Value of Contrast Transesophageal Echocardiography in the Detection of Intrapulmonary Vascular Dilatations in Hepatosplenic Schistosomiasis / Valor do Ecocardiograma Transesofágico com Contraste no Diagnóstico da Dilatação Vascular Intrapulmonar na Esquistossomose Hepatoesplênica

Abstract Background: Hepatopulmonary syndrome (HPS), found in cirrhotic patients, has been little studied in hepatosplenic schistosomiasis (HSS) and includes the occurrence of intrapulmonary vascular dilatations (IPVD). Contrast transesophageal echocardiography (cTEE) with microbubbles is more sensitive than contrast transthoracic echocardiography (cTTE) with microbubbles in the detection of IPVD in cirrhosis. Objective: To assess the performance of the cTEE, compared with that of cTTE, in detecting IPVD for the diagnosis of HPS in patients with HSS. Methods: cTEE and cTTE for investigation of IPVD and laboratory tests were performed in 22 patients with HSS. Agitated saline solution was injected in peripheral vein during the cTEE and cTTE procedures. Late appearance of the microbubbles in the left chambers indicated the presence of IPVD. Results of the two methods were compared by the Student's t-test and the chi-square test (p < 0.05). Results: cTEE was performed in all patients without complications. Three patients were excluded due to the presence of patent foramen ovale (PFO). The presence of IPVD was confirmed in 13 (68%) of 19 patients according to the cTEE and in only six (32%, p < 0.01) according to the cTTE. No significant differences in clinical or laboratory data were found between the groups with and without IPVD, including the alveolar-arterial gradient. The diagnosis of HPS (presence of IPVD with changes in the arterial blood gas analysis) was made in five patients by the cTEE and in only one by the cTTE (p = 0.09). Conclusion: In HSS patients, cTEE was safe and superior to cTTE in detecting IPVD and allowed the exclusion of PFO.

Resumo Fundamento: A síndrome hepatopulmonar (SHP), presente em pacientes cirróticos, é pouco estudada na esquistossomose hepatoesplênica (EHE) e inclui a ocorrência de dilatações vasculares intrapulmonares (DVP). O ecocardiograma transesofágico com contraste (ETEc) de microbolhas é mais sensível que o ecocardiograma transtorácico com contraste (ETTc) de microbolhas na identificação de DVP na cirrose. Objetivo: Avaliar o desempenho do ETEc comparado ao ETTc na identificação de DVP para diagnóstico de SHP em pacientes com EHE. Métodos: Incluímos 22 pacientes com EHE submetidos a ETEc e ETTc para pesquisa de DVP, além de exames laboratoriais. Os ETEc e ETTc foram realizados empregando-se solução salina agitada, injetada em veia periférica. A visualização tardia das microbolhas em câmaras esquerdas indicava presença de DVP. Os resultados foram comparados entre os dois métodos pelos testes t de Stu dent e qui-quadrado (significância p < 0,05). Resultados: Todos os 22 pacientes realizaram ETEc sem intercorrências. Foram excluídos três pela presença de forame oval patente (FOP), e a análise final foi realizada nos outros 19. A DVP esteve presente ao ETEc em 13 pacientes (68%) e em apenas seis ao ETTc (32%, p < 0,01). Não houve diferenças significativas nos dados clínicos e laboratoriais entre os grupos com e sem DVP, incluindo a diferença alveoloarterial de oxigênio. O diagnóstico de SHP (presença de DVP com alterações gasométricas) ocorreu em cinco pacientes pelo ETEc e em apenas um pelo ETTc (p = 0,09). Conclusão: Em pacientes com EHE, o ETEc foi seguro e superior ao ETTc na detecção de DVP não identificada ao ETTc, o que possibilitou adicionalmente excluir FOP.

Métodos de imagem no diagnóstico de esquistossomose hepatoesplânica / Imaging techniques in the diagnosis of hepatosplenic schistosomiasis

A esquistossomose constitui grave problema de saúde pública, com mais de 200 milhões de infectados no mundo. Deste total, cerca de 10% desenvolvem a forma hepatoesplênica da doença caracterizada por fibrose periportal e hipertensão porta. No passado, o diagnóstico da esquistossomose hepatoesplênica (EHE) era realizado por métodos invasivos como esplenoportografia e biópsia hepática. O estudo das alterações no sistema porta e da morfologia hepática e esplênica com métodos de imagem representou um avanço significativo no diagnóstico da doença. Os métodos mais utilizados atualmente são a ultrassonografia abdominal, a ressonância nuclear magnética e a tomografia computadorizada de abdomen. O objetivo do presente artigo é abordar as principais contribuições de cada método no diagnóstico da EHE.

