Schistosomiasis (bilharzia) - cause, transmission mode, symptoms, types, treatment and pregnancy

Schistosomiasis is an acute and chronic parasitic disease caused by blood flukes (trematode worms) of the genus Schistosoma.

What is schistosomiasis or bilharzia?

Schistosomiasis is an acute and chronic disease caused by parasitic worms. It is transmitted when larval forms released by freshwater snails penetrate human skin during contact with infested water.

In which regions is the disease mostly found?

Schistosomiasis is prevalent in tropical and subtropical areas of the world. It is more prevalent in poor communities without access to safe drinking water and adequate sanitation. It is estimated that at least 90% of those requiring treatment for schistosomiasis live in Africa.

Schistosomiasis transmission mode 

Bilharzia is transmitted when people suffering from schistosomiasis contaminate freshwater sources with their excreta containing parasite eggs, which hatch in water. In the body, the larvae develop into adult worms. These worms live in the blood vessels where the females release eggs. Some of the eggs are passed out of the body in the faeces or urine to continue the parasite’s life cycle. Others become trapped in body tissues, causing immune reactions and progressive damage to organs.

Types of Schistosomiasis

There are two major forms of schistosomiasis: 

1. Intestinal Schistosomiasis 
2. Urogenital Schistosomiasis 

Both forms affect mainly poor and rural communities, particularly agricultural and fishing populations.

Symptoms of intestinal schistosomiasis

Intestinal schistosomiasis can cause :- 

• Abdominal pain
• Diarrhoea
• Blood in the stool. 
• Liver enlargement is common in advanced cases and is frequently associated with an accumulation of fluid in the peritoneal cavity and hypertension of the abdominal blood vessels.
• In such cases there may also be enlargement of the spleen.

Symptoms of urogenital schistosomiasis

The classic sign is :- 

• Presence of blood in urine (haematuria). 
• Fibrosis of the bladder and ureter, and kidney damage are sometimes diagnosed in advanced cases. 
• Bladder cancer is another possible complication in the later stages. 
• In women, urogenital schistosomiasis may present with genital lesions, vaginal bleeding, pain during sexual intercourse, and nodules in the vulva. 
• In men, urogenital schistosomiasis can induce pathology of the seminal vesicles, prostate, and other organs.

Is the disease more complicated in women?

Women doing domestic chores in infested water, such as washing clothes in areas endemic for the disease, are greatly at risk. Women can also develop female genital schistosomiasis – which can cause genital lesions, vaginal bleeding, pain during sexual intercourse, and nodules in the vulva. Female genital schistosomiasis is also considered to be a risk factor for HIV infection, especially in women.

How do children get exposed and how can the disease affect them?

Lack of hygiene and certain play habits of school-aged children such as swimming or fishing in infested water make them especially vulnerable to infection. Schistosomiasis can also cause anaemia and stunting and a reduced ability to learn among children.

Treatment of schistosomiasis 

All forms of schistosomiasis can be treated effectively by the WHO-recommended medicine praziquantel. It is effective, safe, and low-cost. 

Even though re-infection may occur after treatment, the risk of developing severe disease is diminished and even reversed when treatment is initiated and repeated in childhood. As part of its global strategy to control the disease, WHO focuses on reducing the disease through periodic, targeted treatment with praziquantel through the large-scale treatment (preventive chemotherapy) of affected populations. This involves regular treatment of all at-risk groups.

Can pregnant women be treated with praziquantel?

Praziquantel is extremely safe and WHO recommends that pregnant women infected with the disease should be treated. But as a general precaution, WHO recommends treatment should be taken after the first trimester.

Should tourists be concerned when traveling to countries that have schistosomiasis?

Tourists can easily avoid infection by not swimming in fresh water in areas where schistosomiasis is likely to occur. Even if infected, the worms do not cause a life-threatening disease for someone who is generally healthy. The disease is only serious for people living in endemic areas who become constantly re-infected and have no access treatment. If infected, treatment with praziquantel is easy, efficacious and safe.

