by biopsy is often unlikely to capture an actual larva for the purpose of making a definitive diagnosis on the basis of larval morphology or DNA detection.
The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation in clinical practice (long version).
© Georg Thieme Verlag KG Stuttgart · New York.
The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation in clinical practice (long version).
Schistosomiasis haematobia is among the most prevalent parasitosis in Angola. The pathology is characterized by serious and irreversible lesions in the urogenital tract induced by chronic infection with the parasite that can eventually lead to squamous cell carcinoma of the bladder. Considering the frequency and severe morbidity observed, even in younger ages, the purpose of this study was to assess the prevalence and morbidity of S. haematobium infection in Angola. A baseline survey was conducted between November 2007 and February 2008. A randomly sample of 300 inhabitants aged 15 to 75 years old participated in this study. Prevalence of S. haematobium infection was 71.7 % (215/300). Infection was higher in females (56.3 %) but no significant difference was found in prevalence and intensity between gender and age groups. The predominant selfreported symptoms were dysuria (91.2 %), hypogastralgia (88.7 %) and haematuria (87.1%) and these symptoms were strongly associated with S. haematobium infection (p<0.05). Ultrasound and cystoscopy examinations performed in a sub-sample of 29 individuals revealed pathological conditions at the urinary tract in all examined. Considering the high prevalence of S. haematobium infections in Angola and schistosomiasis-associated bladder cancer, our results indicate that this population should be targeted for follow up and implementation of measures for treatment and control of schistosomiasis.
Liver diseases are common in inhabitants and migrants of tropical countries, where the liver can be exposed not only to toxins but also to many viral, bacterial, fungal, and parasitic infections. Schistosomiasis-a common parasitic infection that affects at least 240 million people worldwide, mostly in Africa-is regarded as the most frequent cause of liver fibrosis worldwide. We present a case of a 19-year-old male refugee from Guinea with recurrent oesophageal variceal bleeding due to schistosomal liver fibrosis refractory to endoscopic therapy. This case was an indication for portosystemic surgery, which is a highly invasive non-reversible intervention. An alternative, less invasive, reversible radiological procedure, used in liver cirrhosis, is the placement of a transjugular intrahepatic portosystemic shunt (TIPS). After thorough considerations of all therapeutic options we placed a TIPS in our patient. In more than 3 years of observation, he is clinically well apart from one episode of hepatic encephalopathy related to an acute episode of viral gastroenteritis. Bleeding from oesophageal varices has not recurred. In this Grand Round, we review the diagnostic approaches and treatment options for portal hypertension due to schistosomal liver fibrosis.
Copyright © 2015 Elsevier Ltd. All rights reserved.
In 2000, the World Health Organization (WHO) published an ultrasound field protocol for assessing morbidity due to schistosomiasis. The present study aims to review the acceptance of the WHO protocol for Schistosoma haematobium. A PubMed literature research using the keywords “ultrasound OR ultrasonography (US) AND schistosomiasis,” “US AND S. haematobium,” “US AND urinary schistosomiasis” from 2001 through 2014 was performed. Thirty-eight eligible publications reporting on 17,861 patients from 13 endemic and 2 non-endemic countries were analysed. Of these, 33 referred to field studies on 17,317 patients. The Niamey protocol was applied to 15,367/17,317 (88.74 %) patients in 23/33 (69.70 %) of field studies (all studies: 15,649/17,861 [87.61 %] patients (25/38 [68.42 %] studies). The acceptance of the protocol by single country in field studies varied from 0 to 100 %. It varied over time between 55.56 % (5/9) in the period from 2001 to 2004, to 87.50 % (7/8) from 2005 to 2008, to 62.50 % (5/8) from 2009 to 2011 and 75.00 % (6/8) from 2012 through 2014 (all studies: 50 % [5/10], 88.89 % [8/9], 62.50 % [5/8], 63.64 % [7/11], respectively). The Niamey protocol was applied also in 2/5 hospital studies in 282/544 (51.84 %) patients.
The usefulness of the WHO protocol for S. haematobium infections is confirmed by its worldwide acceptance. Some simplifications might facilitate its use also for focused ultrasound examinations performed by less skilled examiners. Organ abnormalities due to schistosomiasis detectable by ultrasonography not yet covered by the WHO protocol should be added to the additional investigations section.
Schistosomiasis affects more than 240 million people worldwide, an infection which may cause urogenital manifestations including, among others, squamous bladder cancer and prostate involvement. We describe the first case of a prostate adenocarcinoma associated with prostatic Schistosoma haematobium infection occurring in Angola. Prostate carcinoma was suspected because of high levels of prostate-specific antigen. This observation prompted us to review the literature on schistosomiaisis with respect to genital pathology and prostate cancer. Described genital manifestations in men include funiculitis, epididymitis, granulomata of the seminal vesicles, testicular masses, and prostate lesions which may cause haematospermia and infertility. In contrast to bladder cancer, only 12 reports including the present case on 17 cases on prostate carcinoma associated with schistosomiasis have been published worldwide. The rarity of reports on prostate carcinoma associated with schistosomiasis is partly due to diagnostic constraints, and its incidence is underestimated. However, in emerging countries, the incidence of prostate cancer appears to increase mainly as a result of urbanization and improved access to health care where schistosomiasis prevalence is decreasing.
