Reversibility of lower reproductive tract abnormalities in women with Schistosoma haematobium infection after treatment with praziquantel — An interim report

ELSEVIER

ACTA TROPICA Acta Tropiea 62 (1996) 289-301

Reversibility of lower reproductive tract abnormalities in women with Schistosoma haematobium infection after treatment with praziquantel - An interim report Joachim Richter ~'*, Gabriele Poggensee a, Eyrun Floerecke Kjetland b, Gertrud Helling-Giese ~, Lester Chitsulo d, Newton Kumwenda d, Svein Gunnar Gundersen b, Andr6 Martien Deelder e, Claus Michael Reimert f, Helmut Haas 8, Ingela Krantz h, Hermann Feldmeier i a Institute of Tropical Medicine, Berlin, Germany b Ullevaal Centre for International Medicine, Research Forum and Department of Infectious Diseases, Ullevaal Hospital, Oslo, Norway ¢ Department of Gynecology and Obstetrics, Finkenau-Hospital, and K&ber AIDS Research Laboratory, Bernhard-Nocht-Institute for Tropical Diseases, Hamburg, Germany d Ministry of Health and Environmental Affairs, Lilongwe, Malawi e Laboratory of Parasitology, University of Leiden, Leiden, The Netherlands f Laboratory of Medical Allergology, University Hospital, Copenhagen, Denmark g Laboratory oflmmunopharmacology, Research Institute Borstel, Borstel, Germany h Nordic School of Public Health, GOteborg, Sweden i Faculty of Medicine, Free University, Berlin, Germany

Abstract

Little is known whether and to what extent antiparasitic treatment cures female genital schistosomiasis (FGS). Using a standard protocol, of twenty-one women with FGS nine were re-examined at two to nine weeks after they had been treated with praziquantel at a single dose of 40 mg/kg. Symptoms related to pathology of the urinary tract and to a lesser extent of genital pathology subsided in most patients. Schistosoma haematobium ova were no longer detectable in urine of any of the patients post-treatment. Efficiency of chemotherapy against adult worms was confirmed by the disappearance of circulating anodic antigen (CAA) in serum. Sandy patches showed resolution in two of four cases after chemotherapy. Papillomata due to schistosomiasis alone improved, but persisted in mixed infection with human papilloma virus (HPV) or when HPV was the only underlying cause. In one patient ulcera could not be related with certainty to schistosomiasis at admission, but resolved after treatment with praziquantel. Leukoplakia (two cases) was not influenced by chemotherapy, or even increased

* Corresponding author. Institute of Tropical Medicine, Engeldamm 62, D-10179, Berlin, Germany. Fax: + 49-30-2746736. 0001-706X/96/$15.00 Copyright © 1996 Elsevier Science B.V. All rights reserved PII S0001-706X(96) 00030-7

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during follow-up, regardless of whether ova had been detected or not. Although the follow-up period was rather short, time intervals were not standardized, and a relatively small number of patients was investigated, it could be shown that genital pathology due to sequestered S. haematobium ova is, at least partially, reversible already two to nine weeks after killing the adult worms by praziquantel. This is paralleled by a normalization of inflammatory immune responses detectable in histological sections and vaginal lavage. Keywords: Female genital schistosomiasis; Schistosoma haematobium; Praziquantel treatment;