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Is there a risk for those handling dead bodies?

For people handling dead bodies (rescue workers, mortuary workers, etc.), there is a risk if the deceased are infected with highly infectious disease (such as Ebola, Lassa fever, cholera). The infectious agents responsible for these diseases last for varying periods after death. The internal organs that harbour organisms such as tuberculosis, which can survive for very long periods after a person’s death, are usually handled only by trained personnel during an actual autopsy. This is not part of any procedure described in this manual. Processes to support persons handling the dead should be in place to deal with any psychological impacts arising from their work.

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The top 10 causes of death in 2019 globally

 In 2019, the top 10 causes of death accounted for 55% of the 55.4 million deaths worldwide.

Top 10 Leading causes of death globally in 2019

S.No.	Disease Name	Number of Deaths (in millions)
1)	Ishaemic heart disease	Near to 09 million
2)	Stroke	More than 06 million
3)	Chronic obstructive pulmonary disease	Near to 04 million
4)	Lower respiratory infection	More than 03 million
5)	Neonatal conditions	Near to 04 million
6)	Trachea, bronchus, lung cancers	Close to 02 million
7)	Alzheimer’s disease and other dementias	Close to 02 million
8)	Diarrhoeal diseases	More than 02 million
9)	Diabetes mellitus	Near to 2 million
10)	Kidney disease	More than 01 million

The top global causes of death, in order of total number of lives lost, are associated with three broad topics: cardiovascular (ischaemic heart disease, stroke), respiratory (chronic obstructive pulmonary disease, lower respiratory infections) and neonatal conditions – which include birth asphyxia and birth trauma, neonatal sepsis and infections, and preterm birth complications.

Causes of death can be grouped into three categories: communicable (infectious and parasitic diseases and maternal, perinatal and nutritional conditions), noncommunicable (chronic) and injuries.

At a global level, 7 of the 10 leading causes of deaths in 2019 were noncommunicable diseases. These seven causes accounted for 44% of all deaths or 80% of the top 10. However, all noncommunicable diseases together accounted for 74% of deaths globally in 2019.

The world’s biggest killer is ischaemic heart disease, responsible for 16% of the world’s total deaths. Since 2000, the largest increase in deaths has been for this disease, rising by more than 2 million to 8.9 million deaths in 2019. Stroke and chronic obstructive pulmonary disease are the 2nd and 3rd leading causes of death, responsible for approximately 11% and 6% of total deaths respectively.

Lower respiratory infections remained the world’s most deadly communicable disease, ranked as the 4th leading cause of death. However, the number of deaths has gone down substantially: in 2019 it claimed 2.6 million lives, 460 000 fewer than in 2000.

Neonatal conditions are ranked 5th. However, deaths from neonatal conditions are one of the categories for which the global decrease in deaths in absolute numbers over the past two decades has been the greatest: these conditions killed 2 million newborns and young children in 2019, 1.2 million fewer than in 2000.  

Deaths from noncommunicable diseases are on the rise. Trachea, bronchus and lung cancers deaths have risen from 1.2 million to 1.8 million and are now ranked 6th among leading causes of death.

In 2019, Alzheimer’s disease and other forms of dementia ranked as the 7th leading cause of death. Women are disproportionately affected. Globally, 65% of deaths from Alzheimer’s and other forms of dementia are women.

One of the largest declines in the number of deaths is from diarrhoeal diseases, with global deaths falling from 2.6 million in 2000 to 1.5 million in 2019. 

Diabetes has entered the top 10 causes of death, following a significant percentage increase of 70% since 2000. Diabetes is also responsible for the largest rise in male deaths among the top 10, with an 80% increase since 2000. 

Other diseases which were among the top 10 causes of death in 2000 are no longer on the list. HIV/AIDS is one of them. Deaths from HIV/AIDS have fallen by 51% during the last 20 years, moving from the world’s 8th leading cause of death in 2000 to the 19th in 2019.

Kidney diseases have risen from the world’s 13th leading cause of death to the 10th. Mortality has increased from 813 000 in 2000 to 1.3 million in 2019.

