Genitourinary Schistosomiasis

Genitourinary Schistosomiasis Overview

• Chronic infection by trematodes of the genus Schistosoma causes genitourinary schistosomiasis.
• Schistosomiasis involves free-swimming cercariae penetrating the skin
• The trematodes mature into adult male and female worms.
• Schistosomiasis affects the venous plexuses of abdominal viscera

Species Location

• S. mansoni and S. japonicum reside in Mesenteric veins, can cause GI and Hepatic disease.
• S. haematobium dwells in the Perivesical Venous Plexus, resulting in Urinary Schistosomiasis.

Boilogy

• Pairs of male and female worms attach to blood vessel endothelia
• Average lifespan of the worms is 3-6 years.
• Most eggs are microembolize in the microvasculature of the lungs, liver etc.
• Around 20% can cross into the lumina of the hollow viscera near the worm pair.
• S. haematobium eggs are predominantly excreted in urine, with few in feces.
• The body entraps eggs in tissue to become calcified and accumulate.
• The host destroys the eggs through a granulomatous immune response, which may lead to clinical morbidity and mortality.
• S. haematobium eggs measure 80-150 μm, are ovoid, and have a small spine at their terminal end.
• Laterally spined S. mansoni eggs are distinct from the terminally spined ones.
• Diagnostic terminally spined eggs are often detected in urine, feces, or human tissue, especially intestinal or bladder wall biopsy.

Freshwater Snail

• The life cycle of S. haematobium begins when eggs from a mammal reach fresh water, hatch, and release miracidia.
• Miracidia can survive 1–3 weeks in fresh water, needing to infect a snail of the genus Bulinus to complete their cycle.
• Snails are found in slow-moving freshwater streams or open water sources, can be natural or artificial.
• Miracidium then grows into an adult sporocyst, releasing larvae cercariae 4–6 weeks post-infection.
• Cercariae are able to survive 72 hours in fresh water.
• Cercariae penetrate the skin of humans/mammals or die.
• Cercariae enter a host by penetrating the buccal mucous membrane.
• The cercariae that are swallowed are digested in the stomach.

Human Phase

• In humans, worms produce eggs that are highly antigenic, leading to an intense granulomatous response.
• Following excretion by the parasite, eggs make their way through the bladder wall and are shed in urine or feces.
• The eggs develop miracidia during their 10-day migration.
• Worms cause micromucosal perforation through egg laying
• Repeated perforation causes hematuria.
• Eggs not secreted remain in the submucosa of the pelvic organs, where they are encapsulated in fibrous granulomas.

Pathogenesis

• Worms are tolerated in veins that don't lead to thrombosis.
• The presence of eggs rather than worms causes disease.
• Disease arises from granulomatous host response to schistosome eggs.
• Histiolytic antigen from deposited eggs leads to a T cell-mediated immune response.
• The infiltrate is characterized by eosinophils which causes polypoid patches surrounded by hyperemia
• At first a granulomatous lesion forms
• Each stage has granulomas present

Pathology Gross

• The areas of granulomatous inflammation form large polypoid masses projecting into the lumen.
• Active schistosomiasis presents with multiple inflammatory polyps linked to heavy egg burden.
• Adult worms die causing inactive urinary schistosomiasis occurring after, characterized by none viable eggs
• The presence of sandy patches are relatively flat tan mucosal lesions, with indefinite borders.
• Inflammation associated with egg-laying wanes forming these patches.
• Remaining entrapped eggs are destroyed as the tissue calcifies

Bilharziasis Of Kidney

• Kidneys are not a primary target of S haematobium.
• It may be affected through ureteral obstruction and VUR.
• Renal disease develops slowly, including hydroureter, and chronic VUR.
• Late-stage fibrosis results from VUR (Renal calculi and hydronephrosis or Pyonephrosis due to ureteral obstruction or Nephrotic Syndrome)
• Hydroureter precedes hydronephrosis.

