Evaluation of Loop-Mediated Isothermal Amplification (LAMP) in Urine Samples for the Diagnosis of Imported Schistosomiasis.

Migratory flows and international travel are triggering an increase in imported cases of schistosomiasis in non-endemic countries. The present study aims to evaluate the effectiveness of the LAMP technique on patients' urine samples for the diagnosis of imported schistosomiasis in a non-endemic area in comparison to a commercial immunochromatographic test and microscopic examination of feces and urine. A prospective observational study was conducted in sub-Saharan migrants attending the Tropical Medicine Unit, Almería, Spain. For schistosomiasis diagnosis, serum samples were tested using an immunochromatographic test (Schistosoma ICT IgG-IgM). Stool and urine samples were examined by microcopy. Urine samples were evaluated by combining three LAMP assays for the specific detection of Schistosoma mansoni, S. haematobium, and for the genus Schistosoma. To evaluate the diagnostic accuracy, a latent class analysis (LCA) was performed. In total, 115 patients were included (92.2% male; median age: 28.3 years). Of these, 21 patients (18.3%) were diagnosed with schistosomiasis confirmed by microscopy, with S. haematobium being the most frequent species identified (18/115; 15.7%). The Schistosoma ICT IgG-IgM test result was 100% positive and Schistosoma-LAMP was 61.9% positive, reaching as high as 72.2% for S. haematobium. The sensitivity and specificity estimated by LCA, respectively, were: 92% and 76% for Schistosoma ICT IgG-IgM, 68% and 44% for Schistosoma-LAMP, and 46% and 97% for microscopy. In conclusion, the Schistosoma-LAMP technique presented a higher sensitivity than microscopy for the diagnosis of imported urinary schistosomiasis, which could improve the diagnosis of active infection, both in referral centers and in centers with limited experience or scarce resources and infrastructure.

Estimation of parasitaemia in imported falciparum malaria using the results of a combined rapid diagnostic test. No big help from haematological parameters.

BACKGROUND: Microscopy continues to be the mainstay for the evaluation of parasitaemia in malaria but requires laboratory support and microbiological experience. Other fast and simple methods are necessary. METHODS: A retrospective observational study of imported malaria treated from July-2007 to December-2020 was carried out to evaluate the association between the degree of parasitaemia and both rapid diagnostic tests (RDT) reactivity patterns and haematological parameters. Plasmodium falciparum monoinfections diagnosed by peripheral blood smear and/or polymerase chain reaction (PCR),which also had a positive RDT result in the same blood sample, were included in the study. RESULTS: A total of 273 patients were included. Most of them were male (n = 256; 93.8%) and visiting friends and relatives (VFR) travellers (n = 252; 92.3%). Patients with plasmodial lactate dehydrogenase (pLDH) or aldolase and histidine-rich protein 2 (HRP-2) co-reactivity (Pan/Pf pattern) had a parasitaemia range between 0 and 37% while those with just HRP-2 reactivity (P. falciparum pattern) had ranges between 0 and 1%. Not a single case of P. falciparum pattern was found for parasitaemia ranges greater than 1%, showing a negative predictive value of 100% for high parasitaemia. All the correlations between haematological parameters and parasitaemia resulted to be weak, with a maximum rho coefficient of -0.35 for lymphocytes and platelets, and of 0.40 for neutrophils-to-lymphocytes count ratio. Multivariate predictive models were constructed reflecting a poor predictive capacity. CONCLUSIONS: The reactivity pattern of RDT allows a rapid semi-quantitative assessment of P. falciparum parasitaemia in travellers with imported malaria, discriminating patients with lower parasite loads. Haematological parameters were not able to estimate parasitaemia with sufficient precision.

Accuracy of Three Serological Techniques for the Diagnosis of Imported Schistosomiasis in Real Clinical Practice: Not All in the Same Boat.

