Schistosomiasis Surveillance

Report of Suspected or Confirmed Case

Department of State

Washington, DC

# Identifying Information

  --------------------- ------------ ------------- ------------ --------------
  Patient Name:                      Date of Birth              ; female
                                     (d-mmm-yy)                 
                                                                

  Post/Country:                                                 

  Return Diagnostic     Name:                                   
  info to:                                                      

                        Address:                                
                                                                

  Email:                Telephone:                 Fax:         
                                                                
  --------------------- ------------ ------------- ------------ --------------

# Clinical Information 

Date of first symptom:       Date of clinical diagnosis       Was
patient hospitalized? Yes; No

# Laboratory Information 

  ----------------------------------- -----------------------------------
  Alkaline phosphatase                    U/L

  ALT (SGPT);     :                   U/L AST (SGOT)     U/L

  Urine dipstick blood                Positive; Negative; Not done
  ----------------------------------- -----------------------------------

# Exposure history

Swimming or bathing in fresh water Yes; No: If yes, Location      
Country      

Dates of exposure       Other known or suspected cases Yes; No

Comments:      

# 

# Signs and Symptoms

Fever Maximum Temperature       Sweats ; Arthralgias ; Abdominal Pain ;
Petechial Rash ; Hepatomegaly ; Spleenomegaly ; Lympadenopathy ;
Diarrhea ; Hematuria ; Dysuria ; Sexual dysfunction ; Neurologic disease
(paraparesis, encephalitis, cerebral mass etc.)

Comments:      

# 

# Laboratory 

Total WBC     Differential: Poly     ; Lymphs     ; Monos     ;
Eosinophils     

  ----------------------- ----------------------- -----------------------
                          Ova and Parasite        Blood

  Stool Exam                                           

  Urine Exam                                           
  ----------------------- ----------------------- -----------------------

Comments:      

Send serum to Laboratory at Office of Medical Services

  ---------------------------- ---------- ---------- ---------------------
  **Exam**                     **Date of  **Date of  **Result**
                               Serum**    Exam**     

  Indirect Florescent Antibody                            
  (DOS Lab) 1:64                                     

  FAST ELISA at Centers for                               
  Disease Control                                    

  Blot analysis at CDC                               *S. mansoni*    ; *S.
                                                     hematobium*    
  ---------------------------- ---------- ---------- ---------------------

Comments on lab:      

# 

# Treatment Administered

Praziquantel 20 mg/kg PO, two doses in one day *S. haematobium, S.
mansoni, S. intercalatum*

Praziquantel 20 mg/kg PO, Three doses in one day *S. japonicum, S.
mekongi*

Other      

Clinical outcome:      

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  Name of Person Completing Report:                    Date:      

  Signature:                                           
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