Delayed diagnosis of spinal cord schistosomiasis in a non-endemic country: A tertiary referral centre experience

Angus de Wilton*, Dinesh Aggarwal, Hans Rolf Jäger, Hadi Manji, Peter L. Chiodini

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

Background Neuroschistosomiasis is a severe complication of schistosomiasis, triggered by the local immune reaction to egg deposition, with spinal cord involvement the most well recognised form. Early treatment with praziquantel and high dose steroids leads to a reduction of neuro-logical sequelae. The rarity of this condition in returning travellers to high income countries can result in delayed diagnosis and treatment. We aimed to evaluate the diagnosis and management of neuroschistosomiasis in a UK national referral centre. Materials/Methods A retrospective review of confirmed clinical cases of spinal schistosomiasis referred to the Hospital for Tropical Diseases, UK, between January 2016 and January 2020 was under-taken. Electronic referral records were interrogated and patient demographic, clinical, labo-ratory, and radiological data collected. Results Four cases of neuroschistosomiasis were identified. The median age at diagnosis was 28 (range 21 to 50) with three male patients. All patients had epidemiological risk factors for schistosomiasis based on travel history and freshwater exposure; two in Uganda (River Nile), one in Malawi and one in Nigeria. All patients presented with features of transverse myelitis including back pain, leg weakness, paraesthesia and urinary dysfunction. The mean time from presentation to health services to definitive treatment was 42.5 days (range 16–74 days). Diagnosis was confirmed with CSF serology for schistosomiasis in all cases. Radiological features on MRI spine included enhancement focused predominantly in the lower thoracic spinal cord in three cases and the conus in one patient. All patients received a minimum of three days of oral praziquantel and high dose steroids. At three-month follow-up, one patient had complete resolution of symptoms and three had residual deficit; one patient was left with urinary and faecal incontinence, another had urinary retention, and the final patient has persistent leg pains and constipation. Conclusion We observed a marked delay in diagnosis of neuroschistosomiasis in a non-endemic coun-try. We advocate undertaking a thorough travel history, early use of imaging and CSF schis-tosomal serology to ensure early diagnosis of neuroschistosomiasis in patients presenting with consistent symptoms. If schistosomal diagnostics are not immediately available, pre-sumptive treatment under the guidance of a tropical medicine specialist should be consid-ered to minimize the risk of residual disability. We advocate for consensus guidelines to be produced and reporting to be performed in a uniform way for patients with spinal schistosomiasis.

Original languageEnglish
Article numbere0009161
JournalPLoS Neglected Tropical Diseases
Volume15
Issue number2
DOIs
Publication statusPublished - Feb 2021
Externally publishedYes

Bibliographical note

Funding Information:
Payment of publication fees was supported by the Hospital for Tropical Diseases Charitable Fund. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Publisher Copyright:
© 2021 de Wilton et al.

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