Reversibility of lesions

1. Introduction It is a general recommendation to treat patients with S. haematobium infection with a single dose of 40 mg/kg body weight of praziquantel, which kills the adult parasites (Davis, 1993). However, since the clinical pathology encountered in schistosomiasis is not due to the adult worms, but to an inflammatory immune response against sequestered eggs, parasitological cure, especially in chronic disease, does not necessarily mean that the pathological changes resolve after chemotherapy (Butterworth, 1993). Whereas e.g. lesions of the urinary tract caused by S. haematobium have been shown to regress in children after chemotherapy, little is known about the reversibility of genital lesions induced by the same parasite (Doehring et al., 1986; Hatz et al., 1990). However, this issue is of pivotal importance, because female genital schistosomiasis (FGS) is a frequent disease manifestation in adolescents and women in endemic areas which has to be considered as an important individual and public health hazard (Renaud et al., 1989; Friedberg et al., 1991,1995; Kjetland et al., 1996; Leutscher et al., 1996). The few follow-up studies performed so far are rather inconclusive. Different anthelminthic drugs in different regimens have been administered and only single patients monitored previously (Attili et al., 1983; Savioli et al., 1990; Friedberg et al., 1991; Carmona, 1992; Goldsmith et al., 1993; Corachan et al., 1995). Prompted by a pilot study on diagnostic approaches in women in Malawi the original study protocol was extended to monitor patients in order to find whether abnormalities in the lower reproductive tract of girls and women with FGS are reversible after treatment with praziquantel when given at a standard dose. The following data are an interim report on the dynamics of pathological changes in a subgroup of patients within the first nine weeks after chemotherapy.

2. Material and methods

Twenty-one women attending the outpatient department of the Mangochi Hospital in Southern Malawi, and in whom FGS had been diagnosed parasitologically either by microscopical examination of a fresh crushed biopsy and/or by histological sectioning of genital tissue were invited for follow-up examinations after treatment.

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The study design is described in detail in an accompanying paper (Kjetland et al., 1996). The patients received praziquantel at a single dose of 40 mg/kg. The drug was swallowed under supervision of one of the investigators immediately after the diagnosis of FGS had been established. When a concomitant sexually transmitted disease (STD) was diagnosed chemotherapy was initiated as follows: Chancroid and/or gonorrhea: a single dose of 600 mg ofloxacin; syphilis: an intramuscular injection of 1.2 million units of benzathine penicilline G in each buttock (total 2.4 million units); candidiasis: econazole endovaginal ovula (150 mg/day inserted once daily for 3-6 days); herpes genitalis: topical acyclovir ointment (every 4 h) for 5-10 days (Population Information Programme, 1993). For details of gynecological and parasitological examinations see the paper by Kjetland et al. (1996). Follow-up investigations were repeated according to the same protocol as at the first visit including parasitological examination of filtered urine, semi-quantitative assessment of microhaematuria, leucocyturia and proteinuria by reagent strips, patient interviews, gynecological examination, colposcopy, taking of biopsies, obtainment of vaginal smears, and vaginal lavage (Feldmeier et al., 1981,1982; Kjetland et al., 1996; Helling-Giese et al., 1996). Viability of ova was determined by the trypan blue staining technique (Feldmeier et al., 1979). Biopsies were routinely taken again from the cervix uteri, and if present, also from suspicious lesions in the vagina or vulva. The biopsy samples taken were divided into four pieces of which one was examined as a fresh crushed biopsy. The remainder were used for histological sectioning and immunohistochemistry. Determination of eosinophil cationic protein (ECP) in vaginal lavage was performed as previously described (Reimert et al., 1991). Circulating schistosome antigens, anti-egg- and adult-worm IgA, IgE and IgG4 antibodies, total IgE and neopterin in serum and vaginal lavage fluid were assessed as described elsewhere (Deelder et al., 1996; Poggensee et al., 1996). The time interval between treatment and follow-up investigations varied between two and nine weeks (median 5 weeks). One woman voluntarily came for two follow-up examinations, at two, second and six weeks post-therapy.

2.1. Statistics The Wilcoxon matched pairs signed rank test was used for the comparison of quantitative data before and after treatment. Relative frequencies were compared by the Fisher's exact test. Homogeneity of data distribution between groups of patients was assessed by the Snedecor-Irvin test.

3. Results

3.1. Demographic data and patients' compliance with follow-up investigations Relevant demographic data concerning the 21 patients are listed in Table 1. Six women did not come for follow-up. These patients did not live further away from

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Table 1 Demographic data of the 21 patients who were asked to come for a follow-up examination All patients (n=21)

Patientswho did not Patients who presented Patients come for follow-up at the hospital, re-examined but declined re-examination (n=6) (n=6) (n=9)

Age (years)a

29 (16-47)

Marital status: Married Divorced Widowed

15 5 1

5 1 0

3 2 1

7 2 0

Housewives

21

6

6

9

Travel time (min)b 120 (30-480)

