© Masson, Paris, 2005.

Gastroenterol Clin Biol 2005;29:652-655

Prevalence of schistomasiasis lesions detected

ORIGINAL by ultrasonography in children in Molodo, Mali
ARTICLE

Adama Diaman KÉITA (1), Hamadoun SANGHO (2), Moussa SACKO (3),
Zoumana DIARRA (4), Sidi Yaya SIMAGA (5), Issa TRAORE (1)
(1) Service d’Imagerie Médicale, CHU Point G ; (2) Centre de Recherche d’étude et de Documentation pour la Survie de l’Enfant (CREDOS), BP 2109 Bamako, Mali ;
(3) Institut National de Recherche en Santé Publique (INRSP), Bamako ; (4) Centre d’Ecoute de Soins d’Animation et de Conseil CESAC, Bamako BP E2561 ;
(5) Faculté de Médecine de Pharmacie et d’Odonto-stomatologie (FMPOS), Bamako BP 1805.

SUMMARY
Aim — To study schistomasiasis infection in school children in
Molodo, an irrigated rice growing region of Mali, by determining
the prevalence of schistomasiasis and lesions identified by ultra-
sonography among children living in this region.
Methods — This cross sectional study included 346 children aged
7 to 14 years selected at random from five schools in Molodo. We
tested for hematuria using urine dipsticks and searched for
Schistosoma haematobium eggs in urine and S. mansoni eggs in
stools. Ultrasonography of the liver, spleen and urinary tract was
performed.
Results — The prevalences of Schistosoma haematobium and
S. mansoni infection were 72% (range: 66.9-76.6%) and 68.2%
(range: 60.9-71.2%) respectively; 55.1% of the children had co-
infection. Ultrasonography of the urinary tract revealed an irregular
bladder wall as the most frequent abnormality (3.4% of children).
Abdominal ultrasonography demonstrated type B hepatic fibrosis in
four children (1.1%), type C in one (0.3%) and type D in one (0.3%).
Conclusion — Few schistosomiasis lesions were detected by ultra-
sonography compared with the prevalence of S. haematobium and
S. mansoni infections. This observation is probably related to mass
treatment programs conducted during a national anti-schistosomia-
sis program.
RÉSUMÉ
Prévalence des lésions bilharziennes analysées
par échographie chez les enfants de Molodo
Adama Diaman KÉITA, Hamadoun SANGHO, Moussa SACKO,
Zoumana DIARRA, Sidi Yaya SIMAGA, Issa TRAORE
(Gastroenterol Clin Biol 2005;29:652-655)
Objectifs — Nous avons entrepris une étude sur la schistosomiase
en milieu scolaire dans une zone de riziculture irriguée au Mali
(Molodo). Le but de cette étude était d’étudier la prévalence et les
lésions par échographie des schistosomiases à Molodo parmi les
enfants scolarisés.
Méthode — Nous avons réalisé une étude transversale auprès de
346 élèves de 7 à 14 ans tirés au sort dans les cinq écoles de
Molodo. Une hématurie était systématiquement recherchée par
bandelettes ainsi que la recherche des œufs de Schistosoma
haematobium dans les urines et S. mansoni dans les selles. Le foie,
la rate et l’appareil urinaire étaient examinés par échographie.
Résultats — La prévalence de Schistosoma haematobium et
S. mansoni était respectivement de 72 % (extrêmes : 66,9 %-
76,6 %), et 68,2 % (extrêmes : 60,9 %-71,2 %]. Les infections mix-
tes ont été observées chez 55,1 % des enfants. L’échographie de
l’arbre urinaire a révélé que l’irrégularité de la paroi vésicale était
l’anomalie la plus fréquente (3,4 % des enfants). L’échographie
abdominale a montré 1,1 % de fibrose hépatique type B (4 cas) ;
0,3 % de fibrose type C (1 cas) et 0,3 % de fibrose type D (1 cas).
Conclusion — Les lésions vues à l’échographie étaient peu impor-
tantes par rapport aux taux de prévalence des infections dues aux
schistosomiases. Cette constatation serait liée aux traitements de
32 masse antérieurs réalisés par l’équipe du programme national
de lutte contre les schistosomiases.