Ultrasound is often the first imaging procedure performed in the evaluation of individuals with suspected or known liver disease. Despite technical advances in ultrasound techniques, sonographic detection and evaluation of diffuse liver disease still remains difficult. This is due to the fact that diffuse liver disease does not always cause distortion of the liver parenchymal texture, internal liver architecture, or shape of the liver. On the other hand, the size of the liver, the echo pattern of the hepatic parenchyma, the analysis of intrahepatic vessels and alterations in perihepatic structures and lymph nodes can be helpful sonographic parameters of diffuse liver disease. Until now, the sonographic appearance of some rare diffuse liver diseases is not well known. However, there are some typical sonomorphological signs that, once identified, can facilitate the differentiation between various diseases. The aim of this paper is to highlight some typical ultrasound findings of liver parenchyma and perihepatic lymph node structures in rare diffuse liver diseases based on a review of published data.
Abstract The aim of this study is to investigate renal involvement in schistosomiasis. This is a retrospective cohort of 60 consecutive patients with schistosomiasis admitted to a university hospital in Maceió, Brazil. The patients were divided into 2 groups: patients with and without acute kidney injury (AKI) according to the RIFLE criteria. We compared the groups for differences in clinical manifestations and laboratory tests. Patients' mean age was 58 ± 16 yr, and 56.7% were female. The average length of hospital stay was 16.4 ± 12.1 days. Patients with hypertension and diabetes were 35% and 21.7% respectively. The main clinical symptoms and signs presented were: ascites (86.7%), splenomegaly (80%) and hepatomegaly (63.3%). Current or previous history of upper gastrointestinal bleeding was found in 45% of patients, esophageal varices on endoscopy were present in 92% and periportal fibrosis on ultrasound examination in 81% of patients. AKI incidence was 43.3% during hospital stay. Mean age and length of hospitalization were higher in the AKI group. Diuretic use, such as furosemide and spironolactone, ascites and AST levels were also associated with AKI. Death occurred in 5 cases (8.5%); 4 of them in the AKI group. The classifications CHILD and MELD presented higher scores among patients with AKI (CHILD: 9.5 ± 1.5 vs. 8.4 ± 1.7, p=0.02; MELD: 19 ± 5.8 vs. 13 ± 3.9, p<0.001). Renal dysfunction is an important feature of schistosomiasis, which is associated with significant morbidity and possible increased mortality. Further studies are necessary to establish the mechanisms through which schistosomiasis can lead to renal dysfunction.
Intestinal ultrasound has become an established and valid diagnostic method for inflammatory bowel disease, diverticulitis, appendicitis, bowel obstruction, perforation and intussusception. However, little is known about sonographic findings in other rarer intestinal diseases. Ultrasound may display the transformation of the intestinal wall from a normal to a pathological state both in inflammatory and neoplastic disease. Besides demonstrating the transmural aspect, it also shows the mesenteric reaction as well as complications such as fistula, abscesses, stenosis, or ileus. Furthermore, in some diseases intestinal ultrasound may serve as a diagnostic clue if typical patterns of the bowel wall and impaired peristalsis can be demonstrated. This may lead to an important reduction of invasive and expensive (follow-up) procedures. The information gained by ultrasound regarding intestinal disease, however, is as important and valid as e. g. in case of focal lesions of the liver. Serving as tertiary referral centers for a broad spectrum of intestinal diseases, we therefore report some aspects of ultrasound in patients with less often recognized diseases. The article is divided into two parts, the first focusing on examination techniques, infectious diseases and celiac sprue and the second on hereditary, vascular and neoplastic diseases and varia.
© Georg Thieme Verlag KG Stuttgart · New York.
The aim of this study is to review the worldwide acceptance of the World Health Organization (WHO) ultrasound protocol for assessing hepatosplenic morbidity due to Schistosoma mansoni since its publication in 2000. A PubMed literature research using the keywords "schistosomiasis and ultrasound," "schistosomiasis and ultrasonography," and "S. mansoni and ultrasound" from 2001 to 2012 was performed. Case reports, reviews, reports on abnormalities due to parasites other than S. mansoni, organ involvement other than the human liver, and reports where ultrasound method was not described were excluded. Six studies were retrieved from other Brazilian sources. Sixty studies on 37,424 patients from 15 countries were analyzed. The WHO protocol was applied with increasing frequency from 43.75 % in the years 2001 to 2004 to 84.61 % in 2009 to 2012. Results obtained using the pictorial image pattern approach of the protocol are reported in 38/41 studies, whereas measurements of portal branch walls were applied in 19/41 and results reported in 2/41 studies only. The practical usefulness of the pictorial approach of the WHO protocol is confirmed by its wide acceptance. This approach alone proved satisfactory in terms of reproducibility, assessment of evolution of pathology, and comparability between different settings. The measurements of portal branches, also part of the protocol, may be omitted without losing relevant information since results obtained by these measurements are nonspecific. This would save resources by reducing the time required for each examination. It is also more feasible for examiners who are not specialized in medical imaging. As with all protocols, incipient liver fibrosis is difficult to distinguish from normal ultrasound findings of the liver. The ability of this protocol to predict complications in severe cases should be further evaluated in a higher number of patients.