30 (19-34)

120 (40-240)

30 (22-47)

120 (60-480)

22 (16-30)

120 (30-360)

Ethnic group: Yao/Chichewa

19/2

6/0

4/2

9/0

Religion: Muslim/Christian

17/4

6/0

3/3

8/1

aMedian and range. bWay to the hospital and back to their home; median and range.

the hospital than those who came for a follow-up investigation. Six of the remaining fifteen patients declined a second gynecological investigation. O f the remaining nine patients, eight agreed to undergo a complete gynecological examination including a biopsy, whereas one accepted a gynecological examination but did not agree to have a biopsy. Age composition and socioeconomic status were similar in the three patient groups.

3.2. Symptoms and signs At admission symptoms and signs were reported with similar frequencies a m o n g the 21 women, the 15 women who presented for follow-up and the 9 women who were re-examined after treatment. The frequency of symptoms and signs related to the urinary tract decreased significantly after treatment in the patient group who presented for follow-up (Table 2). The respective frequencies decreased in a similar way within the subgroups of the 9 patients who agreed to re-examination and the 6 who did not. For ethical reasons the symptoms and signs after treatment of those 6 women who did not present for follow-up were not collected because privacy could not be guaranteed in the village.

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Table 2 Frequency of symptoms and signs8 at admission and two to nine weeks after treatment with praziquantel Symptom/sign

All patients (n = 21 )

Patients who came for follow-up (n= 15) at admission

Macrohaematuria Dysuria Back ache Lower abdominal pain Hypermenorrhea Dysmenorrhea Dyspareunia lntermenstrual bleeding Genital itching

17 (81.0) 10 (47.6) 13 (61.9) 13 (61.9) 9 (42.9) 6 (28.6) 6 (28.6) 3 (14.3) 3 (14.3)

13 (86.7) 10 (66.6) 12 (80.0) 11 (73.3) 5 (33.3) 4 (26.7) 4 (26.7) 0 3 (20)

after treatment 2 (13.3) 2 (13.3) 2 (13.3) 2 (13.3) 2 (13.3) 3 (20) 3 (20) 0 (0.0) 2 (13.3)

Significanceof difference, p
aNumbers of patients and percentages. Frequency of symptoms and signs did not differ significantly between the 21 patients and the subgroup of 15 patients who came for follow-up. Also among the latter patients no significant difference existed between those 6 patients who did not agree to a gynecological re-examination and the 9 patients re-examined. bp values regard the significance of difference between the frequencies of symptoms and signs at admission and after treatment among the 15 patients who came to follow-up, regardless whether they actually agreed with a gynecological re-examination or not. Frequencies of symptoms decreased in a similar way in both patient subgroups, the 9 re-examined and the 6 declining re-examination (latter data not shown).

3.3. Parasitological and gynecological findings A t admission urinary egg counts were low (median 1.43 (range 0 . 0 3 - 2 2 ) ova/10 ml). After treatment no eggs were detected in urine o f any o f the patients. Urine reagent strips indicated the presence o f m i c r o h a e m a t u r i a in nine, o f proteinuria in six and o f leukocyturia in seven w o m e n at admission. After treatment microhaematuria was still present in eight women. The reagent strip index, i.e. the sum o f degrees o f microhaematuria, leucocyturia and proteinuria normalized in only one patient. It i m p r o v e d in three, remained u n c h a n g e d in two, but even worsened in three patients. A t admission ova o f S. haematobium were detected in eight o f nine cervical specimens by a fresh crushed biopsy preparation. The n u m b e r o f ova varied f r o m 0.4 to 25.94 per m m z o f compressed genital tissue. Histology confirmed the presence o f ova in the remainder case. Biopsies taken f r o m suspicious lesions in the vagina contained ova inside sandy patches in one case ( L J) and in three cases with papillom a t a ( M L , AJ, PAk). After treatment ova were detected in three out o f eight cervical biopsies: in one patient ( E M ) the period between treatment and re-examination had been only two weeks. A n o t h e r patient ( M L ) also showed eggs two weeks after treatment in cervical biopsy. However, when this patient was re-examined another four weeks later, n o m o r e eggs were detected in cervical tissue. A biopsy taken f r o m a suspicious lesion in the vagina still contained some ova, although, as j u d g e d by m o r p h o l o g i c a l appearance and staining with t r y p a n blue, these ova were not viable.