Schistosomiasis is a neglected tropical disease despite of being a major public health problem affecting nearly 240 million people in the world. Due to the migratory flow from endemic countries to Western countries, an increasing number of cases is being diagnosed in non-endemic areas, generally in migrants or people visiting these areas. Serology is the recommended method for screening and diagnosis of schistosomiasis in migrants from endemic regions. However, serological techniques have a highly variable sensitivity. The aim of this study was to evaluate retrospectively the sensitivity of three different serological tests used in real clinical practice for the screening and diagnosis of imported schistosomiasis in sub-Saharan migrant patients, using the detection of schistosome eggs in urine, faeces or tissues as the gold standard. We evaluated three different serological techniques in 405 sub-Saharan patients with confirmed schistosomiasis treated between 2004 and 2022: an enzyme-linked immunosorbent assay (ELISA), an indirect haemagglutination assay (IHA) and an immunochromatographic test (ICT). The overall sensitivity values obtained with the different techniques were: 44.4% for IHA, 71.2% for ELISA and 94.7% for ICT, respectively. According to species, ICT showed the highest sensitivity (S. haematobium: 94%, S. mansoni: 93.3%; and S. intercalatum/guineensis: 100%). In conclusion, our study shows that Schistosoma ICT has the best performance in real clinical practice, when compared to ELISA and IHA, in both S. mansoni and S. haematobium infections.

Misleading eosinophil counts in migration-associated malaria: do not miss hidden helminthic co-infections.

BACKGROUND: Lower eosinophil counts observed during acute malaria episodes could hide helminth-related eosinophilia. METHOD: Retrospective observational study with sub-Saharan migrants with imported malaria from May-2007 to May-2020. Absolute eosinophil count was determined upon diagnosis at hospital admission and at least once after clearance of parasitemia. Helminthic co-infections were investigated by searching for stool and urine parasites, serology for Strongyloides spp. and Schistosoma spp., and Knott and/or saponin tests for blood microfilariae. RESULTS: A total of 259 patients were included. Most of them were male (n = 237; 91.5%) and VFR travelers (n = 241; 93.1%). 131 patients (50.6%) were diagnosed with probable schistosomiasis, 15 (5.8%) with confirmed schistosomiasis, 16 (6.2%) with strongyloidiasis, 4 (1.6%) with soil-transmitted helminthiasis, and 4 (1.6%) with filariasis (Mansonella perstans). Prevalence of eosinophilia increased from 2.7% on admission to 32.5% during outpatient follow-up. Eosinophilia did not appear until several weeks after hospital discharge in up to 24% of the confirmed helminthic co-infections and in 61.1% of patients with probable schistosomiasis. Eosinophilia was associated with confirmed schistosomiasis and mansonellosis while 56.2% and 75% of cases with strongyloidiasis and soil-transmitted worms did not present eosinophilia at any time, respectively. CONCLUSIONS: Regardless of the absence of eosinophilia, patients hospitalized because of acute imported malaria might benefit from the screening of the main parasitic diseases, allowing for earlier diagnosis and treatment.

Usefulness of ultrasound in sub-Saharan patients with a serological diagnosis of schistosomiasis.

OBJECTIVE: To evaluate the usefulness of ultrasound examination in patients with just a serological diagnosis of schistosomiasis but no other evidence of active infection. METHODS: 346 sub-Saharan patients with possible schistosomiasis that presented at a Tropical Medicine Unit between 2008 and 2019 were retrospectively selected. Possible schistosomiasis was considered in those patients with a positive serology for schistosomasis in the absence of direct microbiological isolates, hematuria and/or eosinophilia. Data from ultrasound examinations before and after treatment with praziquantel were collected and categorized following the World Health Organization-Niamey score to standardize the use of ultrasonography for the assessment of schistosomiasis-related morbidity. RESULTS: Ultrasound examinations were abnormal in only ten patients (2.89%). Main findings were focal thickening of the bladder wall (n = 6), ureteral dilatation (n = 3) and grade I hydronephrosis (n = 1). No malignant lesions, hepatic lesions nor hepatobiliary related disorders were found. After treatment, the S. haematobium global score (5 vs 3.4, p = 0.06) and the urinary bladder score (2 vs 1, p = 0.059) showed a trend towards improvement after treatment. In three patients the score after treatment dropped to 0, and in another three it remained the same although with signs of improvement. No worsening of the score was observed in any case. CONCLUSION: For those patients with a diagnosis of schistosomiasis based solely in a positive serology, the ultrasound examination could safely be spared due to the low prevalence of pathological findings and its response to treatment anyway.

Migration-associated malaria from Africa in southern Spain.

