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Background Severe hepatosplenic complications arise in patients with chronic Schistosoma mansoni infection after heavy exposure to disease agents in endemic areas. These complications are rarely reported and, hence, underestimated. Case presentation We report on eight patients with severe morbidity associated with S. mansoni infection in Ituri Province, northeastern Democratic Republic of Congo (DRC). The patients were identified during a community-based survey in 2017; one patient was seen at the district hospital. After taking the patients’ history, a clinical examination and an abdominal ultrasonographical examination were performed. S. mansoni infection was diagnosed in fecal (Kato-Katz technique) and urine (point-of-case circulating cathodic antigen test) samples. These eight patients with severe intestinal and hepatosplenic complications were identified from four villages with high S. mansoni infection prevalence and related morbidity. The patients’ ages ranged from 19 to 57 years; four patients were women. Three patients reported hematemesis. Two patients were severely anemic. All patients reported non-specific abdominal symptoms, such as diarrhea (six patients), abdominal pain (seven patients), and blood in the stool (five patients), as well as weight loss (two patients). Abdominal ultrasonography revealed ascites in four patients. All patients had portal hypertension with hepatomegaly (seven patients) or splenomegaly (five patients). Of the six patients with a discernable liver parenchyma pattern, five displayed pattern F and three patient displayed pattern E. Liver parenchyma was not visible for two patients with severe ascites. An S. mansoni infection was confirmed in six patients, with infection intensity ranging from light to heavy. All S. mansoni positive patients were treated with praziquantel (40 mg/kg body weight) and referred to the district hospital for follow-up. One patient with severe ascites died two weeks after we saw her. Due to security and accessibility reasons, the villages could not be visited again and the patients were lost to follow-up. Conclusions Our observations of patients with severe schistosomiasis document the severe degree of endemicity of S. mansoni in the province and suggest an urgent need for adequate schistosomiasis control measures that target vulnerable population groups and address severe complications.

BackgroundControlling morbidity is the main target of schistosomiasis control. Yet only rarely do we assess morbidity linked to Schistosoma sp. infection. In the Democratic Republic of Congo (DRC), and particularly in the north-eastern Ituri province, morbidity associated with Schistosoma mansoni infection is unknown. For this reason, we aimed to assess intestinal and hepatosplenic morbidity associated with S. mansoni infection in Ituri province.Methods / Principal FindingsIn 2017, we conducted a cross-sectional study in 13 villages in Ituri province, DRC. S. mansoni infection was assessed with a Kato-Katz stool test (2 smears) and a point-of-care circulating cathodic antigen (POC-CCA) test in urine. A questionnaire was used to obtain demographic data and information about experienced intestinal morbidity. Each participant underwent an abdominal ultrasonography examination to diagnose hepatosplenic morbidity. Of the 586 study participants, 76.6% tested positive for S. mansoni. Intestinal morbidity, such as abdominal pain (52.7%), diarrhoea (23.4%) and blood in the stool (21.5%) in the previous two weeks, was very frequent. Hepatosplenic morbidity was demonstrated by abnormal liver parenchyma patterns (42.8%), hepatomegaly (26.5%), and splenomegaly (25.3%). Liver pathology (adjusted odds ratio [aOR] 1.20, 95% confidence interval [CI] 1.06–1.37, P=0.005) was positively and significantly associated with S. mansoni infection. Hepatomegaly (aOR 1.52, 95% confidence interval [CI] 0.99–2.32, P=0.053) and splenomegaly (aOR 1.12, 95% CI 0.73–1.72, P=0.619) were positively but not significantly associated with S. mansoni infection at the individual level. At the village level, S. mansoni prevalence was positively associated with the prevalence of hepatomegaly and splenomegaly. Higher S. mansoni infection intensities were associated with diarrhoea, blood in the stool, hepatomegaly, splenomegaly and with liver parenchyma, pathology patterns C, D, E and F. Four study participants were diagnosed with ascites and five reported hematemesis.Conclusions/SignificanceOur study documents a high burden of intestinal and hepatosplenic morbidity associated with S. mansoni infection status in Ituri province. The results call for targeted interventions to address both S. mansoni infection and related morbidity.Author SummarySchistosomiasis caused by Schistosoma mansoni is of great public health importance in sub-Saharan Africa. The World Health Organization (WHO) recommends that control efforts aim to reduce morbidity through large scale intervention programmes. However, intestinal and liver morbidity is rarely assessed in such control programmes. Hence, little is known about (i) the magnitude of the intestinal and liver morbidity burden in each community, or about (ii) the morbidity associated with S. mansoni infection, specifically. We conducted a (cross-sectional) study in which we assessed intestinal morbidity by questionnaire and liver morbidity by abdominal ultrasonography. Further, we determined the infection status of the study participants using standard diagnostic procedures (Kato-Katz technique and point-of-care cathodic circulating S. mansoni antigen [POC-CCA] test in urine). Among 586 study participants, six years and older, from 13 villages in Ituri province, DRC, we observed a high degree of intestinal (e.g. 23.4% with diarrhoea, 21.5% with blood in stool) and hepatosplenic morbidity (e.g. 42.8% with abnormal liver patterns C, D, E, and F, 26.5% with enlarged liver, 25.3% with enlarged spleen). S. mansoni infection was associated with liver and spleen enlargement. Likewise, S. mansoni infection intensity was linked to diarrhoea, to liver and spleen enlargement and to pathological changes in the liver parenchyma. At village level, we observed that the prevalence of enlarged liver and spleen among patients increased with the prevalence of S. mansoni infection. We conclude that the population of Ituri province carries an alarming burden of intestinal, liver and spleen morbidity associated with S. mansoni infection. Therefore, a comprehensive control programme to address this infection and disease burden is urgently required.