Title: A Young Man with Chronic Abdominal pain
1A Young Man with Chronic Abdominal pain
- Aaron DeVries
- Interhospital Case Conference 3/29/05
220 yo M Chronic Abdominal Pain
- Presenting to an ER
- 24 months of chronic intermittent abdominal pain
- Currently R sided extending to R Flank
- In past had been LUQ and RUQ
- Waxes and wanes but severe for the last 2 days
- Occurred from weekly to daily lasting for several
hours each time - No alteration in pain with eating, urination,
defecation - No Fevers/chills, cough, dysuria, hematuria,
diarrhea, constipation, melena, hematochezia
320 yo M Chronic Abdominal Pain
- PMHx none
- SHx refugee from Sudan, arrived in Twin Cities
about 1 year ago
420 yo M Chronic Abdominal Pain
- BP 110/78 P 76 RR 12 Afeb
- Thin uncomfortable, lying or sitting
- HEENT, PULM, CV nml
- Abd tender in RLQ, extending to R flank
- U/A 0 WBC, 5 RBC
- CBC diff, lytes normal
- KUB - No calcifications observed
5CT Abd w/o contrast
- Moderate dilation of the R collecting system with
moderate to severe dilation of the ureter to the
level of the distal ureter. - Smooth linear high attenuation lesions of the mid
and distal portions of the ureter which could
represent calcification and dilated to 1.3 cm - R distal ureter obstruction small stone in
distal ureter vs. congenital obstruction
6Any Thoughts?
- What would be your next test?
7Cystoscopy
- Yellowish, sandy appearing patch on the trigone
as well as within the R ureter
- No obstruction on retrograde pyelogram
- Biopsy taken
- Many schistosomial elements
8Bilharzia a.k.a Schistosomiasis
- Theodore Bilharz was German anatomist teaching in
Cairo. - In 1850 connected death following hematuria with
the parasite. - Died 1852 of typhus
9Schistosomiasis Life Cycle
Life Cycle
- Vertebrates are the principle final hosts
- Reproduce exclusively in humans except S.
japonicom - Fresh water snails are required
Schistosomiasis NEJM 2002 346 1212-20
105 minutes
Cam.University Schistosomiasis Research Group
1110 minutes
Cam.University Schistosomiasis Research Group
1220 minutes
Cam.University Schistosomiasis Research Group
13Species and Location
S. haematobium S. japonicum S. mansoni
Skin X X X
Lung X X X
Left Heart X X X
Portal Venous system X X X
Vesicular venous plexus X
Inf Mesenteric veins and hemorrhoidal veins X
Sup Mesenteric Veins X
14Geography
15Geography Sudan
16Acute Disease
- Swimmers itch from invasion of cercaria into skin
- Acute Schistosomiasis a.k.a Katayama fever
- Onset of the female parasite laying eggs 5
weeks after infection - Fever, Nausea, Headache
- Hepatosplenomegaly
- Leukocytosis with eosinophilia
- Few weeks months
- S. japonicum gt S. mansoni and S. haematobium
17Chronic Disease
- Occurs with Granuloma formation surrounding eggs
- Hepatosplenic Schistosomiasis - S. mansoni and S.
japonicum - Several years after initial infection
- Granulomas form within the liver and biliary tree
- chronic hepato-obstructive disease
- portal hypertension liver failure
- Intestinal Schistosomiasis - S. mansoni and S.
japonicum - Several years after initial infection
- Small and large intestine may be involved
- Adults migrate to intestinal wall
- Lay eggs which migrate into intestinal lumen and
out into stool - Severe anemia from chronic GI blood loss
18Chronic Disease
- Vesico-ureteral - S. haematobium
- Several years after infection
- Adults migrate to small venules around the
bladder and ureter - Eggs are deposited into surrounding tissue and
penetrate out into bladder - Causes calcifications where eggs are trapped
- Characterized by hematuria
- Leads to squamous-cell cancer of bladder
19 World Health Impact
- 200 million infected worldwide
- 80-85 of persons in Sub-Saharan Africa are
infected - In Egypt, squamous-cell carcinoma of the bladder
accounts for 18-28 of all cancer - Incidence of 10.8 per 100,000 persons
- Smoking increases risk even further
- Infected children have substantial growth delay
even after treatment - Co-infection with Hep B and C results in a much
faster progression to liver failure
www.cdc.gov
20Pt referred to ID clinic for treatment
- PMHx fell from a tree as a child with possible
fractured ribs on R side - SHx
- Native of Darfur region of Sudan.
- At approximately the age of 15 his village was
overrun by Sudanese government forces. His
family was killed in front of him. - He was captured and was enslaved by the
Janjaweed. He was given no food or water. - After 4 years of enslavement he escaped by train
into Kartun where he contacted relatives in
Cairo. - They assisted him to Egypt and eventually was
accepted as a refugee to the US facilitated by MN
relatives
21ID Clinic
- PE nml vitals
- ENT, Pulm, CV exam nml
- ABD mildly tender in RUQ
- Urine and stool w/o parasitic elements
- Treatment
- Praziquantal 20mg/kg x 2 doses separated by 8
hours
22Treatment
- Praziquantal
- Kills all forms except schistosomula - migrating
form - 3-21 days
- Cure rate 60-90
- Emerging resistance in Egypt and Kenya reported
- Oxamniquine and Metrifonate are alternatives
- Re-treatment same drug and dose
- If shedding eggs at 4-6 weeks
- If symptoms do not resolve
- If anti-schistosomal antibody remains elevated.
23Follow Up
- He had significant decrease in abdominal pain at
4 weeks - No schistosomal eggs seen in urine or stool
- At six weeks had near complete resolution of
symptoms - Anti-schistosomal Ab 5.8 (nml lt1)
24New CDC RecommendationsJanuary 21, 2005
- Serologic prevalence at a Sudanese refugee
reunion in Arizona in 2004 - 464 participated in the laboratory testing.
- 204 (44) seropositive for S. mansoni or S.
haematobium - 227 (49) seropositive for strongyloides
- 103 (22) seropositive for both
- 315 (69) were seropositive for either
- 88 of were treated (unclear whether remainder
were previously treated or refused treatment) - Recommendations presumptive treatment of all
Lost Boys and Girls of Sudan - All Sudanese
refugees? - Praziquantel 20 mg/kg x 2 doses 6-8 hours apart
- Albendazole 400 mg BID for 3 days.
http//www.cdc.gov/ncidod/dq/lostboysandgirlssudan
/presumptive_tx_recc.htm
25Generally speaking the policy of attacking,
killing and forcibly displacing members of some
tribes does not evince a specific intent to
annihilate, in whole or in part, a group
distinguished on racial, ethnic, national or
religious grounds. Rather, it would seem that
those who planned and organized attacks on
villages pursued the intent to drive the victims
from their homes, primarily for purposes of
counter-insurgency warfare. Report of the
International Commission of Inquiry on Darfur to
the United Nations Secretary-General Geneva, 25
January 2005
1.65 million internally displaced - UN Report 25
January 2005 180,000 300,000 estimated killed
since start of conflict in 2003 - Ivo Daalder -
Brookings Institute - March 14, 2005