Revista da Sociedade Brasileira de M edicina Tropical 17:213-215, O ut-Dez, 1984
R E L A T O D E C A S O
P U L M O N A R Y SC fflS T O S O M IA S IS : B R O N C H O P N E U M O N IT IS PROBABLY D U E
TO SC H IST O S O M U L A E
Ênio Roberto Pietra Pedroso, José Roberto Lambertucci, Manoel Otávio da Costa Rocha,
Dirceu Bartolomeu Greco, Cid Sérgio Ferreira, Davidson Pires de Lima and Pedro Raso.
A clinicai and radiological picture o f bronchopneumonia was observed in a p a tie n t between the second and third weeks post-infection with cercariae o f S. m an so n i.
There was a spontaneous recovery without sequelae in 2 0 days and the clinicai an d radiological alterations were interpreted as associated with the passage o f schistosom ulae through the lungs.
K e y w ords: P u lm o n a ry sc h is to so m ia sis, B r o n c h o p n e u m o n itis and sc h isto so m u la e. P re-p ostu ral sc h is to so m ia sis. L u n g and sc h isto so m u la e .
In B razil v a rio u s p u lm on ary ch a n g es a sso c ia te d
w ith Schistosom a m ansoni in fe ctio n h ave b een re-p orted 8 9 1 0 1 1 . T h e s e re-p u lm on ary a b n orm alities w ere
m a in ly se c o n d a r y to the p resen ce o f the eg g s d evia ted
from th e po rta l sy ste m or to th e ad u lt p arasites and their m eta b o lic prod ucts.
T h is p ap er reports th e c h a n g es v isu a liz e d in the ra d io lo g ica l stu d y o f the th orax , o b ser v ed b e tw e en the
s e c o n d an d third w e e k after th e p ro b ab le in fectin g
b a th e in a S. m ansoni en d em ic area, o f a p a tie n t w h o d e v e lo p e d an acu te n o n to x e m ic form o f sc h is to
so m ia sis .
C A S E R E P O R T
V P R , a 17 y ea r -o ld n o n -c a u c a sia n m ale, b o m and liv in g in the c ity o f B e lo H o r izo n te, B razil, b ath ed
for th e first tim e in stream w ate r in the surroun dings o f h is h o m e tow n . D u r in g th e b ath and im m e d ia te ly
afterw ard s h e co m p la in e d o f d isse m in a ted cu ta n e o u s pruritus w h ich fad ed sp o n ta n e o u sly in a fe w hours. A w ee k la ter a m ild and sp ora d ic cou gh d e v e lo p e d ,
w ith o u t e x p ec to ra tio n or m a la ise . E x a m in e d in an
out-p a tie n t Service a c h e s t x-ra y w a s read as n orm al (F ig u r e 1) an d asp irin w a s p rescrib ed . H e sta y ed a sy m p to m a tic fo r an oth er w ee k w h en co u gh in g started
a ga in , th is tim e m ore in te n se w ith m u c o u s sputum in sm a ll a m o u n ts, m ild d y sp n o e a , a sth e n ia an d sw ea tin g.
H e th en sta rted to h a v e diarrhea, fiv e to e ig h t tim e s a d a y , w ith ten esm u s, w ith o u t p u s, b lo o d or an al pru
ritus. A d m itte d to th e h o sp ita l a c h e s t x -ra y d isc lo se d
N ú c l e o d e E s t u d o s s o b r e E s q u i s t o s s o m o s e . F a c u l d a d e d e M e d i c i n a . U F M G . D e p a r t a m e n t o d e C l i n i c a M é d i c a d a F a c u l d a d e d e M e d i c i n a d a U n i v e r s i d a d e F e d e r a l d e M i n a s G e r a i s . A v . A l f r e d o B a l e n a , 1 9 0 , B e lo H o r i z o n t e , 3 0 . 0 0 0 , M i n a s G e r a i s , B r a s i l .
R e c e b i d o p a r a p u b l i c a ç ã o e m 9 / 4 / 1 9 8 4 .