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What is Ebola virus disease

Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a severe, often fatal illness affecting humans and other primates.

It is thought that fruit bats of the Pteropodidae family are natural Ebola virus hosts.

The virus is transmitted to people from wild animals (such as fruit bats, porcupines and non-human primates) and then spreads in the human population through direct contact with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.

The average EVD case fatality rate is around 50%. Case fatality rates have varied from 25% to 90% in past outbreaks.

The first EVD outbreaks occurred in remote villages in Central Africa, near tropical rainforests. The 2014–2016 outbreak in West Africa was the largest and most complex Ebola outbreak since the virus was first discovered in 1976. There were more cases and deaths in this outbreak than all others combined. It also spread between countries, starting in Guinea then moving across land borders to Sierra Leone and Liberia.

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Addison's disease

Hyposecretion of glucocorticoids and aldosterone due to failure of the adrenal cortex results in the condition called Addison"s disease (primary adrenocortical insufficiency). 

Clinical symptoms include mental lethargy, anorexia, nausea and vomiting, weight loss and hypoglycemia, which leads to muscular weakness. 

Loss of aldosterone leads to elevated K+ and decreased Na+ in the blood, low blood pressure, dehydration, decreased cardiac output, arrhythmias and potential cardiac arrest. Blood level of ACTH is high due to loss of negative feedback inhibition by cortisol. 

At high concentration, ACTH mimics the skin darkening effects of MSH (melanocyte-stimulating hormone). The result is excessive skin pigmentation, especially in unexposed areas in mucous membranes. 

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Polycystic Disease

Polycystic disease may be caused by a defect in the renal tubular system that deforms nephrons and results in cyst like dilations along their course. It is the most common inherited disorder of the kidneys. The kidney tissue is riddled with fluid-filled cysts and small holes, ranging in size from a pinhead to the diameter of an egg.

These cysts gradually increase until they squeeze out the normal tissue, interfering with kidney function and causing uremia.

The chief symptom is weight gain. The kidneys themselves may enlarge from their normal 0.25kg(0.5lb) to as much as 14kg (30lb).

Although the disease is progressive and ultimately fatal, its advance can be slowed by diet, drugs and regulation of fluid intake. 

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Hemoglobin

Hemoglobin

Red blood cells consist of hemoglobin

What is normal value of hemoglobin

The normal level of hemoglobin in men between 11.5 to 17.5 gm/deciliter of blood.

The normal level of hemoglobin in female between 12.0 to 15.5 gm/deciliter of blood.

Normal value of hemoglobin

• Newborn baby - 14 to 24 gm/ deciliter of blood
• Pregnant women - 11 to 12 gm/deciliter of blood 
• Adult male - 11.5 to 17.5 gm/deciliter of blood
• Adult female - 12.0 to 15.5 gm/deciliter of blood

What is dangerously low level of hemoglobin

Dangerously low level of hemoglobin is 7 gm/deciliter, that level of hemoglobin require blood transfusion for ICU patients.

Hemoglobin is made up of which molecules

Hemoglobin is made up of protein and non protein pigment. protein pigment is globin and non protein pigment is heme. Heme portion consist iron ion.

What is normal level of vitamin B12

The normal level of vitamin B12 is between 190 to 900 nanograms / milliliter.

How many hemoglobin molecules in a red blood cells

A red blood cells contains about 280 million hemoglobin molecules.

How does hemoglobin form

Hemoglobin molecule consists of a protein, called globin. Hemoglobin composed four polypeptide chain - two alpha polypeptide chain and two beta poly peptide chain.

Hemoglobin contain a ring like non-protein pigment, called heme. heme is bound each of the four polypeptide chains. At the center of heme ring is an iron ion that can combine reversibly with only one oxygen molecule.

How many oxygen molecules will be bind to a hemoglobin molecule

Each hemoglobin molecule binds four molecules of oxygen.

