SCHISTONOMA MANSONI

A CASE REPORT ON THE UNUSUAL FINDING OF SCHISTOMA MANSONI OVA

1. A CASE REPORT ON THE UNUSUAL FINDING OF SCHISTOMA MANSONI OVA Sivaranjini Alagiri , Anupma Jyoti Kindo , Dhivyalakshmi Sri Ramachandra Medical College & Research Institute Chennai

2. INTRODUCTION Humans are hosts to nearly 300 parasitic species. Parasitic infections are cosmopolitan and contribute considerably to the global burden of communicable diseases. It is one of the chief concerns of public health in under -developed & developing countries. Contributing factors are malnutrition, population density, economic conditions, poor sanitation and life style. Increased incidence in developed countries may be attributed to - mass influx of immigrant population from endemic areas - tourism - immunosuppression F.E.G.Cox.Clin Microbiol Rev.2002

3. GLOBAL BURDEN Global Burden of Disease Study 2013 - nearly 1million deaths are due to parasitic infections, globally. Plos Medicine Journals’ Blog,2015

4. HISTORY Eggs of intestinal helminths have been found in mummified faeces dating thousands of years back. Earliest reports were documented by the Egyptians- Ebers Papyrus of 1500BC. Helminthiases have changed the course of Cold War. Acute schistosomiasis weakened the Chinese troops ,long enough for American fleets to enter straits of Taiwan (blood-fluke that saved Formosa) German scientist Dr.Theodore Bilharz – first described adult schistosomes in portal vein of a cadaver(1851) Sir Patrick Manson(1902) discovered ova of S.mansoni .

5. SCHISTOSOMIASIS - EPIDEMIOLOGY Schistosomiasis is one of the oldest known parasitic infections. Prevalent in tropics & sub-tropics Annual incidence – 200 million globally Estimated annual deaths d/t schistosomiasis is around 200,000 An estimated 600 million people at risk in 76 endemic countries. Schistosomiasis control has been successfully implemented over the past 40 years in several countries, including Brazil, Cambodia, China, Egypt, Mauritius and Saudi Arabia WHO Factsheets.2015 http://whqlibdoc.who.int/trs/WHO_TRS_912

6. GLOBAL DISTRIBUTION OF SCHISTOSOMIASIS Michael Walsh (2012). Schistosomiasis . Infection Landscapes.

7. India is considered non-endemic for schistosomiasis – attributed to absence of intermediate host for human schistosomes . There has been reports of sporadic indigenous cases. Cercarial dermatitis in Tribal villages of Assam , Chhattisgarh, Madhya Pradesh and Jabalpur. Several schistosome species causing zoonotic disease are prevalent in India. Endemic foci for human schistosomiasis - Gimvi village in Ratnagiri district, Maharashtra - Thirupparankundram village, Chennai - Lahager village, Madhya Pradesh M. C. Agrawal and V. G. Rao.Journal of Parasitology Research.2011

8. IMPENDING THREAT TO INDIA Abundance of aquatic bodies and irrigation practices in India provides ideal environment for the intermediate hosts. Population migration from endemic areas d/t globalisation and tourism. Poor sanitation and lack of vector control measures pose a risk for the spread. Under-reporting of schistosomiasis d/t - lack of suspicion - lack of public awareness to seek medical attention

9. EXPERIMENTS TO DETERMINE PREVALENCE OF INTERMEDIATE HOST IN INDIA FINDINGS Soparkar (1919) Cercarial fauna of snails were analysed in the water bodies in Bombay. All 17 species were animal schistosome cercariae Annandale et al(1920) Tested 1532 common snails ,out of which 11 cercariae were found.All were negative for human schistosome and all were resistant to miracidia of S.haematobium Gadgi et al(1956) Identified Ferrissia tenuis as the intermediate host of the S.haematobium , which caused an outbreak in Gimvi village,Maharashtra . These experiments depict the absence of cercariae causing human schistosomiasis due to lack of suitable intermediate hosts and hence naturally controls the spread of schistosomiasis in India. Arunava Kali.Journal of Clinical and Diagnostic Research. 2015

