Diagnosing Acute Schistosomiasis
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CORRESPONDENCE
Note Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. P. Soentjens,1,2 J. Clerinx,2 A. Aerssens,1 L. Cnops,2 M. Van Esbroeck,2 and E. Bottieau2 1
Military Hospital Queen Astrid, Bruynstraat 1, 1120 Brussels; and 2Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
Downloaded from http://cid.oxfordjournals.org/ at OHSU Main Library on March 26, 2015
TO THE EDITOR—We read with interest the article by Lambertucci et al in Clinical Infectious Diseases on 1 July 2013 [1] describing an outbreak of acute schistosomiasis in an nonendemic region in Brazil and would like to bring some additional comments to the readers’ attention. We agree that the diagnosis of acute schistosomiasis (or Katayama syndrome) in nonendemic settings is often delayed due to the low specificity of presenting symptoms. In addition, many studies reporting on schistosomiasis clusters, including this one, have shown that a substantial proportion of recently infected patients remains fully asymptomatic [2] and that diagnosis is often secondarily made by active tracing of other similarly exposed individuals, who should therefore be systematically and repeatedly evaluated for infection. In this report, however, it remains unclear whether all exposed individuals have been finally diagnosed with schistosomiasis, which would reveal a very high attack rate [2], or to which extent additional exposed cases may have been missed. Whereas a careful history taking should easily highlight exposure to surface water in sick travelers returning from endemic regions, this autochthonous outbreak went unrecognized due to a newly established local transmission in a nonendemic area. Such an expansion of schistosomiasis to new susceptible geographical areas is, however, not so exceptional and should not be overlooked by clinicians in areas close to endemic regions [3, 4]. We recently reported on an outbreak of schistosomiasis in Belgian soldiers after a stay in the Kalieme area of the Democratic Republic of Congo (DRC), near Lake Tanganyika, and also investigated features associated with infection in a case-control study [5]. We compared 49 serologically proven cases (including 8 with cercarial dermatitis and 7 with symptoms of acute schistosomiasis) with the remaining 148 seronegative Belgian sol-
diers deployed in DRC. Swimming, skin disorders, gastrointestinal symptoms, and eosinophil cell count >600 cells/µL were significantly more frequent in the seropositive group after multivariate analysis. In the present report, unfortunately, eosinophil count is not reported in the vast majority of cases (90%). Symptoms of acute schistosomiasis are sometimes severe enough to require hospitalization, and complications are not so uncommon. Pulmonary distress [6] and neurological involvement [7] have been regularly described. In this report, the classification of the remaining 3 admitted cases as “severe” seems more debatable and, in the absence of consensus on “severe Katayama,” makes comparisons with other series somehow unvalid. Finally, diagnosis of acute schistosomiasis is not straightforward at first presentation. The addition of a second serological test (such as indirect hemoagglutination) to a single enzyme immunoassay increases the sensitivity [5, 6], but even when combined with parasite examination, diagnosis is not established at first contact in about one-third of cases. Recently developed real-time polymerase chain reaction techniques for detection of Schistosoma species in serum have shown promising results for the early diagnosis of acute schistosomiasis [8, 9] and outperformed classic diagnostic tools in a recent European multicentric prospective study [10]. However, even with the best diagnostic techniques, initial clinical awareness remains critical for early recognition of acute schistosomiasis in the nonendemic setting.