What is the function of hemoglobin in blood

Hemoglobin has a property that it can bind oxygen or carbon di-oxide. Hemoglobin also known as oxygen carrying protein.  Hemoglobin play a important role in transporting oxygen and carbon di-oxide. hemoglobin transport oxygen to the cells. hemoglobin also transport carbon di-oxide from the cells. 

Hemoglobin also play a vital role in regulation of blood flow and blood pressure.

Epithelial cells that line blood vessels released gaseous hormone nitric oxide. Nitric oxide binds to hemoglobin. Nitric oxide cause vasodilation. Vasodilation improve blood flow. Nitric oxide is increase in blood vessels diameter.

  

What is carbamino-hemoglobin 

Hemoglobin that has bound carbon di-oxide is term known as carbaminohemoglobin.

What is oxy-hemoglobin

Hemoglobin that has bound oxygen is term known as oxyhemoglobin

What is hemoglobin lifetime or cycle

The lifetime of hemoglobin is about 120 days.

What is the function of dead hemoglobin in the body

Macrophages in the spleen, bone-marrow or liver by phagocytize ruptured or dead red blood cells. The heme and globin portion of hemoglobin are split apart.

Globin break down into amino acids which can be reused in synthesized some different proteins. Iron separated from heme portion of hemoglobin, in the form of Fe(+++) and it comes back to the blood stream by the help of transporter transferrine.

 

What is the non-iron portion heme

Non-iron portion of heme is called biliverdin which is a green pigment. biliverdin converted into bilirubin, which is a yellow pigment. bilirubin is also released by liver cells in bile. 

Which disease are caused by hemoglobin deficiency

Lack of hemoglobin can cause a lot of different types of disease. 

Disease cause by deficiency of hemoglobin are following-

Hypoxia - Hypoxia also known as cellular oxygen deficiency. decrease amount of oxygen delivered to body tissues.

Anemia - Anemia has many causes lack of certain amino acids, lack of iron and lack of vitamin B12.

Deficiency of iron cause following disease :

• Anemia - iron deficiency anemia
• Excessive menstrual blood loss
• Restless legs syndrome
• Learning disabilities
• Hearing disabilities
• Impaired immune functions
• Tinnitus
• Delayed growth in infants
• Hair loss
• Complication during pregnancy
• Irregular heartbeat

Deficiency of vitamin B12 (Cyanocobalamin) cause of following disease :

• Fatigue
• Weakness
• Rapid heartbeat
• Pernicious anemia
• Pale or jaundiced skin
• Sensation of needles or pins
• Lack of Intrinsic factor

Which disease are caused by increased level of hemoglobin

• Polycythemia cera
• Emphysema
• Chronic obstructive pulmonary disease (COPD)
• Renal cancer
• Hepatic cancer
• Dehydration
• Heart failure
• Other many lung disease
• Other  many heart disease

What can cause  sudden drop of hemoglobin level

Many diseases such as cancer, liver and kidney complications can cause suddenly decrease hemoglobin levels.

What is the best treatment for low level of hemoglobin

Intake vitamin C containing food  are -

• Citrus fruits example - orange and grapefruit
• Kiwi 
• Pineapple
• Mango
• Papaya   
• Strawberry 
• Raspberry
• Watermelon 
• Blueberry  
• Vegetable rich in vitamin C such as 

                               - Cantaloupe

                               - Broccoli

                               - Cauliflower

                               - Green bell peppers 

                               - Kale

Eat Iron rich containing food are -

• Spinach 
• Pumpkin seed
• Masa
• Cuttlefish 
• Mung bean
• Chickpea
• Semolina 
• Oysters 
• Cocoa bean
• Lentil
• Tofu
• Sunflower seed 
• Soybean
• Almond 
• Peanut 

Folic acid containing food

• Rice
• Cornmeal
• Semolina

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TREATMENT AND PREVENTION FOR JAUNDICE

TREATMENT AND PREVENTION FOR JAUNDICE

Jaundice is yellowish discoloration of the skin, sclera and mucous membranes due to hyper bilirubinemia and deposition of bile pigments.

