+
MODEL
Travel Medicine and Infectious Disease (2013) xx, 1e3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
CASE REPORT
A rare case of urinary schistosomiasis in Turkey H. Kirkoyun Uysal a, O. Akgul a,*, E. Aliyev b, M.H. Tunc b, Y.A. Oner a a
Istanbul University, Istanbul Faculty of Medicine, Department of Medical Microbiology, Istanbul, Turkey b Istanbul University, Istanbul Faculty of Medicine, Department of Urology, Istanbul, Turkey Received 22 January 2013; received in revised form 12 April 2013; accepted 7 November 2013
KEYWORDS Schistosomiasis; Haematuria; Turkey
Summary Schistosomiasis is a chronic, parasitic disease and is endemic in some countries, primarily in Africa, Latin America and Asia. In some regions, Schistosoma haematobium is one of the principal causes of haematuria. In Turkey, due to the increasing amount of travel to and from endemic regions, the number of cases is also rising. We report a case of a 22year-old Nigerian male who was admitted to our hospital with haematuria. Direct microbiological examination revealed S. haematobium eggs in his urine specimen. Schistosomiasis was diagnosed by pathology testing. Schistosomiasis has not been seen frequently in Turkey, and we therefore discuss the epidemiology, treatment options and clinical importance of S. haematobium. ª 2013 Elsevier Ltd. All rights reserved.
Introduction Schistosomiasis, also known as bilharziasis, is second only to malaria in public health importance [1]. Schistosoma haematobium is an endemic parasitic disease of the urinary tract. Humans may be infected by cercariae when they are
* Corresponding author. Department of Microbiology and Clinical Microbiology, Faculty of Medicine, Istanbul University, Fatih, 34093 Istanbul, Turkey. Tel.: þ90 5325659944. E-mail address: [email protected] (O. Akgul).
in contact with contaminated fresh water [2]. The urinary bladder, the lower ends of the ureters, and the seminal vesicles are the most commonly affected organs. Infection becomes established 10e12 weeks after cercarial penetration and is manifested by haematuria and urinary excretion of eggs [3]. Schistosomiasis has three different clinical manifestations: first, cercarial dermatitis due to cercarial penetration of the skin; second, acute schistosomiasis or Katayama fever, which coincides with larval maturation and migration; third, chronic schistosomiasis, in which the lesions are the result of the inflammation and subsequent fibrosis caused by the schistosoma eggs [4,5].
1477-8939/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tmaid.2013.11.002
Please cite this article in press as: Uysal HK, et al., A rare case of urinary schistosomiasis in Turkey, Travel Medicine and Infectious Disease (2013), http://dx.doi.org/10.1016/j.tmaid.2013.11.002
+
MODEL
2 According to the World Health Organization, schistosomiasis affects almost 240 million people worldwide, and more than 700 million people live in endemic areas. Every year, more than 200,000 people die from this insidious disease. Several million people worldwide suffer from severe morbidity as a consequence of schistosomiasis [1]. We now report a very rare case of urinary schistosomiasis caused by S. haematobium infection of a 22-year-old Nigerian male patient who has been a student in Istanbul for approximately 1 year.
Case report A 22-year-old Nigerian male visited the Istanbul University Istanbul Faculty of Medicine Department of Urology complaining of bloody urine. Fever was found in his physical examination in the urology department, and he also had terminal haematuria for more than 8 years. There were no significant findings in his medical history. His blood count showed mild leucocytosis. Other biochemistry and routine tests were normal. After multiple polypoid lesions had been revealed in his bladder via ultrasound examination, cystoscopy was planned and showed multiple neoplastic lesions located on the right, left and base wall of the urinary bladder. Transurethral resection of the bladder was performed. Cytological examination of urine was positive for S. haematobium eggs and squamous metaplasia, but due to the lack of the resection material the patient underwent a further operation. Microbiological reexamination revealed S. haematobium eggs in his urine sediment (1000 rpm for 3 min). Medical treatment was started with one dose 40 mg/kg praziquantel and he underwent one more operation for detailed pathological examination which showed no abnormalities, such as neoplasms, and he was therefore discharged.
