Spinal Cord Schistosomiasis: A Report of 2 Cases and Review Emphasizing Clinical Aspects

Abstract

Schistosomal myeloradiculopathy (SMR) is a severe and little known form of presentation of schistosomiasis mansoni and hematobic schistosomiasis. The literature concerning the entity is scarce, and most publications are limited to isolated case reports. Thus, to consolidate and analyze the knowledge currently available about the disease, I reviewed 231 cases, with emphasis on clinical aspects. Although variations occur, in most cases the clinical picture of SMR is highly suggestive in individuals with epidemiologic antecedents of the infection. Thus, a patient with SMR is usually a young male with no other manifestations of schistosomal infection who presents with lumbar pain, often of a radicular nature, soon followed by weakness and sensory loss of rapid progression in the lower limbs associated with autonomic dysfunction, particularly bladder dysfunction. The most suggestive elements of the entity, and therefore of higher diagnostic value, are the low localization of the spinal cord lesion, the acute or subacute onset of the disease, and the association of manifestations due to medullary and radicular involvement. SMR is commonly classified into clinical or anatomoclinical forms. However, I observed no consensus in this classification even in terms of the terminology used. The analysis performed in this review permitted the introduction of a new concept not yet reported in the literature regarding the possibility that the disease consists of a continuous spectrum, with asymptomatic egg laying in the spinal cord at 1 end of the spectrum and devastating forms at the other end, with most cases occupying an intermediate position and with the various types of damage overlapping and associated to different degrees. This concept applies not only to different patients but also to the same patient at different stages of the disease. Chemical and cytomorphologic examination of cerebrospinal fluid (CSF) almost always revealed mildly or moderately increased total protein concentration and predominantly lymphocytic pleocytosis. Eosinophils, the least nonspecific finding, were detected in the CSF of less than half (40.8%) the patients. Myelography and computed tomography-myelography were altered in 63.3% of cases, but this proportion may be an overestimate. The most frequent changes were images of a filling defect due to expansion of the spinal cord and were almost always demonstrated by the 2 imaging modalities. Although still few in number, early reports suggest that magnetic resonance imaging is more sensitive; however, the changes are also nonspecific, such as those revealed by myelography and computed tomography-myelography. Parasite eggs were demonstrated frequently in a biologic specimen (88.3%), but difficulty in detection was not uncommon. Peripheral blood eosinophilia was detected in 64.5% of patients and represented a nonspecific finding. The detection of anti-Schistosoma antibodies in the serum or CSF was also frequent (94.9% and 84.8%, respectively). The presence of anti-Schistosoma antibodies in serum is of li...

Research development of the pathogenesis pathways for neuroschistosomiasis

“…Previous reports indicate that these 3 species may cause similar spinal cord disorders [5,8,[20][21][22] . Ferrari et al [5] have discussed the literature data (280 cases) on spinal cord neuroschistosomiasis mansoni (NSM), published from 1930 to 1996.…”

“…Ferrari et al [5] have discussed the literature data (280 cases) on spinal cord neuroschistosomiasis mansoni (NSM), published from 1930 to 1996. Young adults, teenagers and children of male sex, are more common to be affected, which can be explained by a higher frequency of exposure to fresh water both during childhood and in their work environment [5,20,22] . Actually, concerning the asymptomatic NS, the number of NS patients far exceeds that of the diagnosed cases.…”

“…Based on the clinical presentations, the histopathologic aspects, and findings by imaging methods, Ferrari [5,22] In spinal cord schistosomiasis, the eggs may reach the spinal veins via the valveless venous Batson's plexus, either through the retrograde venous flow when the intra-abdominal pressure rises, or after an anomalous migration through leptomeningeal veins of adult S. mansoni worms, as shown by some pathological studies [12] . This happens especially in the patients with advanced hepatosplenic and hepat-ointestinal diseases, known as fibro-obstructive hepatic schistosomiasis, such as liver cirrhosis and portal hypertension.…”

“…Ferrari has reported that acute neurological manifestation of S. mansoni infection may develop in non-immune individuals, such as tourists, 6-8 weeks after the onset of infection [5] . By observing the patients with chronic severe schistosomiasis mansoni, Pittella [30] conclude that the main factors for the high fre- haematobia usually pass through portosystemic anastamoses to reach the veins surrounding the urinary and the reproductive systems, which could also join the pelvic plexus retrograde flow to the CNS [31,32] . The second stage is the chronic severe infection.…”

Neuroschistosomiasis due to Schistosoma mansoni: a review of pathogenesis, clinical syndromes and diagnostic approaches

“…The most common site of clinically significant NS is the spinal cord 9,12,13,54,56 . The prominent lateral spine of S. mansoni's egg probably hampers the egg from reaching the brain 9,16 .…”