have serious consequences which include: urinary tract strictures

Introduction
In Mali, schistosomisiasis is the second leading parasitic dis-
ease after malaria. Approximately 2.5 million persons have uri-
nary tract schistosomisiasis [1]. The prevalence is high, estimated
at 55.2% for urogenital schistosomiasis [1] and more than 20%
for the intestinal form [2]. The Office du Niger is an irrigated
zone of rice culture which harbors two main Schistosoma spe-
cies, S. haematobium and S. mansoni. Fecal matter is the pri-
mary source of transmission. Infested rivers, stagnant pools,
lakes and irrigation canals harbor snails, which are the interme-
diary hosts and source of human infection. Schistosomiasis can
Reprints: A.D. KÉITA, Service de Radiologie et d’Imagerie Médicale,
CHU Point G, BP 333, Bamako, Mali.
E-mail : gadkeita@hotmail.com
or calcification, sterility, portal hypertension, bladder cancer and
hepatoportal fibrosis. To date, most of the schistosomiasis lesions
observed in children by the research teams from the National
Institute of Public Health have be found in the urinary tract (kid-
ney, ureter, bladder). We wanted to determine the prevalence of
intestinal and urinary tract schistosomiasis in school children in
Molodo, and to describe ultrasonographic lesions secondary to
S. haematobium and S. manosi.
Patients and methods
Study design
Molodo is a rural village in Mali situated in the Segou region of the
Sudanese zone, 350 km north of Bamako. The region has a three-month

652

rainy season from July to September (annual rainfall 500-600 mm). The
village population (3 328 inhabitants according to the 1996 administra-
tive census) is sedentary and irrigated rice growing is the principal eco-
nomic activity. An extensive irrigation system in Molodo exposes the
population to numerous points of contact with water. Children attend a
fundamental (public) school, a community school, and three koranic
schools. Local health facilities include a Community Health Center which
dispenses essential drugs and a private medical practice with its own
drug dispensary. Several anti-schistomatosis campaigns have been con-
ducted in this area by health teams, in particular a national anti-schisto-
matosis program and mass treatment with praziquantel conducted by the
Niono district health center. Our cross sectional study was conducted
from April 17 to 23, 2001.
Study population
The study population was recruited from the five schools. Using the
list of children provided by the school principals, we selected a random
sample of children proportional to enrollment in each of the five schools.
Data collection
Urine dipsticks (Haemastix) were used to search for microscopic hae-
maturia. A 20-mL urine sample was filtered on Whatman paper to
search for S. haematobium eggs. The Kato-Katz technique was used to
search for S. masoni eggs in stools. Two slides were examined for each
stool sample. Less than 100 eggs per gram fecal matter was defined as
low-level excretion and more than 100 eggs per gram fecal matter as
high-level excretion. An Aloka SSD 500 ultrasonograph (3.5 and 5 mHz
heads) was used to search for schistosomiasis lesions. The ultrasonogra-
phy was performed in the supine position with a full bladder. The chil-
dren were asked to drink diluted fruit juice before the examination to
ensure a full bladder. The following organs were explored: kidney, ureter,
bladder, liver and spleen. If the urinary cavities were dilated, a post-mic-
tion ultrasonography was also performed. Urine volume was assessed
before and after miction to search for significant residual volume (defi-
ned as t 10% of pre-miction volume). One experienced operator perfor-
med all ultrasonographic examinations. The Niamey protocol [3]
validated by the WHO was used to determine the stage of periportal
fibrosis (table I). The study was approved by the ethics committee of the
Bamako Faculty of Medicine, Pharmacy and Odontostomatology. Admi-
nistrative authorizations and community and parental consent were
obtained. The study protocol and its purpose were explained to the chil-
dren by groups then individually at the different test stations. All children
attending the five schools were treated with praziquantel (single dose
40 mg/kg) at the end of the study.
Statistical analysis
Minimal sample size was determined from the formula:
N = 2D .p .(1–p)/i2 where P = 0.70 (prevalence of S haematobium in
the neighboring town of Niono in 2000); D risk = 0.05; accuracy
i = 0.05. We increased the sample size by 10% to compensate for pos-
sible drop-outs. The sample size was thus set at 350 children.
Table I. – Classification of fibrosis using WHO Niamey protocol.
Classification des stades de fibrose selon le protocole de Niamey
(OMS).
Classification Results
Stabe A No fibrosis
Stage B Moderate wall thickening of at least two branches
of the portal vein with moderate changes in the main portal
vein and diffuse fine linear echogenicity scattered
over the surface of the liver.
Stage C Moderate wall thickening of at least two branches
of the portal vein mainly peripherally with little
or no thickening of the main portal vein and moderate
stricture of the portal vein branches. Thickening
of the gallbladder walls.
Stage D Moderate to severe thickening of most of the portal vein
branches with marked stricture. The thickening is irregular
and marked at the portal vein bifurcation
(thickness 2-10 mm).
653
Schistomasiasis lesions in children in Molodo
Epi Info version 6.04 was used for data analysis. The chi-square test
was used to compare qualitative variables.
Results
The study population included 192 boys (54.9%) and
158 girls (45.1%). 56.9% of the children (199/350) were aged
7 to 10 years.
Clinical data
Hematuria was the most frequent sign, observed in 25.4% of
the children. Hematuria was identified by questioning the chil-
dren and examining urine samples. Pollakiuria was noted in
19.8% of children. Among the physical signs, splenomegaly was
found in 74.8% and conjunctive tissue pallor in 25.2%. Stage 2
splenomegaly (Hackett classification) was the most frequent
(43.6%).
Parasite data
Urinary schistosomiasis was noted in 72% of children and
intestinal schistosomiasis in 68.2%. The prevalences of
Schistosoma haematobium and S. mansoni infection were 72%
(95%CI 66.9-76.6%) and 68.2% (95%CI 60.9-71.2%), respec-
tively. 24.6% of the children exhibited high-level excretion of
S. haematobium eggs and 35.1% high-level excretion of S. man-
soni eggs. Macrohematuria was identified in 12/291 children
(4.1%). However, dipstick tests revealed microhematuria in 53.7%
of children. Mass treatment with a single dose of praziquantel
(40 mg/kg) was thus instituted at the end of the study.
Ultrasonographic data
The bladder presented a rectangular shape in all children.
An irregular bladder wall was observed in 3.5% and a thick wall
in 2.3% (table II). Bladder masses and pseudo-polyps were
exceptional, found in 2.3% and 0.9% of the children, respectively
(table III). Bladder masses were more frequent in children aged
11-14 years (P = 0.012) (table III). Polyps were rarely observed.
Irregular bladder walls and bladder masses were more frequent
in boys (75% and 62.5%, respectively). The same was true for
pseudo-polyps (66.6%). Presence of post-miction residue was not
related to the presence of a bladder mass. However, all children
with bladder masses presented hematuria. Pyelocaliectasis was
moderate and noted in 54.5% of the children in the 11-14 age
group.
Splenomegaly was observed in 9.5% of the children exam-
ined. The right liver was measured in front of the right kidney
and the left liver in front of the inferior vena cava. The right lobe
was enlarged in 97.4% of children and the left lobe in 98.7%.
Periportal thickening was observed in 0.7%. Fibrosis was noted
in 1.7% (table IV). The portal vein was dilated (diameter
t 12 mm) in three children (0.9%). All cases of fibrosis (2.3%)
Table II. – Frequency distribution of bladder abnormalities.
Répartition des élèves en fonction de l’existence de l’irrégular-
ité de la paroi vésicale.
Irregular bladder walls Number of children (%)
Absent 334 (96,6)
Focale 10 (2,9)
Multifocal/diffuse 2 (0,6)
Total 346 (100)
A. D. Kéita et al.

