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History of fresh water exposure in an endemic area Acute schistosomiasis: fever, headache, myalgias, cough, malaise, urticaria, diarrhea, and eosinophilia Intestinal schistosomiasis: abdominal pain, fatigue, diarrhea, and hepatomegaly, progressing to anorexia, weight loss, and features of portal hypertension

2 Acute schistosomiasis (Katayama syndrome) A febrile illness may develop 2 8 weeks after exposure in persons without prior infection, most commonly after heavy infection with S mansoni or S japonicum Presenting symptoms and signs include acute onset of fever; headache; myalgias; cough; malaise; urticaria; and diarrhea, which may be bloody Laboratory findings may include hepatosplenomegaly, lymphadenopathy, pulmonary infiltrates, leukocytosis, and marked eosinophilia Stool may be negative for eggs, especially early in disease Localized lesions may occasionally cause severe manifestations, including CNS abnormalities and death Acute schistosomiasis usually resolves in 2 8 weeks 3 Chronic schistosomiasis A large proportion of infected persons have light infections and are asymptomatic, but an estimated 50 60% have symptoms and 5 10% have advanced organ damage Asymptomatic infected children may suffer from anemia and growth retardation Symptomatic patients with intestinal schistosomiasis typically experience abdominal pain, fatigue, diarrhea, and hepatomegaly Over years, anorexia, weight loss, weakness, colonic polyps, and features of portal hypertension develop Late manifestations include hematemesis from esophageal varices, hepatic failure, and pulmonary hypertension Urinary schistosomiasis may present within months of infection with hematuria and dysuria, most commonly in children and young adults Fibrotic changes in the urinary tract can lead to hydroureter, hydronephrosis, bacterial urinary infections and, ultimately, renal failure or bladder cancer

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Urinary schistosomiasis: hematuria and dysuria, progressing to hydroureter, hydronephrosis, urinary infections, and renal failure Diagnosis based on characteristic eggs in feces or urine; biopsy of rectal or bladder mucosa; positive serology

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Schistosomiasis, which affects more than 200 million persons worldwide, leads to severe consequences in 20 million persons and about 100,000 deaths annually The disease is caused by five species of trematode blood flukes Four species cause intestinal schistosomiasis, with infection of mesenteric venules: Schistosoma mansoni, which is present in Africa, the Arabian peninsula, South America, and the Caribbean; Schistosoma japonicum, which is endemic in China and Southeast Asia; Schistosoma mekongi, which is endemic near the Mekong River in Southeast Asia; and Schistosoma intercalatum, which occurs in parts of Africa Schistosoma haematobium causes urinary schistosomiasis, with infection of venules of the urinary tract, and is endemic in Africa and the Middle East Transmission of schistosomiasis is focal, with greatest prevalence in poor rural areas Control efforts have diminished transmission significantly in many areas, but high level transmission remains common in sub-Saharan Africa and some other areas Prevalence of infection and illness typically peaks at about 15 20 years of age Humans are infected with schistosomes after contact with fresh water containing cercariae released by infected snails Infection is initiated by penetration of skin or mucous membranes After penetration, schistosomulae migrate to the portal circulation, where they rapidly mature After about 6 weeks, adult worms mate, and migrate to terminal mesenteric or bladder venules, where females deposit their eggs Some eggs reach the lumen of the bowel or bladder and are passed with feces or urine, while others are retained in the bowel or bladder wall or transported in the circulation to other tissues, in particular the liver Disease in endemic areas is primarily due to a host response to eggs, with granuloma formation and inflammation, eventually leading to fibrosis Chronic infection can result in scarring of mesenteric or vesicular blood vessels, leading to portal hypertension and alterations in the urinary tract In previously uninfected individuals, such as travelers with fresh water contact in endemic regions, acute schistosomiasis may occur, with a febrile illness 2 8 weeks after infection.

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