A case report of Schistosoma haematobium infection

Journal of Travel Medicine, 2016, 1–3 doi: 10.1093/jtm/taw076 Brief communication

Brief communication

A case report of Schistosoma haematobium infection in a pregnant migrant raises concerns about lack of screening policies Maria Mazzitelli1,*, Giovanni Matera2, Carmela Votino3, Federica Visconti3, Alessio Strazzulla1, Maria Teresa Loria2, Cinzia Peronace2, Pio Settembre2, 2, Fulvio Zullo3 and Carlo Torti1 Aida Giancotti2, Maria Carla Liberto2, Alfredo Foca Unit of Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, Viale Europa, Catanzaro, Italy, 2Institute of Microbiology, Department of Health Sciences, “Magna Graecia” University, Viale Europa, Catanzaro, Italy and 3Unit of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, Viale Europa, Catanzaro, Italy *To whom correspondence should be addressed. Maria Mazzitelli, MD, U.O. Malattie Infettive, A.O.U. “Mater Domini”, Viale Europa, 88100 Catanzaro, Italy. Tel: þ39 324 8991220. E-mail: [email protected] Accepted 4 October 2016

Abstract Pregnant women with urinary schistosomiasis should be treated, but screening is not implemented in migrants. We report herein a case of a migrant diagnosed late into pregnancy, after diagnosis was made in her husband. Praziquantel was safe and effective. Schistosomiasis should be considered in pregnant women from endemic countries. Key words: Schistosomiasis, pregnancy, migration, screening

Background

Case Report

Schistosomiasis is a highly endemic disease in resource-limited settings, with a global prevalence of 240 millions of cases.1 Forty millions people were treated for schistosomiasis in 2013. Moreover, it is estimated that, in some endemic areas, up to 20% of pregnant women suffer from schistosomiasis.2 Moreover, there are reports of pregnant travellers who acquired Schistosoma species infections in endemic areas.3 The World Health Organization (WHO) recommends that every pregnant woman is treated if a diagnosis of schistosomiasis is made,4 but this recommendation is poorly implemented, partly because of concerns regarding adverse events in pregnancy. Importantly, notwithstanding massive migration phenomenon (involving in Italy especially the southern areas), routine screening for schistosomiasis has not been recommended. Herein we report a case of a migrant women coming from Mali with a Schistosoma haematobium infection diagnosed at 25-week gestation. Outcome and implications of this case are discussed.

A 32 years old man from Mali was referred to our Institution complaining of low abdominal pain, laterally irradiated and dysuria. He had already undergone a computerized tomography (CT) scan at another hospital, revealing extensive calcifications of the urinary tract, suggestive for S. haematobium infection (Figure 1a). This was confirmed by microscopical examination of pellet obtained from centrifuged urine. During consultation, the patient let us know that he migrated with his wife of 20 years old of age, who was pregnant (25-week gestation), together with their two children. He also informed us that his wife was asymptomatic, with the exception of occasional lower abdominal pain during urination, started 6 years before. Her red-blood count revealed mild anaemia (Hb ¼ 9.8 g/dL), white-cell count was 8.460/mm3 and eosinophil count was 381/mm3 (4.5%). Three stool samples obtained every other day were negative for protozoa cysts and trophozoites, as well as for ova, larval and adult forms. Samples of urine were collected between 10:00 AM and 2:00 PM, well mixed and 10 mL of them were forced through an

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8 mm polycarbonate filter, as reported by Peters et al.5 For the evaluation of post-treatment egg viability, miracidium differentiation at 25 in distilled water was followed by light microscopy. Microscopical examination of pellet of centrifuged urine revealed schistosomal eggs (10/10 ml). Schistosoma eggs hatched under the microscopic examination and a swimming miracidium was observed (Figure 1b). Abdominal and fetal ultrasounds during pregnancy were also performed, but without pathological findings, although information on the maternal urinary tract were limited by the pregnancy status. Intrauterine growth restriction (IUGR) under the 10th percentile of the growth curve of the foetus was found. Since WHO recommends treatment for pregnant women, two oral doses of praziquantel (30 mg per kilogram of body weight) were administered in light of a recent trial demonstrating safety of this regimen in pregnancy when used for S. japonicum.6 Praziquantel was administered 3 h apart and the patient was discharged after 8 h. One month after therapy, the patient came back for clinical and parasitological follow-up. In January 2016, S. haematobium ova were still found in urine (6 ova/10 ml), even if eggs did not show any signs of vitality. Parasitological examination of urine became negative in February 2016. In March 2016, the patient delivered at full-term gestation (39 week plus 4 days) an apparently healthy newborn of female gender, whose weight was 2520 g.

