Am. J. Trop. Med. Hyg., 81(4), 2009, pp. 549–550
doi:10.4269/ajtmh.2009.08-0498
Copyright © 2009 by The American Society of Tropical Medicine and Hygiene
Case Report: Cervical Schistosomiasis as a Risk Factor of Cervical Uterine
Dysplasia in a Traveler
Arnaud Dzeing-Ella, Frédéric Mechaï, Paul-Henri Consigny, Laurent Zerat, Jean-Paul Viard,
Marc Lecuit, and Olivier Lortholary*
Faculté de Médecine, Paris Descartes, Centre d’Infectiologie Necker Pasteur, Hôpital Necker Enfants-malades, Service des Maladies
Infectieuses et Tropicales, Paris Cedex, France; Laboratoire d’Anatomopathologie Lavergne, Paris, France
Abstract. Female genital schistosomiasis (FGS) may be under-recognized in endemic areas as a cause of cervical dysplasia, neoplasia, infertility, and as a facilitator of the transmission of HIV. To the best of our knowledge, few cases of FGS
mimicking neoplasia have been reported in travelers. We report a clinical case of a 34-year-old white woman who presented with a severe cervical dysplasia, without any features of human papilloma virus infection, 2 years after bathing in
a waterfall, a source of schistosomiasis, in Mali. Schistosomes eggs were found on the conization. Management included
conization and medical treatment, resulting in a full clinical and histologic recovery. FGS should be kept in mind as a possible cause of cervical dysplasia in endemic areas. Medical treatment with praziquantel improves this condition.
schistosomes leave the portal vein and colonize the anorectal
plexus. After that, worms access easily to the perivesical plexus
and the utero-vaginalis plexus either by traversing the rectovaginal septum or through vascular links between the bladder
and the reproductive organs.3
The clinical and histopathologic pictures of FGS vary
according to the organ affected. Ovaries, Fallopian tubes,
uterus, placenta, cervix, vagina, vulva, clitoris, and breast can
be affected. Hypersensitivity response to S. haematobium
eggs lead to chronic granulomatous inflammation and precancerous or cancerous lesions.3 Symptoms associated with
CS consist of dysmenorrhea, menorrhagia, leukorrhea, lower
abdominal pain, post-coital bleeding, dyspareunia, and intermenstrual bleeding. Additionally, nodular hypertrophy, cauliflower-like growths, and ulcerative and polypoid lesions have
been described.4 These lesions may look malignant and many
women might undergo surgery such as hysterectomy on false
clinical premises. Diagnosis of CS is relatively easy using the
quantitative compressed biopsy technique.5 CS is a curable
disease. Indeed, after a single dose of praziquantel, lesions
usually resolved within 9 weeks.6
Chronic infections with schistosomes species have been thus
far associated with carcinogenesis. There is strong evidence
that S. haematobium is carcinogenic, leading to squamous cell
carcinoma of the urinary bladder. Schistosoma japonicum is
possibly carcinogenic to humans, leading to colorectal cancer
and is a risk factor for hepatocellular carcinoma formation,
and Schistosoma mansoni may still be linked to hepatocellular
carcinoma through potentiating the effects of hepatitis B virus
and hepatitis C virus on the liver.7
CS might play an additional role in HPV-induced cervical
dysplasia and cancer. In fact, Moubayed and others8 observed
that, in all cancer cases in which CS was also present, the
lesions were co-infected with HPV.
In conclusion, for female travelers coming from endemic
areas, CS should be considered as a curable cause of
dysplasia.
INTRODUCTION
Schistosomiasis is a parasitic helminthic disease affecting
~250 millions people in developing countries.1 The infection
occurs when humans enter snail-infested waters.
Schistosomiasis of the lower and upper reproductive tract,
defined as female genital schistosomiasis, has the potential to
be debilitating and can lead to life-threatening sequelae.
CASE REPORT
We report the observation of a 34-year-old white woman hospitalized for genital cervical schistosomiasis (CS). Two years
before admission, she traveled to Mali and took a bath in the
Plate Dogon waterfall, considered to be an important source
of schistosomiasis.2 A cervical smear (Figures 1 and 2) for persistent intermenstrual bleeding was performed. This showed
inflammatory lesions and cytologic changes consistent with dysplasia. At colposcopy, an area of high-grade cervical intraepithelial neoplasia was identified, and a cone biopsy was subsequently
carried out. The endocervical epithelium presented features of
early metaplasia. Human papilloma virus (HPV) hybridization
was negative. Schistosoma haematobium eggs were found inside
the chorion, surrounded by granulomatous inflammation without evidence of malignancy. The patient denied any history of
signs and symptoms consistent with urinary tract schistosomiasis, and clinical examination (gynecologic inspection excluded)
was normal. Parasitologic examination of the urine was negative for schistosomes eggs. HIV screening was negative.
A single dose of 2.4 g praziquantel was administered. The
treatment was well tolerated, and the patient was re-examined
1 month after discharge and was completely asymptomatic.
Another cervical smear was performed 3 months after antiparasitic treatment: parasitologic examination was negative,
and there was no histologic abnormality.
DISCUSSION
Female genital schistosomiasis (FGS) is almost exclusively
caused by S. haematobium. After maturation in the liver, adult
Received September 25, 2008. Accepted for publication March 17,
2009.
* Address correspondence to Olivier Lortholary, Hôpital Necker
Enfants-malades, Service des Maladies Infectieuses et Tropicales, 149,
rue de Sèvres, 75743 Paris Cedex, France. E-mail: olivier.lortholary@
nck.aphp.fr
Authors’ addresses: Arnaud Dzeing-Ella, Frédéric Mechaï, PaulHenri Consigny, Laurent Zerat, Jean-Paul Viard, Marc Lecuit, and
Olivier Lortholary, Faculté de Médecine, Paris Descartes, Centre
d’Infectiologie Necker Pasteur, Hôpital Necker Enfants-malades,
Service des Maladies Infectieuses et Tropicales, 149, rue de Sèvres,
75743 Paris Cedex, France.
549
550
DZEING-ELLA AND OTHERS
Figure 1. A cervical smear with cytologic changes consistent with
dysplasia and organisms consistent with S. haematobium calcified eggs
(arrows) surrounded by granulomatous inflammation.
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