Discussion Schistosomiasis is a parasitic disease caused by trematode flatworms of the genus Schistosoma. Schistosomiasis is an important healthcare problem in many endemic countries. Its incidence is increasing in developed countries due to immigrant populations and tourists. Theodor Bilharz first described the cause of urinary schistosomiasis as a parasitic disease caused by infestation with S. haematobium in 1851 [6]. There are many species of the schistosomas that can infect humans. Intestinal schistosomiasis may be caused by Schistosoma guineensis, Schistosoma intercalatum, Schistosoma mansoni, Schistosoma japonicum or Schistosoma mekongi. Urogenital schistosoma infection is caused by S. haematobium [7], affecting patients at a much younger age (mean 46.7 years) with males predominating over females 5.6-fold [8]. In regions where schistosomiasis is endemic, it constitutes a major risk factor for squamous cell carcinomas, which account for more than 50% of bladder cancers [9]. Chronic infection induces squamous metaplasia, which may evolve into squamous cell carcinoma [10]. In Egypt, the incidence of bladder cancer has decreased in line with schistosomiasis prevalence over the past few decades
H.K. Uysal et al. [11,12]. A multicentre caseecontrol study has suggested that the risk of either squamous cell carcinoma or urothelial carcinoma increases in association with schistosomiasis and tobacco smoking [13]. In Turkey the relationship between schistosomiasis and bladder malignancies has not been investigated. General clinical manifestations of schistosomiasis include haematuria, leucocyturia, urinary tract complaints, tender abdomen, suprapubic tenderness, chronic iron deficiency, anaemia, scarring and deformity of the ureters and bladder, chronic bacterial superinfection, severe damage of urinary tract organs, and ultimately renal failure [14]. The patient in this case report had terminal haematuria, leucocytosis and fever similar to the common symptoms of schistosomiasis. The treatment options for schistosomiasis are limited. Anthelmintic therapy with praziquantel in the form of a single or divided oral administration dose of 40e60 mg/kg is the current recommended treatment for urinary schistosomiasis [15,16]. However, King et al. reported that a low dose regimen (20 mg/kg/day) of praziquantel could have an equivalent effect to that of the standard recommended dose regimen [17]. In addition, praziquantel has little or no effect on eggs and immature worms. The recommended timing for follow-up is therefore 4e6 weeks after the treatment period [18]. For this purpose, the patient received 40 mg/kg of praziquantel daily and has remained under observation. In conclusion, in geographic regions where schistosomiasis is not endemic, such as Turkey, a comprehensive anamnesis is essential for differential diagnosis of this infection. When diagnosing patients with haematuria, it is mandatory for urologists to have knowledge of urinary schistosomiasis and to obtain a detailed history of overseas trips to endemic areas. A multidisciplinary approach, involving a urologist, a microbiologist and an infectious disease specialist, will help in the early identification and targeted treatment of schistosomiasis.
Funding None.
Conflict of interest None declared.
References [1]. World Health Organization coordinated strategy. Preventive chemotherapy in human helminthiasis. Geneva: World Health Organization; 2006. [2]. Webbe G. Infection with S. haematobium. In: Jordan P, Webbe G, editors. Schistosomiasis: epidemiology, treatment and control. 1st ed. London: Pitman Press; 1982. pp. 79e104. [3]. Ghoneim MA. Bilharziasis of the genitourinary tract. BJU Int 2002;89(Suppl. 1):22e30. [4]. Stuiver PC. Acute schistosomiasis (Katayama fever). Br Med J (Clin Res Ed) 1984;288:221e2.
Please cite this article in press as: Uysal HK, et al., A rare case of urinary schistosomiasis in Turkey, Travel Medicine and Infectious Disease (2013), http://dx.doi.org/10.1016/j.tmaid.2013.11.002
+
MODEL
Urinary schistosomiasis in Turkey [5]. Soonawala D, Geerts JW, de Mos M, Yazdanbakhsh M, Visser LG. The immune response to schistosome antigens in formerly infected travelers. Am J Trop Med Hyg 2011;84: 43e7. [6]. Mohammed AZ, Edino ST, Samaila AA. Surgical pathology of schistosomiasis. J Natl Med Assoc 2007;99:570e4. [7]. Neal PM. Schistosomiasis an unusual cause of ureteral obstruction: a case history and perspective. Clin Med Res 2004;2:216e27. [8]. Clements AC, Barnett AG, Nyandindi U, Lwambo NJ, Kihamia CM, Blair L. Age and gender effects in self-reported urinary schistosomiasis in Tanzania. Trop Med Int Health 2008;13:713e21. [9]. Shokeir AA. Squamous cell carcinoma of the bladder: pathology, diagnosis and treatment. BJU Int 2004;93:216e20. [10]. Wong-You-Cheong JJ, Woodward PJ, Manning MA, Sesterhenn IA. Neoplasms of the urinary bladder: radiologicepathologic correlation. RadioGraphics 2006;26: 553e80. [11]. Koraitim MM, Metwalli NE, Atta MA, el Sadr AA. Changing age incidence and pathological types of schistosoma-associated bladder carcinoma. J Urol 1995;154:1714e6. [12]. Fenwick A, Savioli L, Engels D, Robert BN, Todd MH. Drugs for the control of parasitic diseases: current status and
3
[13].
