|Year : 2012 | Volume
| Issue : 2 | Page : 98-100
Cutaneous schistosomiasis: Case report and literature review
Akinfenwa Taoheed Atanda1, Mijinyawa S Mohammad2, Latif Atallah3
1 Department of Pathology, Faculty of Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Internal Medicine, Faculty of Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Dermatology Unit, Murtala Mohammed Specialist Hospital, Kano, Nigeria
|Date of Web Publication||7-Mar-2013|
Akinfenwa Taoheed Atanda
Department of Pathology, Aminu Kano Teaching Hospital, PMB 3452, Kano
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Nigeria is one of the 74 countries endemic for schistosomiasis, with the most common species being schistosoma hematobium and bladder infestation with hematuria as the most common mode of presentation. However, rarely, extra-vesical ectopic sites such as the skin may be affected as it is in this case report of an 18-year-old male. Cutaneous schistosomiasis usually presents as crops of papular rashes with normal skin color on the trunk with or without pruritus and coexisting hematuria. These rare cases pose diagnostic challenges because of their unusual presentation and require high index of clinical suspicion for their identification. However diagnosis can be confirmed by histology of representative skin biopsy.
Keywords: Cutaneous, histology, schistosomiasis
|How to cite this article:|
Atanda AT, Mohammad MS, Atallah L. Cutaneous schistosomiasis: Case report and literature review. Ann Nigerian Med 2012;6:98-100
| Introduction|| |
Schistosomiasis is a parasitic infestation with over 200 million cases worldwide with 85% of these cases being found in Sub-Saharan Africa.  The etiologic agent is varying species of schistosoma with Schistosoma haematobium being the most widespread species in Nigeria.
The prevalence rate for vesical schistosomiasis in Nigeria has varied from 32.2% to as high as 54.4%. , Obasi,  in Zaria, northwestern Nigeria, following literature review, identified eight cases of cutaneous schistosomiasis over a 40-year period with risk factors being travel to countries endemic for schistosomiasis as well as living in countries holo-/hyper-endemic for the disease. , This case report aims to highlight the clinical presentation of ectopic cutaneous schistosomiasis, challenges in its diagnosis, and emphasize the role of histology in its diagnosis.
| Case Report|| |
An 18-year-old male presented with progressive painless skin rashes of 6 months duration associated with pruritus. The lesions were located on the back and neck. Detailed clinical history revealed two important risk factors; he lived in an area where he sometimes swam in river water and had 6-month preceding history of hematuria for which no specific treatment had been given. He did not have hematochezia and there were no eye symptoms. He also had no recollection of preceding febrile illness or cough and did not give any history of ingestion of any drugs prior to the appearance of the rashes. General physical examination was unremarkable. Skin examination revealed lesions on the neck, posterior chest wall, and back measuring 3-7 mm in diameter [Figure 1]. They had similar pigmentation to the surrounding skin and were round, firm, and nontender. A provisional diagnosis of bladder schistosomiasis to exclude comorbidity with filariasis was made and he was investigated along those lines.
Skin scraping for microscopy: negative for microfilaria
Urine microscopy: red blood cells and ova of S. haematobium +++
Skin biopsy histology: positive for schistososmal ova [Figure 2].
|Figure 2: Dermis showing schistosoma ova surrounded by fibrinoid necrosis and granuloma. [H and E, × 20]|
Click here to view
With the laboratory results as documented above, a diagnosis of cutaneous schistosomiasis was made. He was then placed on a stat dose of 2.4 g of Praziquantel. This resulted in gradual improvement and resolution of both the skin lesions [Figure 3] and the pruritus. A repeat urine microscopy 4 weeks after initiation of treatment became negative for ova of S. hematobium. The patient was formally discharged from the dermatology clinic and referred to urologists who are expected to follow him up.
|Figure 3: Resolution of the neck rashes following treatment with Praziquantel|
Click here to view
| Discussion|| |
The organ most commonly affected by Schistosoma haematobium infection is the bladder, and this is due to preferential localization of the parasites in the vesical vascular plexuses from where laid ova penetrate the bladder wall. The fertilized ova may also be carried in the blood to ectopic extra-vesical sites. The occurrence of extra-vesical S. hematobium, though not rare, is however uncommon. It has been diagnosed particularly from the appendix and liver. Its occurrence in the skin is however rare even in areas endemic for the disease. 
Epidemiologically male preponderance and highest frequency in the second to third decades of life have been noted for cutaneous presentation of the disease.  These age and gender patterns, reflected in our index case, highlight the social risk factors at play whereby young adult males in our area visit bodies of water which may harbor Bulinus, the parasite vector, either for leisure or fishing.
When ova are deposited in the skin they may present as papules, as seen in the index case, as crops or as Zosteriform lesions.  However, review of reports by Obasi  from Nigeria, Andrade Filho  from Brazil, and Leman  from the United Kingdom among others has shown papular presentation to be the predominant pattern, and similar to our index case, tends to appear in crops.
While our patient presented with lesions on the neck and posterior trunk, similar to the case reported by van Dijk  and Andrade Filho,  in a review of cases seen in about three decades from different regions of the world, it was documented that the anterior trunk was the site of predilection, with 14 of 25 cases found at this site, and only four in the neck region; yet any part of the body may be affected, including the anogenital skin.  The presence of anastomoses of porto-systemic vessels on the trunk with pelvic vessels may explain this association.