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In the third case (LJ) disintegrating ova were still observed in a cervical biopsy nine weeks after treatment. Interestingly, the cervical epithelium had become completely normal and no more signs of inflammation were detectable in histological sections. The individual gynecological findings before and after treatment are detailed in Table 3. Sandy patches were related to schistosomiasis in all of the four cases showing such lesions (patients LJ, CL, ML, AJ). Eggs were the only underlying cause of papillomata in one case (PAk), whereas in two cases schistosome ova and Human Papilloma Virus (HPV) coincided ( (ML, AJ). In addition, in two cases only HPV was identified inside papillomata (PM, EM). Leukoplakia of the cervix was observed in two cases, in one of these ova were detected in the biopsy. Vaginal or vulvar ulcera could not be related to FGS (PAy, ML). Other findings, suggesting concomitant STD's were diffuse inflammation with purulent vaginal discharge in three patients (ML, PAk, EM). Indeed, eggs were never detected inside purulent material. In one of these cases microscopy revealed gram-negative diplococci, indicating an infection with N. gonorrhoeae (EM). This patient also had multiple condylomata. An infection with T. pallidum was confirmed by a positive VDRL test. In one woman no abnormalities were detected at admission (FT) despite the presence of eggs in cervical biopsy. Two to nine weeks after treatment with praziquantel the following observations were made: Sandy patches disappeared in two cases (LJ, ML) (Fig. 1), but persisted in two patients in whom the lesions had been considerably larger at admission (CL, AJ). Papillomata regressed only in the patient in whom only FGS had been diagnosed as the only underlying cause (PAk), but remained unchanged when HPV infection was present (ML, AJ, PM, EM). In one case vulvar ulcerations healed (ML), but we failed to demonstrate eggs in this case. Leukoplakia of the cervix remained unchanged in the patient in whom ova were detected (EM), its extension even increased in the patient with no ova demonstrated (PAy). Newly detected findings during follow up included diffuse inflammation of the cervix with clumped whitish discharge, suggesting candidiasis in one patient (FT), chancroid in one case (PAy) and herpetic blisters in vulva and perineum of one woman (PAk). At admission eosinophil cationic protein (ECP) was detected in seven out of eight cervical biopsies by immunochemistry. After therapy ECP was detectable in only one biopsy (p <0.02). The results of the determinations of circulating antigens, antibodies against wormand egg-related antigens, IgE, ECP and neopterin are summarized in Table 4. After treatment, the serum concentration of circulating anodic antigen (CAA) decreased significantly (p < 0.001), indicating effective killing of adult worms by praziquantel. The concentration of IgA antibodies against schistosome egg antigen (SEA) and adult worm antigens (AWA) in vaginal lavage tended to decrease after treatment that of IgE against AWA and of total IgE in serum and lavage tended to increase. The differences, though, were not significant. Levels of IgG4 antibodies decreased in lavage fluid, but augmented in serum after treatment. The concentration of neopterin in vaginal lavage decreased significantly after treatment (median 14.5 versus 3.2 nmol/l, p = 0.006).

J. Richter et al./Acta Tropica 62 (1996) 289-301

0

295

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¢) 0 o)

0

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c~N~ 0

~

1 "~ .=

-~ °~ a~

et~

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Ca

0

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f2~

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(a)

(b) Fig. 1. Before treatment: Sandy patches at the cervix (a). Six weeks after treatment: Sandy patches have disappeared completely (b).

