A Young Man with Chronic Abdominal pain

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A Young Man with Chronic Abdominal pain

• Aaron DeVries
• Interhospital Case Conference 3/29/05

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20 yo M Chronic Abdominal Pain

• Presenting to an ER
• 24 months of chronic intermittent abdominal pain
• Currently R sided extending to R Flank
• In past had been LUQ and RUQ
• Waxes and wanes but severe for the last 2 days
• Occurred from weekly to daily lasting for several
  hours each time
• No alteration in pain with eating, urination,
  defecation
• No Fevers/chills, cough, dysuria, hematuria,
  diarrhea, constipation, melena, hematochezia

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20 yo M Chronic Abdominal Pain

• PMHx none
• SHx refugee from Sudan, arrived in Twin Cities
  about 1 year ago

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20 yo M Chronic Abdominal Pain

• BP 110/78 P 76 RR 12 Afeb
• Thin uncomfortable, lying or sitting
• HEENT, PULM, CV nml
• Abd tender in RLQ, extending to R flank
• U/A 0 WBC, 5 RBC
• CBC diff, lytes normal
• KUB - No calcifications observed

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CT Abd w/o contrast

• Moderate dilation of the R collecting system with
  moderate to severe dilation of the ureter to the
  level of the distal ureter.
• Smooth linear high attenuation lesions of the mid
  and distal portions of the ureter which could
  represent calcification and dilated to 1.3 cm
• R distal ureter obstruction small stone in
  distal ureter vs. congenital obstruction

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Any Thoughts?

• What would be your next test?

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Cystoscopy

• Yellowish, sandy appearing patch on the trigone
  as well as within the R ureter

• No obstruction on retrograde pyelogram
• Biopsy taken

• Many schistosomial elements

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Bilharzia a.k.a Schistosomiasis

• Theodore Bilharz was German anatomist teaching in
  Cairo.
• In 1850 connected death following hematuria with
  the parasite.
• Died 1852 of typhus

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Schistosomiasis Life Cycle
Life Cycle

• Vertebrates are the principle final hosts
• Reproduce exclusively in humans except S.
  japonicom
• Fresh water snails are required

Schistosomiasis NEJM 2002 346 1212-20
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5 minutes
Cam.University Schistosomiasis Research Group
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10 minutes
Cam.University Schistosomiasis Research Group
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20 minutes
Cam.University Schistosomiasis Research Group
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Species and Location
  S. haematobium S. japonicum S. mansoni
Skin X X X
Lung X X X
Left Heart X X X
Portal Venous system X X X
Vesicular venous plexus X
Inf Mesenteric veins and hemorrhoidal veins X
Sup Mesenteric Veins X
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Geography
15
Geography Sudan
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Acute Disease

• Swimmers itch from invasion of cercaria into skin
• Acute Schistosomiasis a.k.a Katayama fever
• Onset of the female parasite laying eggs 5
  weeks after infection
• Fever, Nausea, Headache
• Hepatosplenomegaly
• Leukocytosis with eosinophilia
• Few weeks months
• S. japonicum gt S. mansoni and S. haematobium

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Chronic Disease

• Occurs with Granuloma formation surrounding eggs
• Hepatosplenic Schistosomiasis - S. mansoni and S.
  japonicum
• Several years after initial infection
• Granulomas form within the liver and biliary tree
  
• chronic hepato-obstructive disease
• portal hypertension liver failure
• Intestinal Schistosomiasis - S. mansoni and S.
  japonicum
• Several years after initial infection
• Small and large intestine may be involved
• Adults migrate to intestinal wall
• Lay eggs which migrate into intestinal lumen and
  out into stool
• Severe anemia from chronic GI blood loss

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Chronic Disease

• Vesico-ureteral - S. haematobium
• Several years after infection
• Adults migrate to small venules around the
  bladder and ureter
• Eggs are deposited into surrounding tissue and
  penetrate out into bladder
• Causes calcifications where eggs are trapped
• Characterized by hematuria
• Leads to squamous-cell cancer of bladder

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World Health Impact

• 200 million infected worldwide
• 80-85 of persons in Sub-Saharan Africa are
  infected
• In Egypt, squamous-cell carcinoma of the bladder
  accounts for 18-28 of all cancer
• Incidence of 10.8 per 100,000 persons
• Smoking increases risk even further
• Infected children have substantial growth delay
  even after treatment
• Co-infection with Hep B and C results in a much
  faster progression to liver failure

www.cdc.gov
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Pt referred to ID clinic for treatment

• PMHx fell from a tree as a child with possible
  fractured ribs on R side
• SHx
• Native of Darfur region of Sudan.
• At approximately the age of 15 his village was
  overrun by Sudanese government forces. His
  family was killed in front of him.
• He was captured and was enslaved by the
  Janjaweed. He was given no food or water.
• After 4 years of enslavement he escaped by train
  into Kartun where he contacted relatives in
  Cairo.
• They assisted him to Egypt and eventually was
  accepted as a refugee to the US facilitated by MN
  relatives

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ID Clinic

• PE nml vitals
• ENT, Pulm, CV exam nml
• ABD mildly tender in RUQ
• Urine and stool w/o parasitic elements
• Treatment
• Praziquantal 20mg/kg x 2 doses separated by 8
  hours

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Treatment

• Praziquantal
• Kills all forms except schistosomula - migrating
  form
• 3-21 days
• Cure rate 60-90
• Emerging resistance in Egypt and Kenya reported
• Oxamniquine and Metrifonate are alternatives
• Re-treatment same drug and dose
• If shedding eggs at 4-6 weeks
• If symptoms do not resolve
• If anti-schistosomal antibody remains elevated.

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Follow Up

• He had significant decrease in abdominal pain at
  4 weeks
• No schistosomal eggs seen in urine or stool
• At six weeks had near complete resolution of
  symptoms
• Anti-schistosomal Ab 5.8 (nml lt1)

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New CDC RecommendationsJanuary 21, 2005

• Serologic prevalence at a Sudanese refugee
  reunion in Arizona in 2004
• 464 participated in the laboratory testing.
• 204 (44) seropositive for S. mansoni or S.
  haematobium
• 227 (49) seropositive for strongyloides
• 103 (22) seropositive for both
• 315 (69) were seropositive for either
• 88 of were treated (unclear whether remainder
  were previously treated or refused treatment)
• Recommendations presumptive treatment of all
  Lost Boys and Girls of Sudan - All Sudanese
  refugees?
• Praziquantel 20 mg/kg x 2 doses 6-8 hours apart
• Albendazole 400 mg BID for 3 days.

http//www.cdc.gov/ncidod/dq/lostboysandgirlssudan
/presumptive_tx_recc.htm
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Generally speaking the policy of attacking,
killing and forcibly displacing members of some
tribes does not evince a specific intent to
annihilate, in whole or in part, a group
distinguished on racial, ethnic, national or
religious grounds. Rather, it would seem that
those who planned and organized attacks on
villages pursued the intent to drive the victims
from their homes, primarily for purposes of
counter-insurgency warfare. Report of the
International Commission of Inquiry on Darfur to
the United Nations Secretary-General Geneva, 25
January 2005
1.65 million internally displaced - UN Report 25
January 2005 180,000 300,000 estimated killed
since start of conflict in 2003 - Ivo Daalder -
Brookings Institute - March 14, 2005