10. SCHISTOSOMIASIS Water borne helminthic infection Definitive host - Humans Intermediate host - freshwater snails Infective form - cercariae Habitat – mesenteric , vesical & pelvic venous plexus. There are about 23 species of Schistosoma identified so far. Only 7 are anthropophilic .   © Dr Peter Darben , Queensland University of Technology 

11. ANTHROPOPHILIC SCHISTOSOMES Schistosoma species Intermediate Host Schistosomiasis Endemic Region S. haematobium Bulinus species Urogenital Africa , Middle East S. japonicum Oncomelania species Gastrointestinal China, East Asia, Philippines S. mansoni Biomphalaria species Gastrointestinal Africa , South America, Caribbean, Middle East S. intercalatum Bulinus species Gastrointestinal Africa S. mekongi Neotricula aperta Gastrointestinal South East Asia S. guineensis Bulinus forskalii Gastrointestinal West Africa S. malayensis Robertsiella species Gastrointestinal South East Asia

12. Adapted from Melvin, Brook and Salum,1959

13. CASE REPORT Intestinal Schistosomiasis

14. PATIENT HISTORY 26 year old male College student from Chennai Native of Nigeria Recent travel to native place Trekking and swimming PRESENTING COMPLAINTS Episodes of loose stools on & off for 2 weeks , with recent episode lasting 4 days Not associated with fever/ abdominal discomfort / nausea / vomiting

15. INVESTIGATIONS Haemoglobin - 15.3gm/dl RBC count - 5.5 million/mm 3 Total leucocyte count - 5800 cells/mm 3 P 49.7 L 43.2 E 1.9 M 5 B 0.2 Platelet count - 2.49 lakhs /mm 3 PCV - 44.6% MCV - 80.3fl MCH - 27.5pg MCHC - 34.3 The patient was found to be retro-negative

16. STOOL EXAMINATION SAMPLE - freshly passed stool collected in a sterile screw capped container GROSS EXAMINATION Colour – yellowish brown Consistency – watery Blood – present Mucous - present MICROSCOPIC EXAMINATION Saline wet mount – plenty of oval shaped eggs measuring 120-175µm * 40-70µm - prominent sharp lateral spine - embryonated - non operculated

17. Ova of Schistosoma mansoni characterised by a sharp lateral spine

18. RESULTS Based on the morphology, eggs were identified to be S.mansoni ova. Diagnosis was supported by his history of swimming in an area, endemic for schistosomiasis . TREATMENT Praziquantel – 40mg/kg Repeat stool sample was found to be negative for ova. Strict personal hygiene Abstinence from water activities to avoid infestation of water bodies

19. REPORTS OF HUMAN SCHISTOSOMIASIS IN INDIA REPORTED BY FINDINGS Hatch (1878) First case of human schistosomiasis in India Report of urinary schistosomiasis in 12 patients Powell (1903) First indigenous case of human schistosomiasis in India De Sa et al(1949) First case of urinary schistosomiasis in Indian from Gimvi village,Ratnagiri,Maharashtra . Index case leading to discovery of endemic focus Santhanakrishnan et al Identified endemic focus in Thiruparankundram village,Chennai Srivastava et al (1969) Identified lahager village, Madhya Pradesh as an endemic focus. Christopher et al(1905) Polymorphism of eggs. Presence of ova of both S.haematobium and S.spindle in urine of South Indian Hooton (1914) Indigenous case from Rajkot, Gujarat De Mello(1936) Urinary schistosomiasis in a young boy from Goa Gadgil et al(1955) Indigenous case of S.haematobium infection from Nasik district. Arunava Kali.Journal of Clinical and Diagnostic Research. 2015

20. DISCUSSION This case report is evidence enough to indicate that population migration from endemic areas poses a significant threat of schistosomiasis in India. Reports of sporadic cases indicate the possibility of indigenous snails to serve as intermediate host for the parasite. Though cases of human schistosomiasis are very rare in India, occurrence of new hybrid strains due to co-existence of different species may serve as a potential risk for human infections. Physicians are required to have a high level of suspicion for this disease while evaluating parasitic infestations . It heralds importance of a surveillance strategy even in non-endemic areas like India, to enable early identification of cases and initiate prompt treatment ,thereby checking the spread of this neglected tropical disease.