b ila teral m ic r o n o d u les e s p e c ia lly on the right side
(F ig u r e 2 ). H e ap peared to x e m ic , em acia te d , the ax illa ry tem peratu re w a s 3 8 ° C , p u lse w a s 9 8 ,
res-piratory rate 3 0 an d b lo o d p ressu re 1 2 0 /8 0 m m H g. S pa rse b ilateral crep itatin g and su b crepita ting rales w ere presenL C ard ia c a u scu lta tio n d isc lo se d p h y sio
-lo g ic a l S 2 sp litting. T h e ab d ôm en w a s fla t w ith in-c r e a se d p erista lsis. T h e liv er w a s ten der, p alp ab le at
12 cm from th e inferior c o s ta l m agin at the right
h em icla v icu la r lin e. T h e sp lee n w a s en larged and ten d er (B o y d ty p e II). T h e b lo o d co u n t w a s 4 ,5 0 0 ,0 0 0 ery th ro cy tes p er m m 3, h a em o g lo b in 1 4 ,5 h em atocrit
4 2 % , le u k o c y te s 1 6 ,0 0 0 p er m m 3 (2 % bands,
5 0 % se g s, 2 3 % e o sin o p h ils, 0 % b a so p h ils, 20 % lym -p h o c y te s, 3% m o n o c y te s ), E S R 35 m m in o n e hour an d th e prothrom b in tim e 8 0 % o f norm al. T h e le v e is o f tra n sa m in a se s ( S G O T , S G P T ), L D H , alk alin e p h c
s-p h a ta se, u rin aly sis , fastin g g ly c e m ia and urea w ere n orm al. S ev er a l sp utum a n a ly se s for acid fa st b acilli
an d b a c te r io sc o p y sh o w e d o n ly iso la te d gram p o sitiv e
c o c c i. T o a s s is t in th e d ia g n o sis o f th e prepostural a cu te p h a se o f sc h is to so m ia sis a n eed le liv er b io p sy
w a s d on e. It sh o w e d h ep atitis in sm all sy stem a tised fo c i, w ith an ex u d a te o f n eu troph ils, ly m p h o cy tes and
rare e o s in o p h ils. A few h e p a to c y te s w ere n ecrosed . L o s s o f b a so p h ilia w a s se e n and h yd rop ic d eg en eratio n
in oth er h ep a to c y te s. T h e sin u so id s w ere narrow ed in the areas o f d eg en era tio n and sw o lle n in so m e other areas. T h e K u pffer c e lls w ere hy pertrop hic but not
h y p erp la stic. T h e s e fm d in gs su g g est the p re-postu ral
a cu te p h ase o f th e d is e a s e 1. S ix sto o ls a n a ly se s w ere n eg a tiv e for eggs or larvae o f p ara sites. T h e patient
w a s k ept in the h o sp ita l on sy m p to m a tic m ed ic a tio n for 2 0 d a y s an d during th is p eriod the resp iratory co m
-p la in ts d isa -p -p ea red an d ev a c u a tio n and c o n sis te n c y o f the s to o ls b e c a m e norm al. A co n tro l y-ra y 4 0 d ay s
Pedroso E R P , L am bertucci JR, R och a M O C , Greco D B , Ferreira C S, L im a DP, R a so P. P u lm o n a ry schistosom iasis: broncopneum onitis probably due to schistosom ulae. R evista da Sociedade B rasileira de M ed icin a Tropical 17:213-215, Out-Dez, 1984
after th e p ro b ab le in fe ctin g b ath e w a s th e sa m e as
F ig u re 1; th e p a tie n t h a d n o sy m p to m s at th is tim e. O n p h y sic a l e x a m in a tio n liv er and s p le e n rem ain ed
u n cha n ged . T o ta l le u k o c y te co u n t w a s 1 0 0 0 0 per m m 3 w ith 15% e o sin o p h ils, E S R 3 8 m m in o n e h ou r
and th e s to o ls ex a m in a tio n d is c lo s e d v ia b le e g g s o f
S. m ansoni ( K a to ’s m eth od ).
Figure 1:Chest x-ray. One week after the infecting bathe. The same appearance was observed 6 weeks after the infecting bathe.
Figure 2:Chest x-ray. 1 hree weeks after the infecting bathe.
D I S C U S S I O N
P u lm o n a ry in v o lv em e n t in sc h is to so m ia sis m a n so n i h as b e e n reported b o th in an im al in fe ctio n s
and in m an. P u lm o n a ry m igra tion is a criticai p h a se for the p ara site. T h e sc h is to so m u le s during m igration in
ex p er im en ta l an im a is ca n b e foun d in th e lu n gs aroun d 2 2 h ours after th e cercarial p en etratio n r e a ch in g th eir
m a x im u m n um ber b y th e six th d ay . T h e y ca n sta y in
th e lu ngs from three to 21 d a y s 17 an d during th is p eriod
the p arasite d o e s n o t se e m to d e v e lo p . S in c e L a m p e ’s w ork 2 it is k n o w n th at th e le s io n s in th e resp irato ry
sy ste m d u e to th e sc h is to so m u le s are in co n sta n t and u su a lly m ild , b ein g m a in ly arteriolitis, arteritis, en -d oa rteritis an-d fo c i o f n e c r o sis4 5 6 13 C o n g e stio n an-d
rupture o f a lv e o la r ca p illa rie s, w ith sm a ll fo ci o f
h em orrhage in sid e th e a lv e o lu s m a y a ls o o c c u r 17. L ich ten b erg et a fi h a v e re ce n tly o b ser v ed m in im al fo c a l reactio n arou nd th e sc h is to so m u le s in lu n gs o f in fe cted m ic e . S a m i14 and S a m i et a / 15 attributed th e p h e n o m en o n o f sm a ll a ir w a y o b str u ctio n to th e larvae
p a ssin g Ihrough th e lu ngs, p ro b a b ly d u e to h yper-se n sitiv ity re a ctio n s a n d /o r lo c a l d estru ctio n o f the
s c h is to s o m u la e 12.