Similar to this patient being presented, the skin lesions may also appear several months to years after the initial infection , such that clinical history may not be very helpful. This may be the most important diagnostic challenge one is faced with when confronted clinically with such an uncommon lesion. This is exemplified by our case in which the patient had no recollection of time of infection. The average duration before cutaneous lesions appeared was 40 months in Andrade Filho's.  reviewed cases, with a range of 1 month to 20 years; Davis-Reed  reported a 2-month interval, and Ramdial et al. found a mean of 4.2 months before lesions begin to manifest. Even though reports , have documented pruritus as the most common symptom, a symptom also described by our patient, it is not specific as other dermatitides may also present with this symptom. While, like ours, one of the two cases reported by Obasi  copresented with hematuria, the other case as well as those reported by Van Dijk,  Davis-Reed,  and Kick  among others had no copresentation with hematuria or hematochezia. The presence of ectopic ova at other sites, with attendant symptomatology may uncommonly serve as pointers to the presence of the parasite. 
Other helpful features include a pruritic rash (swimmers itch) which may follow cercarial penetration through the skin in the acute stage.  This phase of invasion may manifest with transient mild fever and cough but may also be asymptomatic; either scenario may be lost to the patient's recollection, as was the case in our patient. Definitive diagnosis of the condition, however, is by skin biopsy, with identification of schistosoma ova on histology. The presence of a rim of fibrinoid necrosis surrounding the ova, as featured in this case, is consistent with the observation made by Hoeppli.  This histological phenomenon in which fibrinoid material is seen surrounding components of parasites or fungi is commonly described as the Splendore-Hoeppli phenomenon and is thought to represent antigen-antibody complexes. It is also more commonly seen in young patients with recent and heavy infestation.  Molecular analysis with identification of schistosome genome has also been documented. 
In conclusion, this reported case shows that cutaneous schistosomiasis most commonly presents on the trunk as papular sometimes pruritic lesions, requires high index of clinical suspicion for its identification, and is best diagnosed by histology of skin biopsies.
| References|| |
|1.||Southgate VR, Rollinson D, Tchuem Tchuenté LA, Hagan P. Towards control of scistosomiasis in sub-Saharan Africa. J Helminthol 2005;79:181-5. |
|2.||Morenikeji OA, Idowu BA. Studies on the prevalence of urinary schistosomiasis in Ogun State, South-western Nigeria. West Afr J Med 2011;30:62-5. |
|3.||Sarkinfada F, Oyebanji AA, Sadiq IA, .Iliyasu Z. Urinary schistosomiasis in the Danjarima community in Kano, Nigeria. J Infect Dev Ctries 2009;3:452-7. |
|4.||Obasi OE. Cutaneous schistosomiasis in Nigeria. An update. Br J Dermatol 1986;14:597-602. |
|5.||Andrade Filho Jde S, Lopes MS, Corgozinho Filho AA, Pena GP. Ectopic cutaneous schistosomiasis: Report of two cases and a review of the literature. Rev Inst Med trop Sao Paulo 1998;40:253-7. |
|6.||Leman JA, Small G, Wilks D, Tidman MJ. Localized papular cutaneous schistosomiasis: Two cases in travellers. Clin Exp Dermatol 2001;26:50-2. |
|7.||Findlay GH, Whiting DA. Disseminated and zosteriform cutaneous schistosomiasis. Br J Dermatol 1971;85:98-101. |
|8.||van Dijk K, Starink MV, Bart A, Nilhuis EW, van der Wal AC, van Thei PP, et al. The potential of molecular diagnosis of cutaneous ectopic schistosomiasis. Am J Trop Med Hyg 2010;83:958-9. |
|9.||Davis_Reed L, Theis JH. Cutaneous schistosomiasis: Report of a case and review of the literature. J Am Acad Dermatol 2000;42:678-80. |
|10.||Ramdial PK, Calonje E, Singh B, Sing Y, Govender P. Extra-anogenital bilharziasis cutanea tarda revisited. J Cutan Pathol 2009;36:766-71. |
|11.||Kick G, Schaller M, Korting HC. Late cutaneous schistosomiasis representing an isolated skin manifestation of schistoma mansoni infection. Dermatology 2000;200:144-6. |
|12.||Hoeppli R. Histological observations in experimental schistosomiasis japonica. Chinese Med (Peking) 1932;46:1179-86. |
|13.||von Lichtenberg F, Smith JH, Cheever AW. The Hoeppli phenomenon in schistosomiasis; Comparative pathology and immunopathology. Ame J Trop Med Hyg 1966;15:886-95. |
[Figure 1], [Figure 2], [Figure 3]
|This article has been cited by|
||Cutaneous ectopic schistosomiasis: diagnostic challenge
| ||Cláudia Renata Castro do Rêgo Barros,Daniela Cristina Caetano Maia,Josemir Belo dos Santos,Camila Carolina Queiroz Medeiros,Jessica Guido de Araújo |
| ||Anais Brasileiros de Dermatologia. 2016; 91(1): 109 |
|[Pubmed] | [DOI]|
||Cutaneous Manifestations of Selected Parasitic Infections in Western Pacific and Southeast Asian Regions
| ||Vicente Belizario,John Paul Caesar delos Trinos,Nikko Benjamin Garcia,Maureen Reyes |
| ||Current Infectious Disease Reports. 2016; 18(9) |
|[Pubmed] | [DOI]|
||Bilateral Tubal Gestation Associated with Schistosomiasis in an African Woman
| ||K. H. Odubamowo,O. M. Akinpelu,O. O. Lawal,C. A. Okolo,A. A. Odukogbe,A. O. Adekunle |
| ||Case Reports in Obstetrics and Gynecology. 2014; 2014: 1 |
|[Pubmed] | [DOI]|