were observed in children with high-level egg excretion

(P < 104) (table V). Ultrasonographic images of fibrosis are pre-
sented in figures 1 and 2.

Discussion
Our work demonstrated a high rate of splenomegaly in a
zone of endemic schistosomiasis and malaria. A study of thick
blood smears, stains and schistosoma egg load in children is cur-
rently being conducted in other areas of Mali: Sélingué (dam
reservoir) and Koulikoro (Niger river). We have no explanation
for the discordance between the high rate of splenomegaly
noted clinically (74.8%) and the low rate observed at ultrasonog-
raphy (10%).
Among the school children who participated in this study,
72% had urogenital schistosomiasis. This is higher than the 50%
observed by Dabo et al. [4] in Magnambougou, an urban com- Fig. 1 – Image of fibrosis detected in a school boy from Molodo (district of
Niono) in Mali.
munity near Bamako. The prevalence of intestinal schistosomiasis
Image de fibrose chez un garçon dans une école de Molodo (district
de Niono) au Mali.
Table III. – Distribution of the frequency of bladder masses according to
age.
was 68.2%, a rate close to that reported in N’Diol Maur Senegal
Répartition des enfants en fonction de la tranche d’âge et de
l’existence des masses vésicales. in 1998 (58%), but much higher than observed in the village of
N’Dioungue (29%) [5]. Rates of co-infection (S. mansoni/
S. haematobium) was 55.1%. This is the highest level reported
Bladder mass for an ecological zone in Mali [6].
Age group (years) Absent Present Total An irregular bladder wall was the most frequent lesion
observed at ultrasonography (2.9% with thicken walls), 2.3%
7-10 197 1 198 had bladder masses, and 0.9% had bladder polyps. These rates
11-14 141 7 148
are lower than reported by Kéita et al. [6] who found bladder
wall thickening, masses and polyps in 26.6%, 30.7% and 11.6%
Total 338 8 346 of cases, respectively. The presence of post-miction residue was
observed in 6.2% of the children in this series. Kéita et al. [6]
Fisher’s exact test: P = 0.012 and Kané et al. [7] did not provide data on this element. The
presence of residual urine is explained by incomplete miction
Table IV. – Distribution of children according to development of periportal related to a mass in the bladder (tumor or pseudopolyp).
fibrosis stage. Periportal fibrosis was observed in a few children: stage B
Répartition des enfants en fonction des stades évolutifs de la (1.1%), stage C (0.3%), and stage D (0.3%). These lesions were
fibrose périportale.
found in children who excreted large numbers of S. mansoni
eggs. Clinical signs of portal hypertension were not observed and
Stage N % at ultrasonography the portal trunk was dilated greater than
12 mm in only three children. In Sudan, fibrosis is almost exclu-
A 340 98,3 sively stage C and D [8]. These rates are lower than reported by
B 4 1,1