T h e a n a to m ica l ch a n g es se co n d a r y to th e
pre-se n c e o f s c h is to so m u le s in th e h um an lu n g s are n o t fu lly u n d ersto od s in c e m o st k n o w le d g e ste m s from
an im al w ork . I t is k n o w n th at during th is p erio d in
h u m a n in fectio n tran sien t or p ersisten t resp irato ry sy m p to m s m a y occ u r . S y ste m ic m a n ifesta tio n s like tir e d n ess, vertig o, m u c o sa n g u in e o u s diarrhea, d iffu se
ly m p h a d e n o p a th y , an d sp le n o m e g a ly m a y a ls o o ccu r,
a p ro d ro m e o f a to x ic -in fe c tio u s p r o c e s s 7.
T h e p resen t c a s e is o f a p erson w h o im m e d ia te ly
after c o n ta c t w ith stream w ater h ad a d isse m in a te d cu ta n e o u s pruritus, an d tw o w e e k s la ter d e v e lo p e d a
c lin ic a i p icture o f b ro n ch o p n eu m o n ia , fever, diarrhea, acu te h e p a to sp le n o m e g a ly an d b lo o d eo sin o p h ilia .
T h e p a r a sito lo g ic a l a n a ly sis o f th e fe c e s , n eg a tiv e at
first, b e c a m e p o sitiv e w ith e g g s o f S. m ansoni and the liv e r b io p sy sh o w e d n o n s p e c ific h ep atitis. T h e in itial sy m p to m s p red ic te d a se rio u s c lin ic a i o u tc o m e th at in
fa ct did n o t occu r, th e c lin ic a i c o u rse w a s b en ig n w ith sp o n ta n e o u s re co v e ry . T h is prod ro m al p h a se o f acu te sc h is to so m ia is m a n so n i h a s b e e n p r e v io u sly repor
ted 7 ; h o w ev er, in our p a tie n t w e w ere ab le to w itn e ss
ra d io lo g ica lly th e p u lm on ary ch a n g es in the p re-p o s-tural p h a se o f th e d ise a s e d u e to th e p a ssa g e through
th e lu ng s o f th e sc h is to so m u le s. T h is is d ifferen t to the c a s e reported b y S a n tia g o an d R a tto n 16 se c o n d a r y to
th e egg s. T h e x -ra y r e se m b les a b a cter ia l o r viral in fectio n . T h e c lin ic a i find ings o f e o sin o p h ilia , diarrhea
and th e a p p earan ce o f S. m ansoni e g g s in the sto o ls and the liv e r b io p s y p a tte m co n firm ed the d ia g n o sis o f
lu ng in volv em en t se con d ary to sch is to so m ia sis. W e still h a v e n o w a y o f e x p la in in g th e p red om in an tly right sid e
in v o lv e m e n t o f th e lu n g b u t it m a y b e d u e to th e p a tte m
Pedroso E R P , L a m b ertu cci JR , R ocha M O C , Greco D B , Ferreira CS, L im a DP, R a so P. P u lm o n a ry schistosomiasis: broncopneum onitis p robably due to schistosom ulae. R evista da Sociedade B rasileira d e M edicina T ropical 17:213-215 Out-Dez, 1984
o f m ig ra tio n o f th e sc h is to so m u la e fro m th e lu n g s to th e liv e r T h e c lin ic a i ev o lu tio n e x c lu d e d o th er p arasitic in fe c tio n s.
In th is c a s e th e s c h is to s o m e in fe c tio n b eh a v ed
c lin ic a lly lik e a b ro n ch op n eu m on itis and ra d io lo gically as a d iffu se n on m ig ra tory m icron od u lar co n d en sa tio n
w ith sp o n ta n e o u s and c o m p le te re co v e ry in 2 0 d ays.