Discussion Preventing and reversing major urinary tract lesions (including hydronephrosis) would be the main aim in every patient with

urinary schistosomiasis. However, in females, urogenital schistosomiasis may also cause internal organ granulomatous lesions involving uterus, tubes and ovaries. Thus, infertility, menstrual alterations and cervix inflammation are often observed. Typical ulcerative and sometime fistulous pathologies may involve perianal and vulvar regions; such illnesses are often associated with pelvic discomfort, vaginal discharge and dyspareunia.7 Also, schistosomiasis may influence uterine environment and functions. This could make conception more difficult, leading to sterility and ectopic pregnancy.8 In pregnant subjects, this parasitic disease is also associated with serious anaemia, low weight of the newborns and enhances the risk of maternal mortality.9 A proper diagnostic work-up for schistosomiasis includes as a gold standard parasitological examination of urine first and abdominal ultrasound as additional test to stage the resulting urinary tract diseases before and after treatment in selected cases.5,10,11 In contrast with these recommendations, the husband was referred to us with a CT scan already performed. This fact was due to lack of clinical suspicion, clearly indicating insufficient knowledge about tropical diseases of the consulted doctors in our region. For the wife, we performed parasitological examination of urine first, then an abdominal ultrasound was performed but its result was limited because of the ongoing pregnancy. As an optional exam, we tested viability of the excreted eggs to assess the efficacy of treatment but this interesting option was outside the scope of the average clinical laboratory and not really required for the management of patient as part of the routine clinical care. Since 2002, WHO recommended to use praziquantel during pregnancy and lactation,4 and more recent publications support such drug as a safe and effective therapy in pregnant and breastfeeding women affected by schistosomiasis.6,12 Unfortunately, albeit the fact that sub-Saharian migrants are massively arriving in Southern Italian regions, the problem of schistosomiasis is largely underestimated and screening policy does not include schistosomiasis as a target in pregnant women. Indeed, it was only through recognition of the disease in the husband that we had the chance to contact his pregnant wife and test her. Application of a screening strategy or syndromic surveillance would have led to make the diagnosis and treat this pregnant woman earlier. Clearly, if such approach is extended to the general population of migrants coming from endemic areas, we would prevent autochtonous cases. In two Italian islands (Sardinia and Sicily), the presence of the intermediate host (Bulinus truncatus) has been reported.13 Although no data are available for the Calabria region, it can be hypothesised that this intermediate host is present due to the similar environment, climate and geographical proximity to Sicily. Indeed, reemergence of schistosomiasis in some European regions is of great concern.14,15 Clearly, pregnant women should be primarily targeted for screening and treatment with praziquantel; however, data supported by trials are not available for treatment of S. haematobium in pregnancy. Only data supporting safety of this drug in pregnancy can be deduced from a trial in women infected by S. japonicum.6 Moreover, the expected benefits of this kind of treatment are likely to be optimal if the drug is given in the first stages of pregnancy or, ideally, before conception. Indeed, available data6,16 did not prove any significant benefits on maternal


Figure 1. Diagnostic features of our cases. Computerized tomography showed extensive calcification in the urinary tract of husband (panel a), while microscopical examination of pellet of centrifuged urine of wife revealed a swimming miracidium together with a S. haematobium ovum (panel b).

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anaemia or birthweight. However, low nutritional status of the mothers, low intensity of infections, parasitic or HIV coinfections could have reduced the benefits of treatment.17 Intrauterine growth restriction placed the newborn under the 10th percentile of the growth curve, so the diagnosis of IUGR could be made. Interestingly, the mother did not show any signs of malnutrition, parasitic or HIV co-infection, and the intensity of infection was significant. Hence, it can be hypothesised (but not proven) that schistosomiasis had an impact.18 Overall these considerations suggest that migrant women should be screened and treated pre-conceptionally, even though, to our best knowledge, no cases of congenital schistosmiasis have been published until now.

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7. 8. 9. 10. 11.

Acknowledgements

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Conflict of interest: None declared. 14.

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We thank Dr Veronica Pileggi and Mr Rosario Zurzolo (Jungi Mundi Community for Migrant Assistance, Camini, Italy), the patient herself and her husband.

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