Sarcoidosis is a complex granulomatous disease that affects virtually every organ and tissue, with a prevalence that varies significantly among the sites involved. The role of conventional imaging, such as computed tomography and magnetic resonance imaging, in the assessment of hepatosplenic sarcoidosis is well established by revealing organ enlargement, multiple discrete nodules, and lymphadenopathy. In this review, we aim to describe contrast-enhanced ultrasound (CEUS) findings in liver and spleen involvement by sarcoidosis, reporting evidence from the literature and cases from our experience, after a brief update on safety profile, cost-effectiveness, and clinical indications of this novel technique. Furthermore, we highlight potential advantages of CEUS in assessing hepatosplenic sarcoidosis that may be useful in the clinical practice.
Acute appendicitis associated to Schistosoma haematobium and S. mansoni infection has been found in patients submitted to urgent appendectomy at the Hospital Américo Boavida in Luanda. Due to the high prevalence and morbidity caused by schistosomiasis (or bilharziasis) in the country, we suspect that the involvement of Schistosoma infection on appendicular pathology could be very frequent, in particular for those individuals more exposed to the parasite transmission. We report two clinical cases of acute appendicitis whose surgical specimens of the appendix revealed S. haematobium and S. mansoni eggs in histological samples. The reported patients live in endemic areas and have been exposed to schistosome during childhood, which may explain the infection's chronicity. Information of these clinical cases could be relevant, particularly for surgery specialists and clinical pathologists, due to the possibility of finding more patients with concurrent appendicitis and schistosomiasis.
A 12 year-old boy in Germany developed urinary schistosomiasis in January 2014. He had bathed in rivers in south-eastern Corsica five months earlier. Before this case, human schistomiasis had not been reported on the island, although its vector, the snail Bulinus truncatus, locally transmitted the zoonotic Schistosoma bovis. The boy’s father excreted S. haematobium ova that were not viable; the boy’s three siblings had a positive serology against schistosomes.
Background and aims:
The introduction of a new type of small handheld ultrasound device brings greater portability and affordability. The basic ultrasound approach with these handheld devices has been defined by European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) as "EchoScopy". The current study aimed to assess the image quality, indications and limitations of a portable pocket "EchoScope" compared with a high-end ultrasound system in abdominal diseases.
Methods:
231 consecutive patients were included in this study. Physician A performed ultrasound examinations with a high-end ultrasound system (HEUS), then physician B performed the same ultrasound examination using an EchoScope (Vscan™). In patients with focal lesions, physician B also measured the largest diameters and graded the vascularity by using colour Doppler imaging (CDI) within the lesion on the same plane with both ultrasound systems. Compared with the excellent image quality using HEUS, the image quality of the EchoScope was graded as good, sufficient or non-sufficient.
Results:
Out of all 231 patients, 167 had focal lesions, 19 patients were found with diffuse pathological findings, six with ascites, six after liver puncture and 33 without any pathological findings. The image quality of the pocket device was considered as being good or sufficient to delineate the pathology in 225/231 (97.4 %). The detection rate of the EchoScope for abdominal focal lesion was 162/167 (97 %), only five superficially located lesions could not be detected. Both systems showed agreement in determination of the best positioning to perform abdominal paracentesis and assessing complications after intervention.
Conclusions:
The investigated EchoScope displays a sufficient image quality, in some indications such as detection of focal lesions > 20 mm, detection of ascites, hydronephrosis and other pathological findings with comparable results to HEUS. We conclude that pocket sized EchoScopy devices have a promising future but the indications have to be determined by a prospective study.
There is a wealth of immunologic studies that have been done in experimental and human schistosomiasis that can be classified into three main areas: immunopathogenesis, resistance to reinfection, and diagnostics. It is clear that the bulk of, if not all, morbidity due to human schistosomiasis results from immune response-based inflammation against eggs lodged in the body, either as regulated chronic inflammation or resulting in fibrotic lesions. However, the exact nature of these responses, the antigens to which they are mounted and the mechanisms of the critical regulatory responses are still being sorted out. It is also becoming apparent that protective immunity against schistosomula as they develop into adult worms develops slowly and is hastened by the dying of adult worms, either naturally or when they are killed by PZQ. However, as with anti-egg responses, the responsible immune mechanisms and inducing antigens are not clearly established, nor are any potential regulatory responses known. Finally, a wide variety of immune markers, both cellular and humoral, can be used to demonstrate exposure to schistosomes, and immunologic measurement of schistosome antigens can be used to detect, and thus diagnose, active infections. All three areas contribute to the public health response to human schistosome infections. This article is protected by copyright. All rights reserved.
Recently the European Federation of Societies for Ultrasound in Medicine and Biology Guidelines and Recommendations have been published assessing the clinical use of ultrasound elastography. The document is intended to form a reference and to guide clinical users in a practical way. They give practical advice for the use and interpretation. Liver disease forms the largest section, reflecting published experience to date including evidence from meta-analyses with shear wave and strain elastography. In this review comments and illustrations on the guidelines are given.
The AIM of the paper is to introduce readers to EFSUMB's wide ranging activities which have embraced modern technology. The most recent is the Atlas www.efsumb-atlas.org primarily introduced to accompany the Elastography, CEUS Liver and Non Liver Guidelines but intended to expand to all areas to offer a database of images which can be freely downloaded. Hosting eBooks on our website is another new departure, most importantly the EFSUMB Course Book on Ultrasound which is also in a printed form but allowing chapters to be updated online, an online Student Edition of the ECB to be launched at EUROSON 2013. EFSUMB has been active with updating Guidelines; those mentioned above have all been revised or written in the last two years. The EFSUMB Newsletter in the EJU promotes our activities and topical articles intended to reach all our members with the mailing of Issue 1. The Case of the Month continues to be one of EFSUMB's most visited sites and in the last few years has been translated into seven different languages including Chinese. IN CONCLUSION this article aims to provide a guide to the website educational sites of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB).