It m u st b e e m p h a siz e d t h a t 1. th e e x u b era n ce o f th e prod ro m al p erio d is n o t a lw a y s fo llo w e d b y a se rio u s c lin ic a i co u rse; 2 . the p u lm on ary ch a n g es
s e c o n d a r y to th e s c h is to so m u le s m a y b e in te n se en o u g h to b e e x p r e sse d a s resp iratory sy m p tom s; 3. th e ra d io lo g ica l p ictu re m a y b e th at o f a
bron-c h o p n e u m o n itis; 4 . lo bron-c a l and sy s te m ibron-c h y p e rse n si-tiv ity p h e n o m e n a c o u ld b e re sp o n sib le for th e c lin ic a i
an d r a d io lo g ic a l m a n ifesta tio n s.
R E S U M O
R elata-se o caso de um paciente que após 2 a 3 sem anas de contato infectante com cercárias de senvolveu quadro clínico e radiológico de bron-copneumonite. O pacien te não possu ía infecção es-quistossom ótica anterior. H ouve recuperação espon tânea, sem seqüela em 2 0 d ia s e a s alterações clínico-radiológicas fo ra m interpretadas em associação à passagem de esquistossôm ulos p elo s pulmões.
P a la v r a s ch aves: E s q u is to s s o m o s e pulm onar. B r o n c o p n eu m o n ite p or e s q u isto ssô m u lo . E s q u isto s s o m o se p ré-p ostu ra l. P u lm ã o e es q u isto ssô m u lo .
R E F E R E N C E S
1 . B o g l i o l o L , N e v e s J . O c o r r ê n c i a d e h e p a t i t e n a f o r m a a g u d a o u t o x ê m i c a d a e s q u i s t o s s o m o s e m a n s o n i , a n t e s d a m a n u t e n ç ã o d o s v e r m e s e d a p o s t u r a d o s o v o s c o m a l g u m a s c o n s i d e r a ç õ e s s o b r e a f o r m a a g u d a o u t o x ê m i c a d a e s q u i s t o s s o m o s e . A n a i s d a F a c u i d a d e d e M e d i c i n a d a U n i v e r s i d a d e F e d e r a l d e M i n a s G e r a i s 2 2 : 4 7 - 7 4 , 1 9 6 5 . 2 . L a m p e P H J . B i l h a r z i o s i s i n S u r i n a m . G e n e e s k u n d
z y d s c h r i f t v o o r w e d e r l a n d s c h . I n d i e B a n d o e n g 6 5 : 5 4 6 - 5 6 0 , 1 9 2 5 .
3 . L i c h t e n b e r g F V , S h e r A , M c l n t y r e S A . A l u n g m o d e l o f s c h i s t o s o m e i m m u n i t y i n m i c e . A m e r i c a n J o u r n a l o f P a t h o l o g y 8 7 : 1 0 5 - 1 2 4 , 1 9 7 7 .
4 . M a g a l h ã e s F i l h o A . P u l m o n a r y l e s i o n s i n m i c e e x - p e r i m e n t a l l y i n f e c t e d w i t h S. m ansoni. A m e r i c a n J o u r n a l o f T r o p i c a l M e d i c i n e a n d H y g i e n e 8 : 5 2 7 - 5 3 5 , 1 9 7 7 .
5 . M a r q u e s R J . E s q u i s t o s s o m o s e m a n s ô n i c a , a s p e c t o s s e m i o l ó g i c o s d a c h a m a d a f j r m a c a r d i o p u l m o n a r . J o r n a l B r a s i l e i r o d e M e d i c i n a 8 : 3 2 5 - 3 3 3 , 1 9 6 4 .
6 . M e i r a J A . E s t u d o c l í n i c o d a s f o r m a s p u l m o n a r e s d a e s q u i s t o s s o m o s e m a n s ô n i c a ( D o e n ç a d e M a n s o n - P i r a j á d a S i l v a ) . A r q u i v o d e C i r u r g i a e C l í n i c a E x p e r i m e n t a l 6 : 3 - 1 3 6 , 1 9 4 2 .
7 . N e v e s J , L o b o - M a r t i n s N R L , T o n e l l i E . F o r m a t o x ê m i c a d a e s q u i s t o s s o m o s e m a n s o n i . C o n s i d e r a ç õ e s d i a g n o s t i c a s e m t o r n o d e 5 0 c a s o s i d e n t i f i c a d o s e m B e lo H o r i z o n t e . H o s p i t a l 7 0 : 1 4 3 - 1 6 3 , 1 9 6 6 .
