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      Adventure tourism and schistosomiasis: serology and clinical findings in a group of Danish students after white-water rafting in Uganda

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          Abstract

          Introduction

          Diagnosis of schistosomiasis in travellers is a clinical challenge, since cases may present with no symptoms or a few non-specific symptoms. Here, we report on the laboratory and clinical findings in Danish travellers exposed to Schistosoma-infested water during white-water rafting on the Ugandan part of the upper Nile River in July 2009.

          Case presentation

          Forty travellers were offered screening for Schistosoma-specific antibodies. Serological tests were performed 6–65 weeks after exposure. A self-reporting questionnaire was used to collect information on travel activity and health history, fresh water exposure, and symptoms. Seropositive cases were referred to hospitals where clinical and biochemical data were collected. Schistosoma-specific antibodies were detected in 13/35 (37 %) exposed participants, with 4/13 (31 %) seroconverting later than 2 months following exposure. Four of thirteen (31 %) cases reported ≥3 symptoms compatible with schistosomiasis, with a mean onset of 41 days following exposure. No Schistosoma eggs were detected in stool or urine in any of the cases. Peripheral eosinophilia (>0.45×10 9 cells l −1) was seen in 4/13 cases, while IgE levels were normal in all cases.

          Conclusion

          Schistosomiasis in travellers is not necessarily associated with specific signs or symptoms, eosinophilia, raised IgE levels, or detection of eggs. The only prognostic factor for infection was exposure to freshwater in a Schistosoma-endemic area. Seroconversion may occur later than 2 months after exposure and therefore – in the absence of other diagnostic evidence – serology testing should be performed up to at least 2–3 months following exposure to be able to rule out schistosomiasis.

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          Most cited references 21

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          Human schistosomiasis.

          Schistosomiasis or bilharzia is a tropical disease caused by worms of the genus Schistosoma. The transmission cycle requires contamination of surface water by excreta, specific freshwater snails as intermediate hosts, and human water contact. The main disease-causing species are S haematobium, S mansoni, and S japonicum. According to WHO, 200 million people are infected worldwide, leading to the loss of 1.53 million disability-adjusted life years, although these figures need revision. Schistosomiasis is characterised by focal epidemiology and overdispersed population distribution, with higher infection rates in children than in adults. Complex immune mechanisms lead to the slow acquisition of immune resistance, though innate factors also play a part. Acute schistosomiasis, a feverish syndrome, is mostly seen in travellers after primary infection. Chronic schistosomal disease affects mainly individuals with long-standing infections in poor rural areas. Immunopathological reactions against schistosome eggs trapped in the tissues lead to inflammatory and obstructive disease in the urinary system (S haematobium) or intestinal disease, hepatosplenic inflammation, and liver fibrosis (S mansoni, S japonicum). The diagnostic standard is microscopic demonstration of eggs in the excreta. Praziquantel is the drug treatment of choice. Vaccines are not yet available. Great advances have been made in the control of the disease through population-based chemotherapy but these required political commitment and strong health systems.
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            Schistosomiasis.

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              Katayama syndrome.

              Katayama syndrome is an early clinical manifestation of schistosomiasis that occurs several weeks post-infection with Schistosoma spp (trematode) worms. Because of this temporal delay and its non-specific presentation, it is the form of schistosomiasis most likely to be misdiagnosed by travel medicine physicians and infectious disease specialists in non-endemic countries. Katayama syndrome appears between 14-84 days after non-immune individuals are exposed to first schistosome infection or heavy reinfection. Disease onset appears to be related to migrating schistosomula and egg deposition with individuals typically presenting with nocturnal fever, cough, myalgia, headache, and abdominal tenderness. Serum antibodies and schistosome egg excretion often substantiate infection if detected. Diffuse pulmonary infiltrates are found radiologically, and almost all cases have eosinophilia and a history of water contact 14-84 days before presentation of clinical symptoms; patients respond well to regimens of praziquantel with and without steroids. Artemisinin treatment given early after exposure may decrease the risk of the syndrome.
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                Author and article information

                Journal
                JMM Case Rep
                JMM Case Rep
                JMMCR
                JMM Case Reports
                Microbiology Society
                2053-3721
                April 2018
                2 February 2018
                2 February 2018
                : 5
                : 4
                Affiliations
                [ 1]Laboratory of Parasitology, Department of Bacteria, Parasites and Fungi, Statens Serum Institut , Artillerivej 5, DK–2300 Copenhagen S, Denmark
                [ 2]Department of Pediatrics, Herlev Hospital , Herlev Ringvej 75, DK–2730 Herlev, Denmark
                [ 3]Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet , Blegdamsvej 9, DK–2100 Copenhagen Ø, Denmark
                [ 4]Department of Infectious Diseases, Hvidovre Hospital , Kettegård Alle 30, DK–2650 Hvidovre, Denmark
                Author notes
                *Correspondence: Christen Rune Stensvold, run@ 123456ssi.dk
                Article
                jmmcr005141
                10.1099/jmmcr.0.005141
                5982149
                © 2018 The Authors

                This is an open access article under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

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                Gastrointestinal
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