BACKGROUND: The western area of the province of Almeria, sited in southern Spain, has one of the highest immigrant population rates in Spain, mainly dedicated to agricultural work. In recent years, there has been a significant increase in the number of cases of imported malaria associated with migrants from countries belonging to sub-Saharan Africa. The objective of our study is to describe the epidemiological, clinical and analytical characteristics of malaria patients treated in a specialized tropical unit, paying special attention to the differences between VFR and non-VFR migrants and also to the peculiarities of microscopic malaria cases compared to submicroscopic ones. METHODS: Retrospective observational study of migrants over 14 years of age with imported malaria treated from October 2004 to May 2019. Characteristics of VFR and non-VFR migrants were compared. Malaria cases were divided into microscopic malaria (MM) and submicroscopic malaria (SMM). SMM was defined as the presence of a positive malaria PCR test together with a negative direct microscopic examination and a negative rapid diagnostic test (RDT). Microscopic malaria was defined as the presence of a positive RDT and/or a positive smear examination. RESULTS: Three hundred thirty-six cases of malaria were diagnosed, 329 in sub-Saharan immigrants. Of these, 78.1% were VFR migrants, in whom MM predominated (85.2% of cases). In non-VFR migrants, SMM represented 72.2% of the cases. Overall, 239 (72.6%) patients presented MM and 90 (27.4%) SMM. Fever was the most frequent clinical manifestation (64.4%), mainly in the MM group (MM: 81.1% vs SMM: 20.0%; p < 0.01). The most frequent species was P. falciparum. Patients with SMM presented fewer cytopenias and a greater number of coinfections due to soil-transmitted helminths, filarial and intestinal protozoa compared to patients with MM. CONCLUSIONS: Imported malaria in our area is closely related to sub-Saharan migration. VFR migrants are the main risk group, highlighting the need for actions aimed at improving disease prevention measures. On the other hand, almost a third of the cases are due to SMM. This fact could justify its systematic screening, at least for those travelers at greater risk.

High Prevalence of Strongyloidiasis in Spain: A Hospital-Based Study.

Introduction: Strongyloidiasis is a prevailing helminth infection ubiquitous in tropical and subtropical areas, however, seroprevalence data are scarce in migrant populations, particularly for those coming for Asia. Methods: This study aims at evaluating the prevalence of S. stercoralis at the hospital level in migrant populations or long term travellers being attended in out-patient and in-patient units as part of a systematic screening implemented in six Spanish hospitals. A cross-sectional study was conducted and systematic screening for S. stercoralis infection using serological tests was offered to all eligible participants. Results: The overall seroprevalence of S. stercoralis was 9.04% (95%CI 7.76-10.31). The seroprevalence of people with a risk of infection acquired in Africa and Latin America was 9.35% (95%CI 7.01-11.69), 9.22% (7.5-10.93), respectively. The number of individuals coming from Asian countries was significantly smaller and the overall prevalence in these countries was 2.9% (95%CI -0.3-6.2). The seroprevalence in units attending potentially immunosuppressed patients was significantly lower (5.64%) compared with other units of the hospital (10.20%) or Tropical diseases units (13.33%) (p < 0.001). Conclusions: We report a hospital-based strongyloidiasis seroprevalence of almost 10% in a mobile population coming from endemic areas suggesting the need of implementing strongyloidiasis screening in hospitalized patients coming from endemic areas, particularly if they are at risk of immunosuppression.

Severe complications of imported schistosomiasis, Spain: A retrospective observational study.

BACKGROUND: Chronic schistosomiasis silently leads to severe organ-specific disorders, such as hydroureter, bladder cancer or portal hypertension in around 10% of infected people in endemic zones. However, in non-endemic areas, information on schistosomiasis' severe complications and their actual prevalence is scarce because diagnosis is usually reached when such complications are well established. METHODS: Retrospective observational study of data obtained from a screening protocol designed for sub-Saharan migrants including search for stool parasites and schistosoma serology. After screening 3090 sub-Saharans, 326 (10.5%) confirmed cases of schistosomiasis were found, based on detection of ova in feces, urine or in biopsy samples. Another 830 patients (26.9%) were diagnosed of probable schistosomiasis (positive serology and/or suggestive imaging findings). RESULTS: Only patients with confirmed schistosomiasis were included in the final analysis. Among them, 13 (4%) presented severe complications at the time of diagnosis. Depending on the location, they account for 5% of patients with hepatointestinal schistosomiasis and 3.5% of patients with urogenital infection. CONCLUSIONS: Targeted systematic screening could reduce the prevalence of severe complications by enabling early diagnosis and treatment. Having indigenous transmission been demonstrated in southern Europe, prevention of future cases in non-endemic countries might be another sound reason supporting such screening.