PREVENTION FOR JAUNDICE

Due to the wide range of potential causes, it's not possible to prevent all cases of jaundice. However, there are four main precautions that you can take to minimize your risk of developing jaundice. 

They are Following - 

Ensuring that you stick to the recommended daily amount (RDA) for alcohol consumption. 

Maintaining a healthy weight for your height and build.

If appropriate, ensuring that you're vaccinated against a hepatitis A or B infection, vaccination would usually only be recommended depending on where in the world you're travelling.

Minimizing your risk of exposure to hepatitis C because there's currently no vaccine for the condition.

TREATMENT FOR JAUNDICE

Treatment depends on the cause of the underlying condition leading to jaundice and any potential complications related to it. Once a diagnosis is made, treatment can then be directed to address that particular condition, and it may or may not require hospitalization. 

Treatment may consist of expectant management (watchful waiting) at home with rest. 

Medical treatment with intravenous fluids, medications, antibiotics, or blood transfusions may be required.

If a drug/toxin is the cause, these must be discontinued.

In certain cases of newborn jaundice, exposing the baby to special colored lights (phototherapy) or exchange blood transfusions may be required to decrease elevated bilirubin levels.

Surgical treatment may be required in case of obstruction jaundice.

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WHEN JAUNDICE DEVELOP DURING PREGNANCY

WHEN JAUNDICE DEVELOP DURING PREGNANCY

Jaundice is yellowish discoloration of the skin, sclera and mucous membranes due to hyper bilirubinemia and deposition of bile pigments.

Most of the diseases discussed previously can affect women during pregnancy, but there are some additional causes of jaundice that are unique to pregnancy.

CHOLESTASIS OF PREGNANCY

Cholestasis of pregnancy is an uncommon condition that occurs in pregnant women during the third trimester. The cholestasis often is accompanied by itching but infrequently causes jaundice. The itching can be severe, but can be treated with drugs (ursodeoxycholic acid or ursodiol [Actigall, Urso]).

There also is an association between cholestasis of pregnancy and cholestasis caused by oral estrogens, and it has been hypothesized that it is the increased estrogens during pregnancy that are responsible for the cholestasis of pregnancy.

PRE ECLAMPSIA

Pre-eclampsia, previously called toxemia of pregnancy, is a disease that occurs during the second half of pregnancy and involves several systems within the body, including the liver. It may result in high blood pressure, fluid retention, and damage to the kidneys as well as anemia and reduced numbers of platelets (thrombocytopenia) due to destruction of red blood cells and platelets. It often causes problems in the fetus. Although the bilirubin level in the blood is elevated in pre-eclampsia, it usually is mildly elevated, and jaundice is uncommon. 

ACUTE FATTY LIVER OF PREGNANCY

Acute fatty liver of pregnancy (AFLP) is a very serious complication of pregnancy. The cause of AFLP is unclear, but is often associated with pre-eclampsia. It occurs late in pregnancy and results in failure of the liver. It can almost always be reversed by immediate delivery of the fetus. There is an increased risk of infant death. Jaundice is common, but is not always present in AFLP.

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Diagnostic Test for Jaundice

Test For Jaundice

Jaundice is yellowish discoloration of the skin, sclera and mucous membranes due to hyper bilirubinemia and deposition of bile pigments.

The registered medical practitioner or doctor will perform a physical exam. This may reveal liver swelling.

1. - A bilirubin blood test will be done. 
2. - Other tests vary, but may include.

• Hepatitis virus panel to look for infection of the liver.
• Liver function tests to determine how well the liver is working.
• Complete blood count to check for low blood count or anemia.
• Abdominal ultrasound.
• Abdominal CT scan.
• Endoscopic retrograde cholangiopancreatography (ERCP).
• Percutaneous transhepatic cholangiogram (PTCA).
• Liver biopsy.
• Cholesterol level.
• Prothrombin time.

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Causes of Jaundice

Causes of Jaundice

Jaundice is yellowish discoloration of the skin, sclera and mucous membranes due to hyper bilirubinemia and deposition of bile pigments.