This study examined the hypothesis that the nature of the host cellular immune response to schistosome ova is a risk factor
for urinary tract morbidity in areas in which Schistosoma haematobium is endemic. S. haematobium–infected children and adolescents with bladder pathology assessed by ultrasonography had 54-fold greater tumor necrosis factor
(TNF)–α production and a 120-fold greater ratio of TNF-α to interleukin (IL)–10 release by peripheral blood mononuclear cells
in response to egg antigens, in comparison with control children and adolescents matched by age, sex, and infection severity.
Mycobacterial antigens also stimulated 7-fold more TNF-α among subjects with bladder morbidity than in control subjects, which
suggests an innate predisposition to enhanced TNF-α production. Levels of egg antigen–induced IL-4 and -5 and interferon-γ
were equivalent in subjects with and without bladder pathology. Thus, children and adolescents predisposed to increased TNF-α
production to S. haematobium infection are more likely to develop an exaggerated granulomatous response to ova trapped in the bladder wall, with associated
urinary tract pathology
After praziquantel treatment for schistosomiasis, parasitological cure rates of 60%-90% are usual. Does this response to treatment correlate with the improvement in liver and bladder changes seen on ultrasound in children? This study shows that ultrasound is an effective way to evaluate liver and bladder changes caused by schistosomiasis infection in children and to assess treatment effects after mass treatment programmes.
The clinical part of these Guidelines and Recommendations produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology EFSUMB assesses the clinically used applications of all forms of elastography, stressing the evidence from meta-analyses and giving practical advice for their uses and interpretation. Diffuse liver disease forms the largest section, reflecting the wide experience with transient and shear wave elastography . Then follow the breast, thyroid, gastro-intestinal tract, endoscopic elastography, the prostate and the musculo-skeletal system using strain and shear wave elastography as appropriate. The document is intended to form a reference and to guide clinical users in a practical way.
The technical part of these Guidelines and Recommendations, produced under the auspices of EFSUMB, provides an introduction to the physical principles and technology on which all forms of current commercially available ultrasound elastography are based. A difference in shear modulus is the common underlying physical mechanism that provides tissue contrast in all elastograms. The relationship between the alternative technologies is considered in terms of the method used to take advantage of this. The practical advantages and disadvantages associated with each of the techniques are described, and guidance is provided on optimisation of scanning technique, image display, image interpretation and some of the known image artefacts.
Initially, a set of guidelines for the use of ultrasound contrast agents was published in 2004 dealing only with liver applications. A second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some non-liver applications. Time has moved on, and the need for international guidelines on the use of CEUS in the liver has become apparent. The present document describes the third iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS) using contrast specific imaging techniques. This joint WFUMB-EFSUMB initiative has implicated experts from major leading ultrasound societies worldwide. These liver CEUS guidelines are simultaneously published in the official journals of both organizing federations (i.e., Ultrasound in Medicine and Biology for WFUMB and Ultraschall in der Medizin/European Journal of Ultrasound for EFSUMB). These guidelines and recommendations provide general advice on the use of all currently clinically available ultrasound contrast agents (UCA). They are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis and improve the management of patients worldwide.
A parasitological survey of Schistosoma haematobium and S. intercalatum infection among primary schoolchildren in capital area of Democratic Republic of São Tomé and Príncipe (DRSTP) was undertaken.
Subjects with positive infection were confirmed by the detection of S. haematobium ova in the urine or S. intercalatum ova in the stool by using centrifugation concentration or merthiolate-iodine-formalin concentration method. Totally, 252 urine and stool samples, respectively, were obtained from apparently healthy schoolchildren, of which 121 from boys (9.8 ± 1.4 yr) and 131 from girls (9.7 ± 1.3 yr).
None of participating schoolchildren were found having S. haematobium ova in the urinary specimen. While, among 4 primary schools studied, only schoolchildren from Saint Marçal were detected with S. intercalatum ova in the fecal specimen, making the overall prevalence of S. intercalatum infection among schoolchildren was 2.4% (6/252) and girls had insignificantly higher prevalence (3.1%, 4/131) than that (1.7%, 2/121) in boys (χ(2) = 0.5, P = 0.5).
Water control and sanitation as well as snails eliminated by molluscicides are urgently needed to reduce S. intercalatum infection in DRSTP inhabitants.
Schistosomiasis is a communicable disease which commonly involves urinary bladder causing hematuria, or large bowel causing bloody stool. The common species encountered in this lake region surrounding Lake Victoria in Tanzania are Schistosoma haematobium and Schistosoma mansoni. Complications can lead to portal hypertension due portal fibrosis in liver, and fibrosis in lung can lead to pulmonary hypertension; this commonly seen with S. mansoni. Major complications of S. maeametobium are chronic cystitis with squamous metaplasia with subsequent development of squamous cell carcinoma. Involvement of spinal cord causing paraplegia has been observed in S. haematobium. Other unusual pathology of schistosomiasis has been described, such as involvement of the appendix, ovary, prostate, and cervix. Here, we present a case of schistosomiasis in a 9-year-old boy who presented with left scrotal pain for one year which was accompanied by scrotal swelling; surgical exploration was done, and the finding was hydrocele and atrophic testes with nodules on the surface. Histological examination reveals atrophic testis and heavy active granulomatous inflammation with schistosoma eggs consistent with Schistosoma haematobium in the tunica vaginalis.
