Spinal Schistosomiasis: Differential Diagnosis for Acute
Paraparesis in a US Resident
Tapan N. Joshi, MBBS, MS1; Michael K. Yamazaki, MD2; Holly Zhao, MD, PhD2; Daniel Becker, MD1
1International Center for Spinal Cord Injury, Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore,
Maryland;2Department of Physical Medicine & Rehabilitation, University of California Davis School of Medicine,
Received July 21, 2009; accepted November 12, 2009
Background: Spinal schistosomiasis is a severe presentation of Schistosoma mansoni infection, which is
endemic in South America, the Middle East, and sub-Saharan Africa. With increasing international travel, a
disease can spread from an endemic area to another part of the world easily.
Objective: To present a case of a US resident who developed acute paraparesis due to spinal
schistosomiasis after traveling to sub-Saharan Africa.
Participant: A 45-year-old woman presented with abdominal pain radiating into the bilateral lower
extremities. She was diagnosed with a pelvic mass and underwent an urgent hysterectomy with right
salpingo-oopherectomy. Postoperatively, she developed progressive weakness with worsening pain in her
bilateral lower extremities and neurogenic bladder. Magnetic resonance imaging showed an abnormal T2
hyperintense signal in the entire spinal cord below the T3 level with abnormal contrast enhancement from
T9 through the conus medullaris. Spinal fluid analysis showed lymphocytic pleocytosis and elevated protein.
The patient was diagnosed with transverse myelitis. Subsequently, a detailed history revealed a visit to
Ethiopia 2 years earlier. Tests for S mansoni were positive. After treatment with praziquantel and prednisone,
her neurologic function began to improve.
Conclusions: An increasing incidence of international travel is increasing the likelihood of US physicians’
encountering this treatable condition. Travelers with spinal schistosomiasis may not have symptoms of
systemic infection. Therefore, it is important to include spinal schistosomiasis in the differential diagnosis of
acute inflammatory myelopathy, particularly with a history of travel to endemic areas.
J Spinal Cord Med. June 2010;33(3):256–260
Key Words: Schistosomiasis, spinal; Schistosoma; Schistosoma mansoni; Paraparesis; Myelopathy;
Myeloradiculopathy; Praziquantel; Parasites, helminthic
Schistosomiasis is one of the world’s most widespread
parasitic diseases, and it is caused by the trematode
Schistosoma. It has affected 200 million people world-
wide (1). Schistosoma mansoni, 1 of the 3 main species, is
endemic to South America, the Middle East, and sub-
Saharan Africa (2). S mansoni uses a human as a definitive
host and a freshwater snail (Biomphalaria species) as an
intermediate host. Infection ensues upon direct contact
with fresh water that harbors cercariae, a larval form of
schistosome released from snails. Upon exposure, cer-
cariae penetrate the skin of humans and enter the blood
and lymphatic circulation en route to the lungs. After
several days, cercariae migrate to the portal venous
plexus and sexually mature if they meet the opposite sex.
Then the adult pairs travel to the venous plexus
surrounding the intestines, where they begin egg
production. Eggs pass through the intestinal mucosa
and are shed in the stool. Once excreted, they hatch in
fresh water and release the fresh-living motile form,
miracidia, which, in turn, infect specific freshwater snails.
The life cycle is completed when cercariae are released
from the snails into water (2,3).
Acute schistosomiasis secondary to S mansoni infec-
tion presents with fever, headache, myalgia, diarrhea,
and abdominal pain. Acute respiratory symptoms are
reported in up to 70% of individuals. In the chronic
phase, it commonly involves hepatic and gastrointestinal
Please address correspondence to Tapan N. Joshi, MBBS, MS,
Johns Hopkins School of Medicine, International Center for
Spinal Cord Injury, 707 Broadway, Suite 518, Baltimore, MD
21205; p: 718 724 3277; f: 718 985 5789 (e-mail: joshi@
G2010 by the American Paraplegia Society
256The Journal of Spinal Cord MedicineVolume 33 Number 3 2010