References
Downloaded from http://cid.oxfordjournals.org/ at OHSU Main Library on March 26, 2015
1. Lambertucci JR, Drummond SC, Voieta I, et al. An Outbreak of acute Schistosoma mansoni schistosomiasis in a nonendemic area of Brazil: a report on 50 cases, including 5 with severe clinical manifestations. Clin Infect Dis 2013; 57:e1–6. 2. Jauréguiberry S, Paris L, Caumes E. Acute schistosomiasis, a diagnostic and therapeutic challenge. Clin Microbiol Infect 2010; 16: 225–31. 3. Clerinx J, Cnops L, Huyse T, Tannich E, Van Esbroeck M. Diagnostic issues of acute schistosomiasis with Schistosoma mekongi in a traveler: a case report. J Travel Med 2013; 20: 322–5. 4. Lachish T, Tandlich M, Grossman T, Schwartz E. High rate of schistosomiasis in travelers after a brief exposure to the highaltitude Nyinambuga crater lake, Uganda. Clin Infect Dis 2013; 57:1461–4. 5. Aerssens A, De Vos D, Pirnay JP, et al. Schistosomiasis in Belgian military personnel returning from the Democratic Republic of Congo. Mil Med 2011; 176:1341–6. 6. Bottieau E, Clerinx J, de Vega MR, et al. Imported Katayama fever: clinical and biological features at presentation and during treatment. J Infect 2006; 52:339–45. 7. Clerinx J, Van Gompel A, Lynen L, Ceulemans B. Early neuroschistosomiasis complicating Katayama syndrome. Emerg Infect Dis 2006; 12:1465–6. 8. Cnops L, Soentjens P, Clerinx J, Van Esbroeck M. A Schistosoma haematobium– specific real-time PCR for diagnosis of urogenital schistosomiasis in serum samples of international travelers and migrants. PLoS Negl Trop Dis 2013; 7:e2413. 9. Soentjens P, Cnops L, Peetermans W, et al. Diagnosis of a travel-related Schistosoma mansoni infection in a cohort of 21 subjects. In: Conference of the International Society for Travel Medicine, Maastricht, Netherlands, 19–23 May 2013. Poster P0-11.06. 10. Wichmann D, Panning M, Quack T, et al. Diagnosing schistosomiasis by detection of cell-free parasite DNA in human plasma. PLoS Negl Trop Dis 2009; 3:e422. Correspondence: P. Soentjens, MD, Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium ( [email protected]). Clinical Infectious Diseases 2014;58(2):304–5 © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. for Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/cit683
CORRESPONDENCE
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CID 2014:58 (15 January)
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304
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CID 2014:58 (15 January)
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CORRESPONDENCE
Note Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. P. Soentjens,1,2 J. Clerinx,2 A. Aerssens,1 L. Cnops,2 M. Van Esbroeck,2 and E. Bottieau2 1
Military Hospital Queen Astrid, Bruynstraat 1, 1120 Brussels; and 2Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
Downloaded from http://cid.oxfordjournals.org/ at OHSU Main Library on March 26, 2015
TO THE EDITOR—We read with interest the article by Lambertucci et al in Clinical Infectious Diseases on 1 July 2013 [1] describing an outbreak of acute schistosomiasis in an nonendemic region in Brazil and would like to bring some additional comments to the readers’ attention. We agree that the diagnosis of acute schistosomiasis (or Katayama syndrome) in nonendemic settings is often delayed due to the low specificity of presenting symptoms. In addition, many studies reporting on schistosomiasis clusters, including this one, have shown that a substantial proportion of recently infected patients remains fully asymptomatic [2] and that diagnosis is often secondarily made by active tracing of other similarly exposed individuals, who should therefore be systematically and repeatedly evaluated for infection. In this report, however, it remains unclear whether all exposed individuals have been finally diagnosed with schistosomiasis, which would reveal a very high attack rate [2], or to which extent additional exposed cases may have been missed. Whereas a careful history taking should easily highlight exposure to surface water in sick travelers returning from endemic regions, this autochthonous outbreak went unrecognized due to a newly established local transmission in a nonendemic area. Such an expansion of schistosomiasis to new susceptible geographical areas is, however, not so exceptional and should not be overlooked by clinicians in areas close to endemic regions [3, 4]. We recently reported on an outbreak of schistosomiasis in Belgian soldiers after a stay in the Kalieme area of the Democratic Republic of Congo (DRC), near Lake Tanganyika, and also investigated features associated with infection in a case-control study [5]. We compared 49 serologically proven cases (including 8 with cercarial dermatitis and 7 with symptoms of acute schistosomiasis) with the remaining 148 seronegative Belgian sol-
