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Genitourinary Schisto- Somiasis: Life Cycle and Radiologic-Pathologic Findings1 Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights. GENITOURINARY IMAGING 1031 Genitourinary Schisto- somiasis: Life Cycle and Radiologic-Pathologic Findings1 Haytham M. Shebel, MD • Khaled M. Elsayes, MD • Heba M. Abou El ONLINE-ONLY CME Atta, MBBCh, PhD • Yehia M. Elguindy, MBBCh • Tarek A. El-Diasty, MD See www.rsna .org/education Genitourinary schistosomiasis is produced by Schistosoma haemato- /rg_cme.html bium, a species of fluke that is endemic to Africa and the Middle East, and causes substantial morbidity and mortality in those regions. It also LEARNING may be seen elsewhere, as a result of travel or immigration. S haemato- OBJECTIVES bium, one of the five fluke species that account for most human cases After completing this of schistosomiasis, is the only species that infects the genitourinary journal-based CME activity, participants system, where it may lead to a wide spectrum of clinical symptoms will be able to: and signs. In the early stages, it primarily involves the bladder and ure- ■■Describe the pathogenesis of ters; later, the kidneys and genital organs are involved. It rarely infects genitourinary schis- the colon or lungs. A definitive diagnosis of genitourinary schistoso- tosomiasis. miasis is based on findings of parasite ova at microscopic urinalysis. ■■Recognize the clin- ical manifestations of Clinical manifestations and radiologic imaging features also may be genitourinary schis- suggestive of the disease, even at an early stage: Hematuria, dysuria, tosomiasis. and hemospermia, early clinical signs of an established S haematobium ■■Identify imaging features suggestive infection, appear within 3 months after infection. At imaging, fine ure- or indicative of geni- teral calcifications that appear as a line or parallel lines on abdomino- tourinary schistoso- miasis. pelvic radiographs and as a circular pattern on axial images from com- puted tomography (CT) are considered pathognomonic of early-stage schistosomiasis. Ureteritis, pyelitis, and cystitis cystica, conditions that are characterized by air bubble–like filling defects representing ova de- posited in the ureter, kidney, and bladder, respectively, may be seen at intravenous urography, intravenous ureteropyelography, and CT urog- raphy. Coarse calcification, fibrosis, and strictures are signs of chronic or late-stage schistosomiasis. Such changes may be especially severe in the bladder, creating a predisposition to squamous cell carcinoma. Genital involvement, which occurs more often in men than in women, predominantly affects the prostate and seminal vesicles. ©RSNA, 2012 • radiographics.rsna.org RadioGraphics 2012; 32:1031–1046 • Published online 10.1148/rg.324115162 • Content Codes: 1From the Department of Radiology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt (H.M.S., H.M.A., T.A.E.); and De- partment of Radiology, University of Texas M.D. Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030 (K.M.E., Y.M.E.). Presented as an education exhibit at the 2010 RSNA Annual Meeting. Received September 16, 2011; revision requested October 12 and received December 20; ac- cepted January 10, 2012. For this journal-based CME activity, the authors, editor, and reviewers have no relevant relationships to disclose. Address correspondence to K.M.E. (e-mail: [email protected]). ©RSNA, 2012 1032 July-August 2012 radiographics.rsna.org Introduction Two major forms of schistosomiasis exist: in- Schistosomiasis, one of the most protean diseases testinal and genitourinary. Intestinal schistosomi- in humans, was known to the pharaohs more asis may be caused by any of five main species of than 5000 years ago. The presence of snail spe- blood flukes (Table). However, only Schistosoma cies in the Paleolithic Age in Africa may indicate haematobium affects the genitourinary system (5). an even older history for this parasitic disease. S haematobium is endemic throughout Africa, The ancient Egyptians recognized schistosomiasis Madagascar, Mauritius, the southern shore of the as a cause of bloody urine and stools and knew Mediterranean, and the Middle East, including that the condition was due to worms (1). Turkey. It primarily involves the urinary tract and In 1851, Theodor Bilharz described this para- the hepatic portal system, but it may also affect sitic infection, which consequently became known the colon and lungs (1,4,6). as bilharziasis but was later renamed schistosomia- sis. Schistosomiasis (also known as “snail fever”) Life Cycle of S Haematobium is a complex of parasitic infections that are caused The life cycle of S haematobium consists of two by various trematodes of the genus Schistosoma, main stages, one of which