Cystic echinococcosis (CE) is a chronic, complex and neglected disease caused by the larval stage of Echinococcus granulosus. The effects of this neglect have a stronger impact in remote rural areas whose inhabitants have no chances of being diagnosed and treated properly without leaving their jobs and travelling long distances, sometimes taking days to reach the closest referral center.
In 1980 our group set up a control program in endemic regions with CE in rural sections of Rio Negro, Argentina. Since 1997, we have used abdominopelvic ultrasound (US) as a screening method of CE in school children and determined an algorithm of treatment.
To describe the training system of general practitioners in early diagnosis and treatment of CE and to evaluate the impact of the implementation of the field program.
In 2000, to overcome the shortage of radiologists in the area, we set up a short training course on Focused Assessment with Sonography for Echinococcosis (FASE) for general practitioners with no previous experience with US. After the course, the trainees were able to carry out autonomous ultrasound surveys under the supervision of the course faculty. From 2000 to 2008, trainees carried out 22,793 ultrasound scans in children from 6 to 14 years of age, and diagnosed 87 (0.4%) new cases of CE. Forty-nine (56.4%) were treated with albendazole, 29 (33.3%) were monitored expectantly and 9 (10.3%) were treated with surgery.
The introduction of a FASE course for general practitioners allowed for the screening of CE in a large population of individuals in remote endemic areas with persistent levels of transmission, thus overcoming the barrier of the great distance from tertiary care facilities. The ability of local practitioners to screen for CE using US saved the local residents costly travel time and missed work and proved to be an efficacious and least expensive intervention tool for both the community and health care system.
In developing countries, it is difficult to rally a radiologist to conduct field studies. Here, we report how a radiologist taught a clinician to carry out the ultrasound examination as defined by the World Health Organization (WHO) record sheet for Schistosoma haematobium related lesions. In a population infected with S. haematobium, the learner and teacher performed two ultrasound exams and the results were compared. One hundred thirty-two children were prospectively included, during 8 ultrasonography sessions split over 23 days. After 51 examinations the learner's sensitivity was above 90%. After the fifth session the specificity reached 100% (results remained stable until the end of the study period). This study shows that a clinician can quickly learn how to carry out a simple ultrasound examination to gather the items needed for the follow-up of S. haematobium related lesions, suggesting that clinicians could implement networks of ultrasound-based surveillance on the field.
Intestinal ultrasound has become an established and valid diagnostic method for inflammatory bowel disease, diverticulitis, appendicitis, bowel obstruction, perforation and intussusception. However, little is known about sonographic findings in other rarer intestinal diseases. Ultrasound may display the transformation of the intestinal wall from a normal to a pathological state both in inflammatory and neoplastic disease. Besides demonstrating the transmural aspect, it also shows the mesenteric reaction as well as complications such as fistula, abscesses, stenosis, or ileus. Furthermore, in some diseases intestinal ultrasound may serve as a diagnostic clue if typical patterns of the bowel wall and impaired peristalsis can be demonstrated. This may lead to an important reduction of invasive and expensive (follow-up) procedures. The information gained by ultrasound regarding intestinal disease, however, is as important and valid as e.g. in case of focal lesions of the liver. Serving as tertiary referral centers for a broad spectrum of intestinal diseases, we therefore report some aspects of ultrasound in patients with less often recognized diseases. The article is divided into two parts, the first focusing on examination techniques, infectious diseases and celiac sprue and the second on hereditary, vascular and neoplastic diseases and varia.
Schistosoma haematobium, a parasitic flatworm that infects more than 100 million people, mostly in the developing world, is the causative agent of urogenital schistosomiasis, and is associated with a high incidence of squamous cell carcinoma (SCC) of the bladder. Schistosomiasis haematobia also appears to negatively influence fertility, and is particularly associated with female infertility. Given that estrogens and estrogen receptors are key players in human reproduction, we speculate that schistosome estrogen-like molecules may contribute to infertility through hormonal imbalances. Here, we review recent findings on the role of estrogens and estrogen receptors on both carcinogenesis and infertility associated with urogenital schistosomiasis and discuss the basic hormonal mechanisms that might be common in cancer and infertility.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Urogenital Schistosomiasis Presenting Genital and Urinary Tract Lesions and Abdominal Discomfort in a Sterile Angolan Woman
Background: Schistosomiasis or bilharziasis is a parasitic disease caused by blood fluks of the genus Schistosoma. Schistosoma haematobium has been found in the Middle East, India, Portugal and Africa and it is responsible by urogenital schistosomiasis, pathology with strong economic and health repercussions in the endemic countries. The repercussions of schistosome infection in the health of an Angolan woman are presented and the effects of urogenital schistosomiasis in the human fertility are discussed.
Methods: A woman who came to the hospital for gynaecologic consultation because of primary sterility. She presented micturition problems, abdominal discomfort and back pain. Biopsies of the bladder and uterus epithelium showed Schistosoma haematobium ova. The patient was subdued to parasitological, ultrasonographical and cystoscopical examinations and treatment of the schistosomiasis associated to drug to prevent bacterial super-infection.