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297

Table 4 Determination of circulating schistosome antigens, egg- and worm-related antibodies, IgE, eosinophil cationic protein and neopterin before and after treatment with praziquantel (n = 9). Data indicate median and 95% confidence intervals Parameter

Assessed in

Before treatment

After treatment

Significance of difference

CA/t" CAA b CCA" CCA b IgA-SEA c IgA-SEA IgG4-SEA IgG4-SEA IgE-SEA IgE-SEA IgA-AWAa IgA-AWA IgG4-AWA IgG4-AWA IgE-AWA IgE-AWA Total IgE e Total IgE ECP f Neopterin s

serum lavage serum lavage serum lavage serum lavage serum lavage serum lavage serum lavage serum lavage serum lavage lavage lavage

87.6 (32.6-383.7) 0.0 (0-0) 0.0 (0-26.3) 0.0 (0-0) 5.6 x 105(4.7-7.1 x 105) 1506 (406-10398) 7.3 x 10s(2.2-14.0 x 105) 446 (0-2056) 0.5 x 105 (0.3-0.6 x 10s) 0 (0-755) 1.0 x 106 (0.7-2.2 x 106) 2808 (27-3208) 0.3 x 106 (0.2-0.3 x 106) 10 (0-148) 0.9 x 105 (0.5-2.2 x 105) 0 (0-9) 2892 (2083--4601) 0.6 (0.1-1.5) 39.0 (11.7-128.0) 14.5 (3.0-25.1)

0.0 (0-3.6) 0.0 (0-0) 0.0 (0-18.7) 0.0 (0-0) 6.1 x 105 (6.0-6.5 x 10s) 494 (367-1661) 9.8 x 10s (6.1-10.3 x 105) 0 (0-0) 0.4 x 105 (0.2-0.6 x 105) 0 (0-0) 0.8 x 106 (0.8-1.4 x 106) 2310 (1149-2984) 1.4 x 106 (0.7-2.6 x 106) 0 (0-83) 1.4 x 105 (0.9-2.0 x 105) 486 (9-848) 4465 (1908-5769) 0.8 (0.4--1.4) 20.1 (0.3--44.0) 3.2 (2.2--7.1)

p <0.001 n.s. n,s. n,s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. p=0.006

"Circulating anodie (CAA) and circulating cathodic (CCA) antigen (ng/ml). bCAA and CCA were detected in only 1/9 and 3/9 lavage samples, respectively. CSEA =soluble egg antigen: Results are expressed as arbitrary units (AU)/ml. dAWA =adult worm antigen: Results are expressed as arbitrary units (AU)/ml. ~ng/ml. fECP= eosinophil cationic protein (ng/ml). Snmol/l.

4. Discussion

A comprehensive review of the existing literature on FGS has made it clear that women with such a manifestation of a Schistosoma haematobium infection endure considerable suffering (Feldmeier et al., 1995). Since FGS also seems to negatively influence the sexual life of many affected women it is safe to assume that FGS causes not only physical pain but also mental strain and distress (Kjetland et al., 1996). Moreover, genital lesions caused by sequestered eggs are easily confounded with pathology related to STD's even by experienced gynecologists or misinterpreted as neoplasies resulting in inappropriate treatment or unnecessary or even debilitating surgery (Janovski and Douglas, 1972; Gloor et al., 1979; Attili et al., 1983). Finally, it is a matter of concern, that FGS may facilitate the infection with STD's including the propagation of HIV (Feldmeier et al., 1994). Thus, reliable data are urgently needed on the reversibility of lower reproductive tract pathology in women with