Schistosomiasis is a serious public health problem with over 200 million infected worldwide. Nearly 10% of infected individuals develop the hepatosplenic form of the disease characterized by periportal fi brosis and portal hypertension. In the past, the diagnosis of hepatosplenic schistosomiasis (HHS) was performed by invasive methods such as liver biopsy and splenoportography. The study of changes in portal system and morphological aspects of liver and spleen with imaging techniques represented a significant advance in the diagnosis of the disease. The most widely used techniques are abdominal ultrasonography, magnetic resonance imaging and computed tomography of the abdomen. The aim of this article is to discuss the main contribution of each technique in the diagnosis of HHS.

role of ultrasonography to discriminate between schistosomiasis and virus-related chronic liver disease

The aim of our study was to assess the role of ultrasonography in patients with chronic liver diseases in discriminating between schistosomiasis and viral hepatitis infections in Egypt, an area where these infections are endemic. We assessed 114 patients with chronic liver disease, clinically, ultrasonographically, biochemically, virologically, parasitologically and by liver biopsy. According to histological diagnosis; 7.9% of patients had portal fibrosis, 43% chronic hepatitis, 47.4% cirrhosis and 1.8% hepatic malignancies. Patients with cirrhosis 44 [49.4%] of them had pure HCV infection. The longitudinal diameter of the spleen was significantly higher in patients with cirrhosis- virus related liver disease than those with pure schistosomiasis, while no significant differences were found in the degree of periportal thickening between the two groups. This study shows that ultrasonography alone can not be used as a screening procedure to discriminate between schistosomiasis and viral hepatitis infections in areas where these infections are highly associated, such as in Egypt

Interleukin-2 in hepatic schistosomiasis

Interleukin-2 was assayed in 10 patients with early hepatic schistosomiasis [group I], 10 others with chronic HBV [group II] and 10 more with mixed schistosomal and HBV infections [group III] as well as 10 normal healthy controls [group IV]. Besides routine laboratory tests, ultrasound, liver biopsies and serological tests were used for proper diagnosis and grouping of patients. The results revealed that the mean interleukin-2 was lower in the three groups of patients than in controls. It was lowest in cases with chronic hepatitis B only and highest in those with early hepatic schistosomiasis. It could be suggested that low interleukin-2 production, particularly in early hepatic schistosomal patients, might be related to the fact that peripheral mononuclear cells do not reflect the true image of what is happening in affected tissues

Epidemiologic study of schistosomiasis in two rural areas with different topographic characteristics in El-Minia governorate

Schistosomiasis is a major health problem in Egypt as in other tropical and subtropical areas. The present study was designed to measure the prevalence of schistosomal infection in two rural areas with different topographic and ecological characteristics in El Minia governate and to evaluate some human host factors that might influence schistosomiasis spread. The study was done in the Internal Medicine department, El Minia Faculty of Medicine over the period from October, 1993 to October, 1994. It was conducted on 650 subjects: 500 from El Hawaslia village [264 males and 236 females with their ages ranging from 4-92 years] and from Dir El Adra village [74 males and 76 females with ages ranging from 5-71 years]. All subjects were subjected to thorough history taking, clinical examination and both qualitative and quantitative urinalysis and stool examination. Abdominal ultrasonographic examination was performed as well. As regards schistosomiasis haematobium, the study reported a prevalence rate of 10.3% in El Hawasila, while Dir El Adra village only one case was detected. In El Hawaslia the highest prevalence was found among the youngest age group [4-20 years]. The total prevalence was higher in males [11.5%] than in females [8.9%]. Nevertheless females reported higher prevalences among older age groups 62.5%, 66.7% and 66.7% in females versus 37.5%, 33.3% and 33.3% in males in the age groups 21-40, 41-60 and >/= 61 years respectively. Occurpation, irrigation system and water contact activities played an effective role in schistosomiasis haematobium spread in El Hawaslia. Regarding S. mansoi one case was reported in El Hawaslia [indeed it was mixed infection of S. haematobim and S. mansoni]. No schistosomiasis mansoni was detected in Dir El Adra. In conclusion, schistomosiasis had not been yet controlled in our locality inspite of the many control programs. Contaminated water contact was far the most important factor in spreading the infection. Schistosoma mansoni began to spread from Lower to Upper Egypt and this might change the spectrum of morbidity of bilharziasis in Upper Egypt