Results: Ultrasonography showed hypertrophy and irregularity of the bladder wall. Hystologic analysis showed S. haematobium eggs in the uterus epithelium and bladder. Cystocopy revealed sandy patches and ulceration at the ureteric meatus.
Conclusions: This was the first documented description of female genital schistosomiasis in Angola. Considering that S. haematobium is endemic in Angola, it is expected that a lot of similar cases of urogenital schistosomiasis are occurring in Angola. Then, preventive actions and early treatment of schistosomiasis should be implemented in endemic areas.
Purpose:
Gross and microscopic haematuria both are a common cause of referral to urology clinics. It has a wide spectrum of differential. In many occasions, it is a presentation of underlining serious urological problems. Evaluation of gross and significant microscopic haematuria is of paramount importance. This study was conducted to assess and compare the findings and diagnostic competency of transabdominal ultrasonography (US) versus cystourethroscopy in patients with haematuria of lower urinary tract origin.
Methods:
Prospective hospital-based study done at Ibn Sina Specialized and Omdurman Military Hospitals from June 2012 to March 2013. The study included 109 patients. Structured questionnaires were used to gather data from patients. All patients were evaluated by transabdominal US before cystourethroscopy examination.
Results:
One hundred and nine patients were studied. Patients' mean (SD) age was 57.9 (18.8) years. Fifty-four patients (49.5 %) presented with macroscopic haematuria, while 55 patients presented with microscopic haematuria. The sensitivity and specificity of the US in detecting prostate enlargement, vesical stones, bladder wall tumour, cystitis and schistosomiasis were [(84, 80 %); (82.6, 97.7 %); (64.7, 92.1 %); (15.3, 96.8 %); and (15.3, 98.9 %)], respectively, as compared to cystoscopic finding as the gold standard.
Conclusions:
Ultrasonography is accepted only as a first-line imaging tool for evaluation of haematuria in poor settings, but cannot replace or became as good as cystoscopy, which remains the gold standard.
Background
Travel-related acquisition of schistosomiasis in Africa is well established. Data concerning Schistosoma infection in pregnant travelers are lacking and treatment derives from studies in endemic regions.Methods
This study was a retrospective case-series of pregnant patients who were infected with Schistosoma species. Data regarding exposure history, clinical presentation, diagnosis, treatment, and fetal outcomes were collected and analyzed. Diagnosis of schistosomiasis was based on serology tests and/or ova recovery.ResultsTravel-related schistosomiasis during pregnancy was diagnosed in 10 travelers (with 20 pregnancies). Of the 10 women, 4 pregnant travelers with recent exposure were treated during their pregnancy with praziquantel (PZQ). The course and outcome of pregnancy in these patients was uneventful, and treatment had no apparent adverse effects on either the mothers or their babies. Six asymptomatic women were diagnosed years after exposure. During this period, they gave birth to 13 babies. They were never treated with PZQ. Birth weights of their infants were significantly smaller as compared with those of the infants of the women who were treated during their pregnancy (median 2.8 vs 3.5 kg). One baby was born preterm. One patient had three miscarriages.Conclusion
This is the first case-series of pregnant travelers with schistosomiasis. Although a small case-series with possible confounders, it suggests that schistosomiasis in pregnant travelers can be treated. A trend of lower birth weights was observed in the infants of the pregnant travelers who were not treated. PZQ therapy during pregnancy was not associated with adverse pregnancy or fetal outcomes in those four cases. Our results emphasize the importance of screening female travelers of childbearing age with a relevant history of freshwater exposure. Further studies are needed to reinforce these recommendations.
Schistosomiasis is a widespread helminthic infection which sometimes may affect travelers to endemic areas. We report on a case of urogenital and placental schistosomiasis in a 28-year-old German woman who had been exposed to schistosomiasis in Lake Malawi one year earlier. She experienced painless macrohaematuria in her 21st week of pregnancy. Cystoscopy revealed vesical lesions typical for urogenital schistosomiasis. Histopathology confirmed ova of Schistosoma (S.) haematobium. The patient was treated with praziquantel 40 mg/kg/body weight/day for 3 days. After 285 days of gestation and 18 weeks post treatment, the patient delivered a healthy girl. Histopathology of placenta revealed eggs of S. haematobium in placental stroma. The infant proved negative for anti-Schistosoma spp. antibodies at the age of 15 months. This is the first report on placental schistosomiasis since 1980 and the first case occurring in a traveler.
Purpose of review:
Cystic echinococcosis is a chronic, complex, and neglected disease. The need for a simple classification of cyst morphology that would provide an accepted framework for scientific and clinical work on cystic echinococcosis has been addressed by two documents issued by the WHO Informal Working Group on Echinococcosis in 2003 (cyst classification) and in 2010 (Expert consensus for the diagnosis and treatment of echinococcosis).
Recent findings:
Here we evaluate the use of the WHO Informal Working Group on Echinococcosis classification of hepatic cystic echinococcosis, the acceptance by clinicians of recommendations regarding the use of albendazole, and the implementation of the long-term follow-up of patients with hepatic cystic echinococcosis in the scientific literature since the WHO Informal Working Group on Echinococcosis recommendations were issued.
Summary:
Of the publications included in our review, 71.2% did not indicate any classification, whereas 14% used the WHO Informal Working Group on Echinococcosis classification. Seventy-four percent reported the administration of peri-interventional albendazole, although less than half reported its modality, and 51% the length of patient follow-up. A joint effort is needed from the scientific community to encourage the acceptance and implementation of these three key issues in the clinical management of cystic echinococcosis.