Submicroscopic Malaria in Migrants from Sub-Saharan Africa, Spain.

In a screening program, we detected submicroscopic malaria in 8.9% of recent migrants to Spain from sub-Saharan Africa. Hemoglobinopathies and filarial infection occurred more frequently in newly arrived migrants with submicroscopic malaria than in those without. Our findings could justify systematic screening in immigrants and recent travelers from malaria-endemic areas.

Chronic hepatitis B genotype E in African migrants: response to nucleos(t)ide treatment in real clinical practice.

BACKGROUND: Hepatitis B virus (HBV) genotype E is a poorly studied genotype that almost exclusively occurs in African people. It seems to harbour intrinsic potential oncogenic activity and virological characteristics of immune scape but a paucity of information is available on clinical and virological characteristic of HBV genotype E-infected patients as well as on the efficacy of anti-HBV drugs for such patients. The increasing flow of migrants from high endemic HBV sub-Saharan Africa, where genotype E is the predominant one, to Western countries makes improving such knowledge critical in order to deliver proper medical care. METHODS: Prospective observational study of naïve patients of sub-Saharan origin treated for chronic HBV genotype E infection at a Tropical Medicine clinic sited in Spain from February 2004 to January 2018. The aim of the study was to describe the response of chronic HBV genotype E infection to nucleos(t)ide analogues (NA), entecavir or tenofovir, in real clinical practice. RESULTS: During the study period, 2209 sub-Saharan patients were assisted at our Tropical Medicine Unit and 609 (27.6%) had chronic HBV (CHB) infection. Genotype information was available for 55 naïve patients initiating treatment with NA (entecavir or tenofovir), 43 (84.3%) of them being genotype E, although 15 were excluded because they did not meet study inclusion criteria. Thus, a total of 28 CHB genotype E patients were included and followed for 24 months at least. Twenty-one patients were in HBeAg-negative chronic hepatitis phase and 7 patients in HBeAg-positive chronic hepatitis phase. After one year of treatment, among those with good adherence, 89.4% (17/19) of the HBeAg-negative patients and 80% of the HBeAg-positive ones had undetectable viral loads. Response rates reached 100% in both groups after 15-18 months of follow-up. Out of the 7 HBeAg-positive patients, 6 (85.7%) presented HBeAg loss in a median time of 31.8 months. Neither serious adverse effects nor hepatocarcinoma cases happened during the study period. CONCLUSIONS: HBV genotype may influence disease progression and antiviral response. Our study provides precious information on the efficacy and safety of NA treatment for CHB genotype E infection, a fairly unknown genotype with and increasing epidemiological impact.

Newly Arrived African Migrants to Spain: Epidemiology and Burden of Disease.

The aim of this study is to describe the epidemiological profile, clinical characteristics, and microbiological findings in African immigrants newly arrived to Spain attended at a specialized reference unit from October 2004 to February 2017. A common protocol for the screening of imported and cosmopolitan diseases was designed to evaluate patients with ≤ 12 months of stay in Spain. A total of 523 patients were included in the study, 488 (93.3%) of sub-Saharan origin. A high number of helminthic infections were diagnosed in sub-Saharan patients, including geohelminthiasis (hookworms 14.3%; Trichuris trichiura 4.1%; Ascaris lumbricoides 3.1%), schistosomiasis (12.3%), strongyloidiasis (17.2%), and filariasis (8.4%). Thirty-five patients (7.2%) had malaria, most by Plasmodium falciparum. Among communicable diseases, 33.6% of sub-Saharans presented HBsAg positivity compared with 5.7% of North African patients (P = 0.001). Thirteen patients were diagnosed with active tuberculosis. Seventy percent of the sub-Saharans and 40% of the North Africans who were tested had a latent tuberculosis infection (LTI). Treatment of LTI was administered in selected cases (14%), achieving end of treatment in 80% of them. In light of these results, effective screening strategies, particularly within the sub-Saharan immigrant population, including potentially communicable diseases and certain potentially serious parasitic diseases (Strongyloides, Schistosoma), should be implemented. It is necessary to facilitate fully and free of charge access to the public health system to newly arrived immigrants, as well as to implement programs and actions aimed at favoring care and follow-up, especially for communicable diseases. Empirical treatment of some parasitic diseases could be a cost-effective action.