C 1 0,3

D 1 0,3

Total 346 100

Table V. – Frequency of fibrosis related to S. mansoni infection.

Répartition des enfants en fonction de la fibrose associée à S.
Mansoni.

Number of eggs/g fecal matter Periportal fibrosis

Absent Present Total

< 100 237 0 237

t100 101 8 109

Fig. 2 – Image of fibrosis detected in a school girl from Molodo (district of
Total 338 8 Niono) in Mali, April 2001.
Image de fibrose chez une fille élève dans une école de Molodo
Fisher’s exact test: P = 0.000081 (district de Niono) au Mali, avril 2001.

654

Lamothe et al. [9] who found 60.8% fibrosis (45.5% stage B) in
children living in the Ivory Coast. These differences can be
explained in part by the small number of children with a high level
of egg excretion (less than 50% in both studies), by the periodic
treatments with praziquantel during visits by health care teams, or
other factors which have not been studied, including S. mansoni/
S. haematobium co-infection and the immune status of the
infected children. In Brazil, Giovani et al. [10] found a prevalence
of 73% for stage B periportal fibrosis and 75% for stage C. Richter
et al. [11] reported that 100% of their patients with S. mansoni
hepatosplenic infection (27 from Brazil and 32 from Sudan) had
periportal fibrosis. Inversely, Fattaar et al. [12] reported only
0.28% stage B fibrosis in their patients living in Egypt.
Despite the high prevalence of infection, morbidity was low.
This observation was also made by Lanuit et al. [13] in the Rich-
ard Tool region of Senegal and by Alfidja et al. [14]. The expla-
nation is the young age of the subjects since visceral
complications become apparent only after several years of infec-
tion. The different anti-schistosomiasis campaigns (national pro-
gram, district health center) and the introduction of mass
treatment with praziquantel have reduced the rate of complica-
tions. Ultrasonography demonstrated the infraclinical nature of
visceral lesions and can be used to follow lesion progression.
Since visceral lesions, particularly hepatoportal lesions, are
exception in children aged less than 10 years, the target popula-
tion for ultrasonography would be above this age.
Cases of hepatic fibrosis regression after praziquantel treat-
ment have been reported [15, 16]. In endemic zones, severe
hepatic fibrosis can be prevented by prescribing chemotherapy
twice during childhood then again as needed [16]. A comple-
mentary approach, e.g. vaccination, should be associated with
anti-schistosomiasis chemotherapy [17]. The goal of anti-schisto-
somiasis vaccination is to prevent infection or to reduce parasite
fertility, but remains a subject of debate. New immune targets
should be useful for developing improved vaccines [17].
Conclusion
Urogenital and intestinal schistosomiasis is a serious public
health problem in Mali, particularly in Molodo and other rural
communities in the Office du Niger irrigation zone, the Dogon
Plateau, and the Senegal river basin. Ultrasonography has con-
siderably contributed to the search for visceral lesions involving
the liver, the spleen and the urinary tract. In general, few lesions
are identified at ultrasonography in comparison with the preva-
lence of parasite infections in this area of Mali. This would be a
consequence of the different mass treatment campaigns con-
ducted by the national public health institute which has an anti-
schistosomiasis research team. A study of the immunological
implications of S. mansoni/S. haematobium co-infection would
be useful to determine the reason for the low rates of periportal
fibrosis observed in children in Molodo.
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