Some following reason develop jaundice -

Too much bilirubin being produced for the liver to remove from the blood.

For example, patients with hemolytic anemia have an abnormally rapid rate of destruction of their red blood cells that releases large amounts of bilirubin into the blood.

A defect in the liver that prevents bilirubin from being removed from the blood, converted to bilirubin/glucuronic acid (conjugated) or secreted in bile.

Blockage of the bile ducts that decreases the flow of bile and bilirubin from the liver into the intestines. For example, the bile ducts can be blocked by cancer, gallstones, or inflammation of the bile ducts. The decreased conjugation, secretion, or flow of bile that can result in jaundice is referred to as cholestasis: however, cholestasis does not always result in jaundice.

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Symptoms of Jaundice

Symptoms of Jaundice

Jaundice is yellowish discoloration of the skin, sclera and mucous membranes due to hyper bilirubinemia and deposition of bile pigments.

Common signs and symptoms seen in individuals with jaundice include : -

• Yellow discoloration of the skin
• Mucous membranes
• The white part of the eyes becomes yellow 
• Light-colored stools
• Dark-colored urine
• Itching of the skin
• Nausea and vomiting
• Abdominal pain
• Fever
• Weakness
• Loss of appetite
• Headache
• Confusion
• Swelling of the legs and abdomen

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Types of Jaundice

Type Of Jaundice

Jaundice is mainly three types -

Pre-Hepatic / Hemolytic Jaundice

Excessive amount of bilirubin is presented to the liver due to excessive haemolysis, in pre-hepatic jaundice. Elevated un-conjugated bilirubin in serum. During pre-hepatic jaundice, haemolytic anemia develops.

Urine color - Normal

Stool color - Normal

Pruritus  - No

Hepatic Jaundice

Impaired cellular uptake, defective conjugation or abnormal secretion of bilirubin by the liver cell. Both conjugated and un-conjugated  bilirubin may be elevated in serum.

Symptoms 

Hepatitis
Cirrhosis
Crigler-Najjar Syndrome
Dubin-Johnson Syndrome
Rotor’s Syndrome

Diagnostic Test result -

Urine color - Dark
Stool color - Normal 
Pruritus - No

Post hepatic / Obstructive/ Surgical jaundice

Obstructive jaundice caused by following factors :-

1. Failure of hepatocyte to initiates bile flow.
2. Obstruction of bile flow in the bile duct or portal tracts.
3. Obstruction of bile flow in the extra-hepatic bile duct.
4. Bilirubin formation rate is normal.
5. Conjugation is normal equal to direct bilirubin.

Symptoms 

Gallstone

Malignancy

Inflammation

Diagnostic Test result 

Urine color - Dark

Stool color - Acholic

Pruritus - Yes

Some other type of Jaundice-

Pathologic Jaundice

Pathologic jaundice can occur in children and adults and is diagnosed when jaundice presents a health risk. Several forms of hepatitis, cirrhosis of the liver and other liver diseases, bile duct blockage, along with infections and medications, can also cause pathological jaundice.

Gilbert Syndrome jaundice

Gilbert's syndrome is a harmless hereditary condition that results in mild jaundice. During times of illness or stress, people with Gilbert's syndrome will experience low levels of some bilirubin-processing enzymes in their livers. Once diagnosed, Gilbert's syndrome does not require further medical treatment.

Obstructive Jaundice

Obstructive jaundice caused by following factors :-

• Failure of hepatocyte to initiates bile flow.
• Obstruction of bile flow in the bile duct or portal tracts.
• Obstruction of bile flow in the extra-hepatic bile duct.
• Bilirubin formation rate is normal.
• Conjugation is normal equal to direct bilirubin.

Neonatal Jaundice

Jaundice is clinically detectable in the newborn when the serum bilirubin levels are greater than 85 μmol/L. This occurs in approximately 60% of term infants and 80% of preterm infants.

Neonatal jaundice first becomes visible in the face and forehead. Blanching reveals the underlying color. Jaundice then gradually becomes visible on the trunk and extremities.

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