Human schistosomiasis-or bilharzia-is a parasitic disease caused by trematode flukes of the genus Schistosoma. By conservative estimates, at least 230 million people worldwide are infected with Schistosoma spp. Adult schistosome worms colonise human blood vessels for years, successfully evading the immune system while excreting hundreds to thousands of eggs daily, which must either leave the body in excreta or become trapped in nearby tissues. Trapped eggs induce a distinct immune-mediated granulomatous response that causes local and systemic pathological effects ranging from anaemia, growth stunting, impaired cognition, and decreased physical fitness, to organ-specific effects such as severe hepatosplenism, periportal fibrosis with portal hypertension, and urogenital inflammation and scarring. At present, preventive public health measures in endemic regions consist of treatment once every 1 or 2 years with the isoquinolinone drug, praziquantel, to suppress morbidity. In some locations, elimination of transmission is now the goal; however, more sensitive diagnostics are needed in both the field and clinics, and integrated environmental and health-care management will be needed to ensure elimination.
Chronic infection with the blood fluke, Schistosoma haematobium, is associated with squamous cell carcinoma of the bladder. Previously, it has been shown that soluble extracts of mixed sex adult S. haematobium worms (SWAP) are tumourigenic, both in vitro and in vivo. In addition, oestrogen-related molecules in SWAP of S. haematobium down-regulate oestrogen receptors (ERs) alpha and beta in oestrogen responsive cells. Moreover, schistosome oestrogens occur in sera of persons with schistosomiasis haematobia and repress transcription of ERs in urothelial cells. Given that eggs of S. haematobium are the developmental stage directly responsible for urogenital disease during schistosomiasis haematobia, we suspected that soluble antigens from S. haematobium eggs exhibit similar or more potent tumorigenic capacity. Here we investigated the tumorigenic potential of soluble egg antigens (Sh-SEA) of S. haematobium and the endocrine system in favouring parasitism by schistosomes. The findings confirmed that 6.25μg/ml of Sh-SEA was enough to stimulate cell proliferation, reduce apoptosis and increase oxidative stress of Sh-SEA-exposed urothelial cells. In addition, genotoxic effects of Sh-SEA on these cells were determined by using alkaline single-cell gel electrophoresis (Comet). Furthermore, Liquid Chromatography Diode Array Detection Electron Spray Ionisation Mass Spectrometry indicated the presence of catechol-oestrogens in S. haematobium SEA. A prospective oestrogen-DNA adduct mediated pathway in S. haematobium egg induced bladder cancer is also discussed.
To investigate the possibility of inhibiting the progression of pancreatic ductal adenocarcinoma (PDAC) by facilitating the expression of E-cadherin through the enforced expression of microRNA-101 (miR-101).
In situ hybridization was conducted with archival tissue using a double digoxigenin-labeled probe. Chromatin immunoprecipitation (ChIP) assay was conducted with EZ-Magna ChIPTM A. Gene profile analysis, Western blot, and immunoprecipitation assays were performed using standard protocols.
We found that decreased miR-101 expression observed in archival patient tissues was significantly associated with poor prognosis indicated by low-intensity staining in high-grade tumors. ChIP assays using anti-enhancer of zeste homolog 2 (EZH2) antibodies indicated not only the interaction of EZH2 to the CDH1 (E-cadherin) promoter, but also that this interaction was significantly diminished in cells transfected with pre-miR-101. We observed a global downregulation of trimethylated lysine 27 of H3 histone (H3K27me3) along with upregulation of the enzymes histone deacetylase -1 and -2 with the re-expression of miR-101. Further, we observed lesser levels of transcriptional factors that inhibit the CDH1 promoter with pre-miR-101 treatment. Western blot analysis confirmed the enhanced E-cadherin expression. PANC-1 cells transduced with pre-miR-101 displayed markedly attenuated growth in SCID mice.
These results suggest the potential therapeutic use of miR-101-enforced expression for inhibition of PDAC.
INTRODUCTION: Imaging techniques, primarily ultrasound, are useful in the diagnosis and monitoring of patients with schistosomiasis in endemic areas. METHODS: Study of 219 patients treated in sub-Saharan Tropical Medicine Unit with a diagnosis of imported schistosomiasis by imaging techniques investigations including plain abdominal radiography and ultrasound. RESULTS: A total of 17.8% of patients who had an abdominal X-ray showed findings suggestive of schistosomiasis, in most cases bladder calcifications. In 73 patients (41%) ultrasound showed pathological findings, mainly diffuse or focal wall thickening (26 patients), nodular lesions (n=14), and pseudopolyps (n=8). One patient, who had a large bladder mass (9cm) and bilateral ureterohydronephrosis, was finally diagnosed with squamous cell carcinoma of the bladder. Ultrasound liver abnormalities were found in 10 patients, 4 with signs of portal hypertension, of which 3 had the characteristic periportal fibrosis in schistosomiasis. CONCLUSION: Imaging studies, especially abdominal and bladder ultrasound, are useful for diagnosis, the study of disease and monitoring of patients with schistosomiasis in non-endemic countries.
To provide systematic review of the literature on the long-standing complications of genitourinary schistosomiasis.
The PubMed literature database was searched from inception to December 2010. The following keywords were used: schistosomiasis, bilharziasis, and genitourinary. Only English language publications were utilized.
