Schistosomes: beware the water

Over 700 million people worldwide are at risk from parasitic worms called schistosomes (blood flukes), which are transmitted via swimming in contaminated water. The worms are a major problem and can cause a severe debilitating disease called schistosomiasis in their hosts, which, sadly, kills nearly 200 million people each year.

This is an adult male blood fluke. Note its highly developed mouth piece on the right, which is uses to 'clamp' onto the inside of blood vessels and anchor itself against the blood flow. Once secured, it feeds on the nutrients carried in the host's blood. The fold that you can see running through the centre of the worm is called the gynacophoric canal, in which the much smaller female worm lies in permanent copulation.

Due to the large distribution of the schistosomes and their prevalence in third world countries that have very little infrastructure, they are of huge concern to the World Health Organisation, who is trying to reduce the levels of infection by educating people in endemic areas of the dangers, improving sanitation and by ensuring that the drug praziquantel is readily available to as many patients as possible.

Unfortunately, praziquantel treatment is extremely unpleasant and results in a range of negative side effects in humans, including: dizziness, somnolence, seizures, arachnoiditis and diarrhoea. To make matters worse, the parasites themselves actually worsen these side effects and patients undergoing treatment can also suffer from urticaria, rashes and pruritus. This is due to the sheer volume of dead parasitic material that is released into the blood at any one time, which can also cause eosinophilia in leukocytes.

Schistosomes are waterborne and infect human hosts when they swim in contaminated water. As the host swims, they leave a trail of fatty acids from their skin in the water behind them. The parasite is attracted to these fatty acids (L-arginine inparticular) and then attaches itself to the host's skin. Once attached, schistosomes secrete acids and enzymes from acetabular glands and literally burn through the skin until they enter the bloodstream! The distinctive and unpleasant rash that results is often called 'swimmers itch'.

Due to the problems associated with praziquantel, many health agencies are beginning to acknowledge that the best way to combat schistosomiasis is to prevent human infection in the first place. The easiest way to do this is to treat infected waters with insecticides that kill water snails – another vector that is essential to the schistosome life cycle. Without water snails, schistosomes will be completely unable to infect humans and the problem of schistosomiasis is thereby solved!

Like most parasites, schistosomes have an extremely complicated life cycle where they morph through a range of different forms and, at different stages, live in more than one host.

One of the reasons schistosomes are such a major problem is because males and females live in permanent copulation with each other inside the human body so can literally release thousands of eggs in a very short space of time. Rather than the parasites themselves, it is actually these eggs that cause the symptoms of schistosomiasis – a chronic, severely debilitating disease that is usually fatal. The exact symptoms of schistosomiasis vary (depending on the species that has infected the host and where the worms prefer to take up residence), but the most common symptoms are given below:

• Intestinal schistosomiasis is caused by the bowel-living species of blood flukes Schistoma mansoni and S. japonicum, and is associated with abdominal pain, diarrhoea and bloody faeces. Liver enlargement is frequently seen in advanced cases, which leads to gross abdominal swelling as fluid is forced into the host's peritoneal cavity as a side effect of abnormally high blood pressure
• Urogenital schistosomiasis is caused by S. haematobium, which lives in the bladder, and is commonly characterised by haematuria (blood in the urine); lesioning and scarring of bladder tissue; ureter and kidney damage; genital lesions that lead to pain during sexual intercourse; and, in advanced cases, can lead to infertility and a variety of cancers

Liver enlargement is one of the most debilitating symptoms of schistosomiasis and is fatal in almost all cases. This is due to the large-scale, irreversible damage it causes to the host's body.

What makes schistosome eggs so problematic is the large spike that protrudes from their surface. This spike is designed to slice through the walls of blood vessels so the eggs can pass into their hosts urine or faeces (and thereby be passed back into water where they hatch and infect more snails), but can become caught in the host’s tissues upon occasional. Once an egg has become lodged, the host’s immune system identifies it as 'foreign material' and a type of leukocyte called a macrophage activates in response. Macrophages quickly form a granuloma around the egg, which is essentially just a tough wall of inert proteins that prevents the egg from interacting with the body’s tissues. Ordinarily, granulomas are beneficial and are eventually removed from the body, but this cannot happen with the trapped egg. Due to this long-term presence, the surrounding tissue begins to inflame and no longer functions correctly. This problem is exacerbated as an ever increasing amount of eggs build up in the organ and are themselves enclosed by granulomas! Eventually, the organ becomes so blocked and damaged that it is unable to function correctly - leading to the symptoms of schistosomiasis!

Scientists are currently working on a waterproof cream that mask the fatty acids on our skin when we swim (which will help prevent schistosomes from invading our body), but this research is still in its early stages and doesn't look likely to have a practical application anytime soon. For now, you should simply avoid swimming in any water where schistosomiasis is prevalent (no matter how inviting it may look). If you are travelling aboard, such as to Africa (where schistosomiasis is a particular problem), I strongly recommend that you consult your doctor and travel professionals to familiarise yourself with the risks of the area before you head out.