Impact of using artemisinin-based combination therapy (ACT) in the treatment of uncomplicated malaria from Plasmodium falciparum in a non-endemic zone.

BACKGROUND: Artemisinin-based combination therapy (ACT) has been adopted by the World Health Organization as a first-line treatment for uncomplicated Plasmodium falciparum malaria. In endemic regions, it has proven more effective in treating the disease, and even in reducing its transmission. Nonetheless, there is a scarcity of studies carried out in non-endemic areas on imported uncomplicated malaria. METHODS: This is a retrospective, observational study performed on patients diagnosed and admitted with uncomplicated P. falciparum malaria between 2004 and 2015. The objective was to compare the parasite clearance period and the average hospital length of stay for patients treated with ACT vs those receiving other treatment regimens. RESULTS: Eighty-five patients were included in the study. Fifty-one received ACT treatment (dihydroartemisinin-piperaquine) and thirty-four patients were treated with quinine sulfate+doxycycline or atovaquone/proguanil. The parasite clearance period was shorter in the group of patients treated with ACT compared to those receiving other treatment types: 24 h (IQR 24) vs 48 h (IQR 48), p < 0.01. The average hospital stay was also shorter in the ACT group with respect to the second group: 2.67 days (IQR 1.08) vs 3.96 days (IQR 2.87), p < 0.001. A mild case of hepatitis was registered in the group treated with ACT. CONCLUSIONS: ACT treatment of admitted hospital patients with imported uncomplicated malaria from P. falciparum reduced the days spent hospitalized as well as producing a more rapid parasite clearance compared to classic treatment. In spite of being treated with safe medications, one has to be alert to possible adverse effects such as hepatitis and delayed haemolytic anaemia.

Infectious Diseases in Immigrant Population Related to the Time of Residence in Spain.

The aim of this study was to evaluate the data on the main imported infectious diseases and public health issues arising from the risk of transmission of tropical and common diseases in the immigrant population. During the period of study, 2,426 immigrants were attended in the Tropical Medicine Unit of the Hospital of Poniente. For each patient, a complete screening for common and tropical diseases was performed. The prevalence and main features of intestinal and urinary parasites, microfilarias, Chagas disease, malaria, hepatitis B (HBV) and C (HCV) viruses, extrapulmonary tuberculosis and syphilis was investigated taking into account the length of stay in Spain. Sub-Saharan Africa patients who had lived for <3 years in Spain had a high significantly number of infections produced by hookworms, Ascaris lumbricoides, Trichuris trichiura, Schistosoma mansoni, Giardia lamblia, Entamoeba histolytica/dispar and Plasmodium spp. In patients who had lived for more than 3 years, there were significantly high rates of HBV infections, although HBV rates in sub-Saharan African patients are high even if the patients have been in Spain for <3 years. However, patients with large stays in Spain had also an important number of parasitological diseases. The main objective of the diagnosis is to avoid important public health problems and further complications in patients. It is advisable to carry out a screening of the main transmissible infections in all immigrant population regardless of the time outside their country. This screening should be individualized according to the geographical area of origin.

Evaluation of eosinophilia in immigrants in Southern Spain using tailored screening and treatment protocols: A prospective study.

OBJECTIVE: To determine the etiology of eosinophilia in immigrant patients in Southern Spain. METHODS: Prospective study of immigrant patients with eosinophilia (> 500 Eo/µL) attended in a reference Tropical Medicine Unit and evaluated through the implementation of a specific protocol structured in different levels meant to be accomplished depending on the findings of each previous level. RESULTS: Out of the 549 patients included in the study (89.6% from sub-Saharan countries), a diagnosis of helminthiasis was reached in 417 (75.9%), mainly by Strongyloides stercoralis (n = 190), Schistosoma (n = 33) and Hookworms (n = 126). 30 patients (5.5%) had a non-parasitic disorder (asthma, allergic rhinoconjunctivitis, skin conditions and drug-related eosinophilia). Multiple helminthic infections were very common: in 107 patients (19.5%) 2 helminth species were identified, three in 21 patients (3.8%), and four or more in 6 patients (1.1%). Eosinophilia was resolved in 31 of the 33 patients (93.9%) who received empirical treatment with ivermectin, albendazole and praziquantel as an etiological diagnosis was not reached after applying the whole protocol. CONCLUSIONS: Diagnosis of helminthic infections in immigrant patients with eosinophilia can be improved by using tailored protocols based on geographical exposure. The implementation of these protocols may also save costs by systematizing diagnostic explorations. Empirical treatment with ivermectin, albendazol and praziquantel in sub-Saharan population when an etiologic diagnosis of eosinophilia has not been attained is an effective measure.