Variable tissue reactions to bilharzial eggs with subsequent healing or progression and complications in the urinary tract mainly affect the urinary bladder and pelvic segments of the ureters. These lesions may assume an atrophic, proliferative, or neoplastic pattern. Although the pathology is usually extensive in the submucosal, all layers from the mucous membrane through deep to the perivesical or periureteral tissues may be involved. Main fixed bilharzial urologic sequelae include chronic bladder ulcers, leucoplakia, vesical granuloma, contracted bladder, bladder neck contracture, stricture ureters, and bladder carcinoma. These sequelae may lead to marked morphologic and functional changes of the urinary tract, and ultimately, mortality can follow from renal failure or bladder cancer.
Urinary schistosomiasis is a preventable disease through nationwide snail control and mass therapy with oral antibilharzial drugs. If not properly treated, long-standing urinary complications may result in serious sequelae that may lead to mortality from renal failure or bladder cancer.
In this overview the variety of current evidence based diagnostic options of EUS are discussed.
© Georg Thieme Verlag KG Stuttgart · New York.
Emergency department bedside ultrasonography (EUS) can expedite treatment for patients. However, it is unknown how much experience is required for competency in the sonographic diagnosis of cholelithiasis and cholecystitis.
The objective was to assess the learning curve of physicians training in right upper quadrant (RUQ) EUS.
This was a prospective study at an urban, academic emergency department from August 1999 to July 2006. Patients with suspected biliary tract disease underwent RUQ EUS followed by abdominal ultra sonography (AUS) by the Department of Radiology. Results of EUS were compared to AUS using a predesigned, standardized data sheet.
A total of 1,837 patients underwent EUS by 127 physicians. The overall sensitivity and specificity of EUS for cholelithiasis were 84% (95% confidence interval [CI] = 81% to 86%) and 86% (95% CI = 83% to 88%), respectively. The overall sensitivity of EUS for ductal dilation, gallbladder wall thickening, pericholecystic fluid, and sludge were each < 60%. When analyzing the EUS test characteristics, for every increase in 10 examinations up to 50 examinations, there was no significant improvement in the sensitivity or specificity for any of these sonographic findings. Moreover, on probit regression analysis, accounting for clustering or correlation among the examinations performed by each of the operators, there was no improvement for detecting any of the sonographic findings except for pericholecystic fluid for every 10 additional examinations performed.
When adjusting for operator dependence, performing up to 50 EUS examinations appears to have little effect on the accuracy of RUQ EUS. Rather than simply requiring an arbitrary number of examinations, another method of competency assessment may be necessary.
The purpose of this study was to prospectively assess the learning curve of emergency physician training in emergency bedside sonography (EBS) for first-trimester pregnancy complications.
This was a prospective study at an urban academic emergency department from August 1999 through July 2006. Patients with first-trimester vaginal bleeding or pain underwent EBS followed by pelvic sonography (PS) by the Department of Radiology. Results of EBS were compared with those of PS using a predesigned standardized data sheet.
A total of 670 patients underwent EBS for first-trimester pregnancy complications by 1 of 25 physicians who would go on to perform at least 25 examinations. The sensitivity and specificity of EBS for an intrauterine pregnancy increased from 80% (95% confidence interval [CI], 71%-87%) and 86% (95% CI, 76%-93%), respectively, for a physician's first 10 examinations to 100% (95% CI, 73%-100%) and 100% (95% CI, 63%-100%) for those performed after 40 examinations. Likewise, the sensitivity and specificity for an adnexal mass or ectopic pregnancy changed from 43% (95% CI, 28%-64%) and 94% (95% CI, 89%-97%) to 75% (95% CI, 22%-99%) and 89% (95% CI, 65%-98%), whereas the sensitivity and specificity for a molar pregnancy changed from 71% (95% CI, 30%-95%) and 98% (95% CI, 94%-99%) to 100% (95% CI, 20%-100%) and 100% (95% CI, 81%-100%). Although detection of an intrauterine or a molar pregnancy improved with training, even with experience including 40 examinations, the sensitivity of EBS for an adnexal mass or ectopic pregnancy was less than 90%.
There is an appreciable learning curve among physicians learning to perform EBS for first-trimester pregnancy complications that persists past 40 examinations.
Reference values for B-mode abdominal ultrasound are being controversially discussed due to the limited data in the literature. A systematic survey of data published so far is presented for liver and hepatic vessels.
A literature search for reference values in the abdomen from 1970 to 2010 in healthy subjects 18 years of age and older was carried out. In accord with the determination of reference intervals for laboratory values, reference values are generally determined with the aid of 95 % reference intervals and the associated 90 % confidence intervals. Evaluated parameters were the size and volume of the liver, the portal vein diameter and cross-section and the diameters of the hepatic veins.
Liver size is usually determined by its longitudinal diameter in the midclavicular line. Although not sufficiently evaluated, < 16 cm can be used as a reference value. Numerous methods, which are not comparable, have been described for the determination of liver volume. For the portal vein diameter, refererence intervals could be deduced from 6 studies. Data from 4 studies on the liver veins differ depending on the exact localisation of measurement.
Normal values are helpful in delineating numerous pathological changes in the respective organs. Unfortunately, data are scarce and the examination technique, so far, has not been standardised sufficiently to compare data. A multicentre trial is required to standardise examination techniques and improve the quality of the results.