Bilharziasis Of the Ureter

• Ureteral schistosomiasis involvement has been reported in around 65% of cases.
• Eggs can be located in all layers, like suburothelially and between the muscle layers.
• Intramural involvement leads to mural fibrosis, loss of muscle, and peri-ureteric adhesions.
• The sum of these changes results in obstructive uropathy with stricture, atony, and dilatation.
• The condition is sometimes referred to as VUR.
• Eventually, urinary stasis invites infection and stone development.
• Ureteric bilharzial lesions include, ureteritis cystica or calcinosa and urethritis glandularis.
• You see ureteral wall fibrosis with degenerated, obliterated mucosa which causes ureteric strictures
• Ureteral dilation is an early stage where ureteral dysfunction, and not tissue damage, is seen.
• Obstruction is the result of concentric polypoid lesions.

Schistosomal Obstructive Uropathy

• The obstruction is caused by "girdling" the ureteral muscle in intramural and adjacent extravesical ureter.
• Fibrosis causes ureteral strictures later in the infection
• 80%+ of the earliest structures happen in Intavesical Segment of Ureter which is the 2-5cm

Types of hydroureter

• 25% of obstructive uropathy occurs in cases that involve segmental ureteral dilation, 80% happen in lower ureter, concentric muscular obliteration, fibrosis.
• These infections rarely cause significant hydronephrosis.
• Tonic hydroureter accounts for 30% obstructive and thick, trabeculated muscles, and marks uretal action and function.
• It's accompanied by significant hydronephrosis that reverses where obstruction relieves
• Atonic Hydroureter accounts for 45% of obstructive and tortuous, and thin walled with the fibrosis

Cause And Effect of Bilharzia

• Schistosomal can results in severe or mild Hydronephrosis, renal pelvic dilation, medullary atrophy or cortical atrophy
• The abrogation of tubular is tubular and glomerular failure

Bilharzia and Bladder lesions

• Ground-glass ischemic mucosa with Cystitis cystica and Bladder Wall calcifications caused by Bladder and Leukoplakia
• Submucosal causes Bilharzial (Fibrosis with calcification and Bilharzial nodules)
• Muscular, Muscle degeneration causes bilharzial to reach children

Acute and Chronic Stages

• Polyposis and ulceration (acute)
• Sand patches and small bladder(chronic)
• Hyperplasia, Metaplasia, Dysplasia causes Cancer

Bladders tubercles and Bilharzial Polyps Incidence

• Early active seeds of yellowness prominate, that are distinct and larger
• Active desnity granuloma and submucosa(usually trigone), red and clusterd

Bilharzal Villous Polyps

• Similar of papillomata is reaveled by distinctive granulations in polyps
• Ischemia from bilarzial vessels from bacteria

###Bilharzia Ulcers

• Infections are seein in children and found from granulomata and epithelium
• Surface easily from distention
• Ulcers are often infection sequelae, dense and morhpoic from margins.
• Bleeding and circumferential bleeding with elvetative

Bilharzia Mucosa

• Infestation loses with healthy pink luster, dull is more visible because lack of branching

Clacific PLaque and Bladder Wall

• Localized is a rise in a white plateu is deposited, and looks more common in young patients.
• Eggs in the mucosa and the number is calcified eggs form linear pattern.
• Calcified deposits shows chronic schistosomiasis of a fetal head.

Bilharzia and Calcification Patterns

• This depends on the fine graunlar or irregular if marked
• It resolve in submucsa or by excretion in bladder, but it still have some indruated margins

Sandy and Other Patches

• Athrophy thins by old calcified, with the surface epithelium over, appear with shallow water
• Urothesis budds with von Brunn in laming and that differentiate and intestinal mucins leads to Adenocarcinoma

Bladders and Leukiopakias

• Glandual cysts look for mucosa cobblestones is velvty but mass occurs with carcinoma in a neck
• The urosepsis that causes chronic irriations occurs if deficiency is present

Real-Time Pcr or the Diagnosis

• Developmnet is nearly 100X that is better than most sensitivitiv diagnostic that detects a chronicity

IVPS and VCUGS

• Polypoid lesions defact for obstructions and postvoid is the fluroscopy allows differeetiation

Medical and Prevention

• A mechanisms interrupts transmition for calcium to allow reduced absoprtion with active forms and helps presence of antibody

Symptoms of bladder in the ureters

• The constant pain for pain are lower stomach makes diagnosis based on urine to lower the need for surgery and help

Prevention

• If no infections, good prognosis is dependent for schistosomaiasis

Treatments

• Prazinquantel and other meds often improve dramatically when uropathy resolves