[14].
[15].
[16].
[17].
[18].
development in schistosomiasis. Trends Parasitol 2003;19: 509e15. Zheng YL, Amr S, Saleh DA. Urinary bladder cancer risk factors in Egypt: a multicenter caseecontrol study. Cancer Epidemiol Biomarkers Prev 2012;21:537e46. Sousa-Figueiredo JC, Basanez MG, Khamis IS, Garba A, Rollinson D, Stothard JR. Measuring morbidity associated with urinary schistosomiasis: assessing levels of excreted urine albumin and urinary tract pathologies. PLoS Negl Trop Dis 2009;6:526. Palanca BA, Zaragoza QJ, Meseguer BJ, Perez CF, Trullenque EF, Sempere PF. Bladder infection by schistosoma: an uncommon cause of hematuria. Actas Urol Esp 2008;32:253e5. WHO Expert Committee. Prevention and control of schistosomiasis and soil-transmitted helminthiasis. Geneva: World Health Organization; 2002. King CH, Muchiri EM, Mungai P, Ouma JH, Kadzo H, Magak P, et al. Randomized comparison of low-dose versus standarddose praziquantel therapy in treatment of urinary tract morbidity due to Schistosoma haematobium infection. Am J Trop Med Hyg 2002;66:725e30. Renganathan E. An international initiative on praziquantel use. Parasitol Today 1998;14:390e1.
Please cite this article in press as: Uysal HK, et al., A rare case of urinary schistosomiasis in Turkey, Travel Medicine and Infectious Disease (2013), http://dx.doi.org/10.1016/j.tmaid.2013.11.002
MODEL
Travel Medicine and Infectious Disease (2013) xx, 1e3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
CASE REPORT
A rare case of urinary schistosomiasis in Turkey H. Kirkoyun Uysal a, O. Akgul a,*, E. Aliyev b, M.H. Tunc b, Y.A. Oner a a
Istanbul University, Istanbul Faculty of Medicine, Department of Medical Microbiology, Istanbul, Turkey b Istanbul University, Istanbul Faculty of Medicine, Department of Urology, Istanbul, Turkey Received 22 January 2013; received in revised form 12 April 2013; accepted 7 November 2013
KEYWORDS Schistosomiasis; Haematuria; Turkey
Summary Schistosomiasis is a chronic, parasitic disease and is endemic in some countries, primarily in Africa, Latin America and Asia. In some regions, Schistosoma haematobium is one of the principal causes of haematuria. In Turkey, due to the increasing amount of travel to and from endemic regions, the number of cases is also rising. We report a case of a 22year-old Nigerian male who was admitted to our hospital with haematuria. Direct microbiological examination revealed S. haematobium eggs in his urine specimen. Schistosomiasis was diagnosed by pathology testing. Schistosomiasis has not been seen frequently in Turkey, and we therefore discuss the epidemiology, treatment options and clinical importance of S. haematobium. ª 2013 Elsevier Ltd. All rights reserved.
Introduction Schistosomiasis, also known as bilharziasis, is second only to malaria in public health importance [1]. Schistosoma haematobium is an endemic parasitic disease of the urinary tract. Humans may be infected by cercariae when they are
* Corresponding author. Department of Microbiology and Clinical Microbiology, Faculty of Medicine, Istanbul University, Fatih, 34093 Istanbul, Turkey. Tel.: þ90 5325659944. E-mail address: [email protected] (O. Akgul).
in contact with contaminated fresh water [2]. The urinary bladder, the lower ends of the ureters, and the seminal vesicles are the most commonly affected organs. Infection becomes established 10e12 weeks after cercarial penetration and is manifested by haematuria and urinary excretion of eggs [3]. Schistosomiasis has three different clinical manifestations: first, cercarial dermatitis due to cercarial penetration of the skin; second, acute schistosomiasis or Katayama fever, which coincides with larval maturation and migration; third, chronic schistosomiasis, in which the lesions are the result of the inflammation and subsequent fibrosis caused by the schistosoma eggs [4,5].