diers deployed in DRC. Swimming, skin disorders, gastrointestinal symptoms, and eosinophil cell count >600 cells/µL were significantly more frequent in the seropositive group after multivariate analysis. In the present report, unfortunately, eosinophil count is not reported in the vast majority of cases (90%). Symptoms of acute schistosomiasis are sometimes severe enough to require hospitalization, and complications are not so uncommon. Pulmonary distress [6] and neurological involvement [7] have been regularly described. In this report, the classification of the remaining 3 admitted cases as “severe” seems more debatable and, in the absence of consensus on “severe Katayama,” makes comparisons with other series somehow unvalid. Finally, diagnosis of acute schistosomiasis is not straightforward at first presentation. The addition of a second serological test (such as indirect hemoagglutination) to a single enzyme immunoassay increases the sensitivity [5, 6], but even when combined with parasite examination, diagnosis is not established at first contact in about one-third of cases. Recently developed real-time polymerase chain reaction techniques for detection of Schistosoma species in serum have shown promising results for the early diagnosis of acute schistosomiasis [8, 9] and outperformed classic diagnostic tools in a recent European multicentric prospective study [10]. However, even with the best diagnostic techniques, initial clinical awareness remains critical for early recognition of acute schistosomiasis in the nonendemic setting.
References
Downloaded from http://cid.oxfordjournals.org/ at OHSU Main Library on March 26, 2015
1. Lambertucci JR, Drummond SC, Voieta I, et al. An Outbreak of acute Schistosoma mansoni schistosomiasis in a nonendemic area of Brazil: a report on 50 cases, including 5 with severe clinical manifestations. Clin Infect Dis 2013; 57:e1–6. 2. Jauréguiberry S, Paris L, Caumes E. Acute schistosomiasis, a diagnostic and therapeutic challenge. Clin Microbiol Infect 2010; 16: 225–31. 3. Clerinx J, Cnops L, Huyse T, Tannich E, Van Esbroeck M. Diagnostic issues of acute schistosomiasis with Schistosoma mekongi in a traveler: a case report. J Travel Med 2013; 20: 322–5. 4. Lachish T, Tandlich M, Grossman T, Schwartz E. High rate of schistosomiasis in travelers after a brief exposure to the highaltitude Nyinambuga crater lake, Uganda. Clin Infect Dis 2013; 57:1461–4. 5. Aerssens A, De Vos D, Pirnay JP, et al. Schistosomiasis in Belgian military personnel returning from the Democratic Republic of Congo. Mil Med 2011; 176:1341–6. 6. Bottieau E, Clerinx J, de Vega MR, et al. Imported Katayama fever: clinical and biological features at presentation and during treatment. J Infect 2006; 52:339–45. 7. Clerinx J, Van Gompel A, Lynen L, Ceulemans B. Early neuroschistosomiasis complicating Katayama syndrome. Emerg Infect Dis 2006; 12:1465–6. 8. Cnops L, Soentjens P, Clerinx J, Van Esbroeck M. A Schistosoma haematobium– specific real-time PCR for diagnosis of urogenital schistosomiasis in serum samples of international travelers and migrants. PLoS Negl Trop Dis 2013; 7:e2413. 9. Soentjens P, Cnops L, Peetermans W, et al. Diagnosis of a travel-related Schistosoma mansoni infection in a cohort of 21 subjects. In: Conference of the International Society for Travel Medicine, Maastricht, Netherlands, 19–23 May 2013. Poster P0-11.06. 10. Wichmann D, Panning M, Quack T, et al. Diagnosing schistosomiasis by detection of cell-free parasite DNA in human plasma. PLoS Negl Trop Dis 2009; 3:e422. Correspondence: P. Soentjens, MD, Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium ( [email protected]). Clinical Infectious Diseases 2014;58(2):304–5 © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. for Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/cit683
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