Strongyloidiasis in immigrants in Southern Spain

OBJECTIVE: To analyse clinical and epidemiological characteristics of immigrant patients diagnosed with strongyloidiasis in our area. METHODS: An analyse was performed on patients with strongyloidiasis seen in the Tropical Medicine Unit of the "Hospital de Poniente" in Almeria (Spain), from April 2004 to May 2012. RESULTS: A total of 320 patients were diagnosed with Strongyloides stercoralis infection, and 284 out of 314 patients (90.4%) had a positive specific serology. Forty-two percent of the patients reported symptoms and 45% had eosinophilia. The serological results were monitored in some of the patients, confirming a loss of antibodies in all 20 patients studied. CONCLUSIONS: Strongyloidiasis is a parasitic disease increasingly diagnosed in developed countries due to increased migratory flows from endemic areas. Often being asymptomatic, its diagnosis and treatment may prevent fatal outcomes, especially in immunocompromised patients

OBJETIVO: Analizar las características clínicas y epidemiológicas de los pacientes inmigrantes diagnosticados de strongyloidiasis en nuestra área. MÉTODOS: Se analizaron retrospectivamente los pacientes con strongyloidiasis que acudieron a la Unidad de Medicina Tropical del Hospital de Poniente de Almería (España), entre abril de 2004 mayo de 2012. RESULTADOS: 320 pacientes han sido diagnosticados con infección por S. stercoralis, 284/314 pacientes (90,4%) tenían una serología específica positiva. 42,3% de los pacientes presentaron síntomas y el 45% de los pacientes tenían eosinofilia. La monitorización del tratamiento confirmó la pérdida de anticuerpos en los 20 pacientes estudiados. CONCLUSIONES: La estrongiloidiasis es una parasitosis diagnosticada cada vez con más frecuencia en países desarrollados debido al aumento de los movimientos migratorios procedentes de zonas endémicas. Siendo a menudo asintomática, su diagnóstico y tratamiento pueden prevenir resultados fatales

Strongyloidiasis in immigrants in Southern Spain.

OBJECTIVE: To analyse clinical and epidemiological characteristics of immigrant patients diagnosed with strongyloidiasis in our area. METHODS: An analyse was performed on patients with strongyloidiasis seen in the Tropical Medicine Unit of the "Hospital de Poniente" in Almeria (Spain), from April 2004 to May 2012. RESULTS: A total of 320 patients were diagnosed with Strongyloides stercoralis infection, and 284 out of 314 patients (90.4%) had a positive specific serology. Forty-two percent of the patients reported symptoms and 45% had eosinophilia. The serological results were monitored in some of the patients, confirming a loss of antibodies in all 20 patients studied. CONCLUSIONS: Strongyloidiasis is a parasitic disease increasingly diagnosed in developed countries due to increased migratory flows from endemic areas. Often being asymptomatic, its diagnosis and treatment may prevent fatal outcomes, especially in immunocompromised patients.

Filariasis in sub-Saharan immigrants attended in a health area of southern Spain: clinical and epidemiological findings.

Filariasis is still an endemic disease in several countries worldwide. Patients with mansonellosis result in only relatively mild symptoms, but these infections could produce many visits to health care providers. In Spain, this infection is imported due to the increase of immigrant population reaching our country during last years. The health area of the Hospital of Poniente has a rate of immigrants around to 20%, with a high percentage coming from sub-Saharan countries, being Mansonella perstans the main filarial infection in the majority of cases. In the protocol for the immigrants, it has been included the diagnosis of filarial infections in order to treat them. This manuscript describes epidemiological and clinical aspects of patients with this kind of infection.

Esquistosomiasis urinaria / Urinary schistosomiasis

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