8 . N e v e s J , P e d r o s o E R P , G r e c o D , S o u z a D W C , R o c h a M O C , R a s o P . E s q u i s t o s s o m o s e p u l m o n a r I . F o r m a c r ô n i c a e x t e n s a s e m h i p e r t e n s ã o p u l m o n a r e n a a u s ê n c i a d e h i p e r t e n s ã o p o r t a l . R e v i s t a d a S o c i e d a d e B r a s i l e i r a d e M e d i c i n a T r o p i c a l 1 3 : 2 5 - 3 4 , 1 9 7 9 / 8 0 .
9 . N e v e s J , P e d r o s o E R P , S o u z a D W C , G r e c o D , R o c h a M O C , R a s o P . E s q u i s t o s s o m o s e p u l m o n a r I I . F o r m a c r ô n i c a r e a t i v a d a c o m h i p e r t e n s ã o e c o r p u l m o n a l e . R e v i s t a d a S o c i e d a d e B r a s i l e i r a d e M e d i c i n a T r o p i c a l
1 3 : 3 5 - 4 4 , 1 9 7 9 / 8 0 .
1 0 . N e v e s J . P e d r o s o E R P , O r ê f i c e F , S o u z a D W C , G r e c o D , R o c h a M O C , R a s o P . E s q u i s t o s s o m o s e p u l m o n a r I I I . F o r m a c r ô n i c a e x t e n s a c o m h i p e r t e n s ã o p u l m o n a r e n a v i g ê n c i a d e h i p e r t e n s ã o p o r t a l a s s o c i a d a a p r o v á v e l c o r o i d i t e e r e t i n i t e e s q u i s t o s s o m ó t i c a . R e v i s t a d a S o c i e d a d e B r a s i l e i r a d e M e d i c i n a T r o p i c a l 1 3 : 4 5 - 5 3 ,
1 9 7 9 / 8 0 .
1 1 . P e d r o s o E R P , N e v e s J , M a r i n h o R P , L a m b e r t u c c i J R , S o u z a D W C , R o c h a M O C . E s q u i s t o s s o m o s e p u l m o n a r c r ô n i c a I V . A l t e r a ç õ e s p u l m o n a r e s p ó s - t r a t a m e n t o c o m o x a m n i q u i n e . X I V C o n g r e s s o d a S o c i e d a d e B r a s i l e i r a d e M e d i c i n a T r o p i c a l , J o ã o P e s s o a . R e s u m o s d o s t e m a s l i v r e s , p . 1 1 2 , 1 9 7 8 .
1 2 . R a s o P , B o g l io l o L . P a t o l o g i a . In : C u n h a A S ( e d ) E s q u i s t o s s o m o s e m a n s o n i . U S P , S ã o P a u l o , C a p . 5 , p . 7 7 - 1 3 0 , 1 9 7 0 .
1 3 . R i t c h i e L S , B e r r i o s - D u r a n L A . A s i m p l e p r o c e d u r e f o r r e c o v e r i n g s c h i s t o s o m e e g g s i n m a s s f r o m t i s s u e s . J o u r n a l o f P a r a s i t o l o g y 4 7 : 3 6 3 - 3 6 5 , 1 9 6 1 .
1 4 . S a m i A A . P u l m o n a r y m a n i f e s t a t i o n s o f s c h i s t o s o m i a s i s . D i s e a s e s o f t h e C h e s t 1 9 : 6 9 8 - 7 0 5 , 1 9 5 1 .
1 5 . S a m i A A , G o m e s T , E l - A l a m i M . P a r e n c h y m a t o u s , b r o n c h o p u l m o n a r y , m a n i f e s t a t i o n s o f p u l m o n a r y b i l h a r - z i a i s . D i s e a s e s o f t h e C h e s t 3 8 : 5 2 8 - 5 3 2 , 1 9 6 0 . 1 6 . S a n t i a g o J M , R a t t o n J L . Q u a d r o c l í n i c o d a s f o r m a s
p u l m o n a r e s . I n : C u n h a A S ( e d ) E s q u i s t o s s o m o s e m a n s o n i , U S P , S ã o P a u l o , C a p . 6 , p . 1 7 9 - 1 8 3 , 1 9 7 0 .
1 7. W i l k s N E . L u n g - to - l i v e r m i g r a t i o n o f s c h i s t o s o m e s in t h e l a b o r a t o r y m o u s e . A m e r i c a n J o u r n a l o f T r o p i c a l M e d i c i n e a n d H y g i e n e 1 6 : 5 9 9 - 6 0 5 , 1 9 6 7 .