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FGS after elimination of the adult worms by chemotherapy. To this end, and as a first step in a series of investigations women were treated using a single dose standard treatment with praziquantel (Davis, 1993). Of twenty-one women invited to see the physician again, fifteen came for follow-up, of whom only nine agreed to a second gynecological examination. Comparison of relevant demographic parameters supports the notion that the gynecological re-examination of only a subgroup of the initial patients did not lead to a selection bias. The complete disappearance of eggs in urine and the almost total decrease of CAA and CCA in serum indicated that adult worms were efficiently killed by praziquantel. Symptoms typically related to urinary schistosomiasis, e.g. macrohaematuria and dysuria subsided in the majority of patie~ats. The significant diminution of non-specific symptoms such as back-ache, and lower abdominal pain suggests that these have been caused by schistosomiasis, too. The reversibility of menstruation abnormalities could not be evaluated due to the short time of monitoring. Unexpectedly, microhaematuria, proteinuria and leucocyturia remained more or less unchanged as indicated by reagent strips. This observation gives credit to the assumption that in women urine samples are frequently contaminated by vaginal secretions and that single strip readings when used as screening method for urinary schistosomiasis in women are limited by the occurrence of false positive results (Feldmeier and Poggensee, 1993; Gundersen et al., 1996). It is important to note that genital lesions considered to be pathognomonic for FGS, i.e. sandy patches, completely resolved in two patients. The persistence of sandy patches in the remaining two patients with such lesions might be explained by the observation that in these cases the lesions were very extended. Thus, presumably, they existed for a long time. Moreover, the follow-up interval for one of these patients was only three weeks. Interestingly, persistence of intense and presumably long-lasting egg-related lesions in male reproductive organs after therapy with praziquantel have been reported (Corachan et al., 1994). Since in several women FGS was accompanied by common STD's and as diagnostic facilities for agents of STD's were very limited, it is perceivable that in some women single lesions simply did not disappear after treatment with praziquantel, because they were caused by STD's. Indeed, papillomata healed only when egg related, but not in the cases with concomitant HPV infection or when due to HPV alone. In all but three cases biopsies taken during follow-up were negative for ova: Two of the patients with persistent eggs in genital tissue were re-examined very early (two weeks) after treatment. Complete dissolution of eggs, however, may require even several months as shown by the third case where dead disintegrating eggs were still present nine weeks after chemotherapy and effective killing of adult parasites was corroborated by the disappearance of circulating antigens. Perioval inflammatory changes had almost disappeared and macroscopical alterations had completely resolved in this case. Genital pathology not related to schistosomiasis, as e.g. diffuse acute purulent cervico-vaginal inflammation did not improve after antiparasitic treatment. Two other observations support our assumption that the elimination of adult

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parasites subsequently leads to the disappearance of egg-related lesions in the lower reproductive tract. First, ECP, a cytotoxic protein released by activated eosinophils attracted by deposited eggs, could be demonstrated by immunohistochemistry in seven out of nine biopsy specimens before treatment, while it was detectable in only one case after treatment. Second, histological sections showed resolution of inflammatory alterations in the majority of cases. Moreover, also in those women who declined a second gynecological examination symptoms subsided with similar frequency as among the patients re-examined. It seems reasonable to assume that this observation applies also to the remainder women who did not show up for follow-up since no selection bias seems to have occurred. Although IgA as well as IgG4 antibodies present in vaginal lavage tended to decrease after treatment, no clear-cut differences could be detected after treatment as to the various immunological parameters investigated. Interestingly, neopterin, a second messenger molecule of macrophage activation, which is known to be generated in high concentrations in patients with schistosomal hepatic fibrosis was also elevated in vaginal secretion in women with FGS (Zwingenberger et al., 1988a, b). After elimination of the adult worms by praziquantel the concentration of neopterin in vaginal lavage dropped to approximately one fifth of its initial concentration. So far, no systematic study has been performed in order to assess the reversibility of genital pathology in women with FGS after antiparasitic therapy. Although single cases of regression of pathology after niridazole have been reported, before the advent of praziquantel genital lesions due to schistosomiasis were considered irreversible and therefore treated surgically (Janovski and Douglas, 1972; Attili et al., 1983). There is no report on the efficacy of metrifonate in FGS, and to the best of our knowledge, the entire number of patients in whom gynecological examinations were performed after treatment with praziquantel amounts to 12 cases, all but one European travellers (Savioli et al., 1990; Carmona, 1992; Goldsmith et al., 1993; Corachan et al., 1995). Since these European patients had been exposed to schistosomiasis rather recently and only for short periods during their holidays, the conclusions drawn from such case reports cannot be applied to the situation of chronically infected women like our Malawian patients. Whereas in our patients macroscopically impressive lesions were frequently multiple, gynecological findings in the European women with FGS were rather unimpressive, such as minor papilloma and swelling and/or itching of the labia. Complete resolution of polypoid lesions within six months after treatment with praziquantel has been reported in one nine years old girl living in Pemba Island (Savioli et al., 1990). In a twelve years old Sudanese girl with a genital mass surgical resection had been preferred because the clinicians assumed that fibrosis was too extensive to resolve after chemotherapy alone (Mawad et al., 1992). Based on our results a conservative approach in the treatment of FGS seems to be warranted and future studies have to clarify whether there are indications for surgical treatment or not. Concluding, it is important to point out that although this study was limited by the rather short and variable periods of follow-up and a small number of patients, its results show that already within a few weeks after a standard single dose treatment