is completed in fresh- whose first hosts are aquatic or amphibious snail water snails, and the other, in humans and other species that live in fresh water. Humans and other mammals (Fig 1). mammals may be infected through contact with water containing the parasites. Schistosomiasis is First Stage: Freshwater Snails a major source of morbidity and mortality in the The life cycle of S haematobium begins when eggs developing countries of Africa, South America, the of the parasite excreted by a mammal host reach Caribbean, the Middle East, and Asia; however, fresh water, where they hatch and release mira- tourism to and immigration from endemic areas cidia. The free-swimming miracidia can survive may lead to occurrences of the disease anywhere 1–3 weeks in fresh water. During this time, the in the world (2,3). miracidia must infect a snail of the genus Bulinus In 1996, the World Health Organization (4) es- in order to complete their life cycle. These snails timated that more than 200 million people world- may be found in slow-moving freshwater streams, wide were affected by schistosomiasis, mainly irrigation ditches, or nearly any other open water those living in rural agricultural and periurban source (natural or artificial) in endemic regions. areas. Of that number, it was estimated that 20 In the snail, the miracidium develops into an million were severely affected by the disease and adult sporocyst, from which thousands of larval that another 120 million were symptomatic. cercariae are released 4–6 weeks after the initial According to the World Health Organization, infection (7,8). The cercariae, fork-tailed free- schistosomiasis is one of the most widespread hu- swimming larvae approximately 1 mm in length, man parasitic infections, ranking second to malaria can survive only 72 hours in fresh water. During in terms of its effects on the socioeconomic status that time, they must either attach themselves to and health of populations living in tropical and and penetrate the skin of humans or other sus- subtropical regions. It is considered to be the most ceptible host mammals or die. Cercariae also may prevalent waterborne disease and a major occupa- enter a human or other mammal host by pen- tional health risk in rural areas of developing coun- etrating the buccal mucous membrane; however, tries, where it results primarily from the unsanitary cercariae that are swallowed are digested in the disposal of human and animal wastes, combined stomach (9–12). with repeated daily contact of people with contam- inated freshwater sources (eg, in fishing, farming, Second Stage: swimming, bathing, and recreation) (5). Humans and Other Mammals After penetrating the skin of the human or mam- Epidemiologic Character- mal host, the larvae shed their tails and become istics and Forms of Schistosomiasis schistosomula. The schistosomula enter the lym- Schistosomiasis is prevalent in tropical and sub- phatic system and pass through the thoracic duct tropical regions, especially in poor communities into the right side of the heart. They then travel with no access to safe drinking water or adequate through the lungs to the left side of the heart and sanitation. Of the 207 million people with schis- proceed along the mesenteric capillaries to the tosomiasis, 85% live in Africa (1,4). hepatic portal system and liver, where they mature and copulate. This journey takes 10–21 days. They then migrate along the endothelium, against the RG • Volume 32 Number 4 Shebel et al 1033 Figure 1. Schema shows the two-stage life cycle of S haematobium. Geographic Distribution of Schistosoma Species That Infect Humans Species by Targeted Body System Endemic Countries and Geographic Regions Intestinal tract S mansoni Africa, Middle East, Caribbean, Brazil, Venezuela, Suriname S japonicum China, Indonesia, Philippines S mekongi Several districts of Cambodia, Laos S intercalatum Rain forests of central Africa S guineensis Rain forests of central Africa Genitourinary system S haematobium Africa, Middle East portal blood flow, to the vesicular venous plexus, wall and are shed in urine or feces. During this which envelops the lower part of the bladder and migration, which takes approximately 10 days, the base of the prostate; there, they produce eggs. miracidia develop inside the eggs. Eggs that are Maturation of the parasite also may occur in other not shed successfully may remain in the host’s organs, especially the lungs, but copulation outside tissues, where they soon become nonviable, or the liver is uncommon (8,13). may be swept back from the mesenteric vessels The eggs are highly antigenic and may induce to the portal circulation or from the vesicular an intense granulomatous response in human vessels via the inferior
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