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with praziquantel ova disappear from genital tissue and macroscopical changes caused by sequestered eggs regress or even vanish completely. Further studies are needed to investigate, whether the present standard regimen is optimal or if other regimens are more effective, e.g. praziquantel in combination with topic antiinflammatory drugs.

Acknowledgements The study was supported by grants of the Schistosomiasis and other Trematodes Infections Unit of the WHO, of the Director's Initiative Fund of the UNDP/WB/WHO Special Programme for Research and Training in Tropical Diseases (TDR) and of the Danish Research Council. It was also supported by the Kongregation der Franziskanerinnen, Salzkotten, Germany, and from the Research Forum and the Department of Infectious Diseases, Ullevaal Hospital, and Norwegian Lions International. The authors whish to thank to Dr. K.E. Mott and Dr. N.R. Bergquist for encouraging the study, without their active support this study would not have been feasible. We are indebted to Dr. V. van Oosterzee and Dr. E.F. van de Velde of Mangochi Hospital, Ms. C. MacDonald, Guelph Nutrition Project, to Ms. R. Maziyaya, Mrs. Ph. Nyalugwe, Mr. D.N. Kalua, Mrs. T. Cullinan and Professor W. Cullinan. Leisegang Feinmechanik-Optik GmbH & Co. provided an excellent photocolposcope.

References Attili, R.V., Hira, S.K. and Dube, M.K. (1983) Schistosomai genital granulomas: A report of 10 cases. Br. J. Vener. Dis. 59, 269-272. Butterworth, A. (1993) Immunology of schistosomiasis. In: P. Jordan, G. Webbe and R.F. Sturrock (Eds.), Human Schistosomiasis. CAB International WaUingford, UK, pp. 331-366. Carmona, F. (1992) Vulvar lesion in a Spanish traveler to Mali. Int. J. Gynecol. Obstetr. 41, 94-95. Corachan, M., Vails, M.E., Gascon, J., Almeda, J. and Vilana, R. (1994) Hematospermia: A new etiology of clinical interest. Am. J. Trop. Med. Hyg. 50(5), 580-584. Corachan, M., Ahneda, J., Pous,. E., Vilana, R., VaUs, M.E. and Gascon, J. (1995) Genital Schistosomiasis. Eur. Conf. on Trop. Med. Hamburg, FRG, October 22-26. Abstr. No. C 24: 35.' Davis, A. (1993) Antischistosomal drugs and clinical practice. In: P. Jordan, G. Webbe, R.F. Sturrock (Eds.), Human Schistosomiasis. CAB International Wallingford, UK, pp. 367-404. Deelder, A.M, Kornelis, D., van Dam, G., Krijger, F.W., Poggensee, G., Haas, H., Kjetland, E.F., Helling-Giese, G., Richter, J., Chitsulo, L., Kumwenda, N., Gundersen, S.G., Krantz, I. and Feldmeier, H. (1996) Female genital schistosomiasis: Antibodies and circulating antigens in serum, vaginal lavages and urine. Manuscript in preparation. Doehring, E., Ehrich, J.H.H., Reider, F., Dittrich, M., Schmidt-Ehry, G. and Brodehl, J. (1986) Reversibility of urinary tract abnormalities due to Schistosoma haematobium infection. Kidney Int. 30, 582-585. Feldmeier, H., Bienzle, U., Dietrich, M. and Sievertsen, H.J. (1979) Combination of a viability test and quantification method for Schistosoma haematobium eggs (filtration trypan blue staining technique). Tropeumed. Parasitol. 30, 417-422. Feldmeier, H., Zwingenberger, K., Steiner, A. and Dietrich, M. (1981) Diagnostic value of rectal biopsy

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