1477-8939/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tmaid.2013.11.002
Please cite this article in press as: Uysal HK, et al., A rare case of urinary schistosomiasis in Turkey, Travel Medicine and Infectious Disease (2013), http://dx.doi.org/10.1016/j.tmaid.2013.11.002
+
MODEL
2 According to the World Health Organization, schistosomiasis affects almost 240 million people worldwide, and more than 700 million people live in endemic areas. Every year, more than 200,000 people die from this insidious disease. Several million people worldwide suffer from severe morbidity as a consequence of schistosomiasis [1]. We now report a very rare case of urinary schistosomiasis caused by S. haematobium infection of a 22-year-old Nigerian male patient who has been a student in Istanbul for approximately 1 year.
Case report A 22-year-old Nigerian male visited the Istanbul University Istanbul Faculty of Medicine Department of Urology complaining of bloody urine. Fever was found in his physical examination in the urology department, and he also had terminal haematuria for more than 8 years. There were no significant findings in his medical history. His blood count showed mild leucocytosis. Other biochemistry and routine tests were normal. After multiple polypoid lesions had been revealed in his bladder via ultrasound examination, cystoscopy was planned and showed multiple neoplastic lesions located on the right, left and base wall of the urinary bladder. Transurethral resection of the bladder was performed. Cytological examination of urine was positive for S. haematobium eggs and squamous metaplasia, but due to the lack of the resection material the patient underwent a further operation. Microbiological reexamination revealed S. haematobium eggs in his urine sediment (1000 rpm for 3 min). Medical treatment was started with one dose 40 mg/kg praziquantel and he underwent one more operation for detailed pathological examination which showed no abnormalities, such as neoplasms, and he was therefore discharged.
Discussion Schistosomiasis is a parasitic disease caused by trematode flatworms of the genus Schistosoma. Schistosomiasis is an important healthcare problem in many endemic countries. Its incidence is increasing in developed countries due to immigrant populations and tourists. Theodor Bilharz first described the cause of urinary schistosomiasis as a parasitic disease caused by infestation with S. haematobium in 1851 [6]. There are many species of the schistosomas that can infect humans. Intestinal schistosomiasis may be caused by Schistosoma guineensis, Schistosoma intercalatum, Schistosoma mansoni, Schistosoma japonicum or Schistosoma mekongi. Urogenital schistosoma infection is caused by S. haematobium [7], affecting patients at a much younger age (mean 46.7 years) with males predominating over females 5.6-fold [8]. In regions where schistosomiasis is endemic, it constitutes a major risk factor for squamous cell carcinomas, which account for more than 50% of bladder cancers [9]. Chronic infection induces squamous metaplasia, which may evolve into squamous cell carcinoma [10]. In Egypt, the incidence of bladder cancer has decreased in line with schistosomiasis prevalence over the past few decades
H.K. Uysal et al. [11,12]. A multicentre caseecontrol study has suggested that the risk of either squamous cell carcinoma or urothelial carcinoma increases in association with schistosomiasis and tobacco smoking [13]. In Turkey the relationship between schistosomiasis and bladder malignancies has not been investigated. General clinical manifestations of schistosomiasis include haematuria, leucocyturia, urinary tract complaints, tender abdomen, suprapubic tenderness, chronic iron deficiency, anaemia, scarring and deformity of the ureters and bladder, chronic bacterial superinfection, severe damage of urinary tract organs, and ultimately renal failure [14]. The patient in this case report had terminal haematuria, leucocytosis and fever similar to the common symptoms of schistosomiasis. The treatment options for schistosomiasis are limited. Anthelmintic therapy with praziquantel in the form of a single or divided oral administration dose of 40e60 mg/kg is the current recommended treatment for urinary schistosomiasis [15,16]. However, King et al. reported that a low dose regimen (20 mg/kg/day) of praziquantel could have an equivalent effect to that of the standard recommended dose regimen [17]. In addition, praziquantel has little or no effect on eggs and immature worms. The recommended timing for follow-up is therefore 4e6 weeks after the treatment period [18]. For this purpose, the patient received 40 mg/kg of praziquantel daily and has remained under observation. In conclusion, in geographic regions where schistosomiasis is not endemic, such as Turkey, a comprehensive anamnesis is essential for differential diagnosis of this infection. When diagnosing patients with haematuria, it is mandatory for urologists to have knowledge of urinary schistosomiasis and to obtain a detailed history of overseas trips to endemic areas. A multidisciplinary approach, involving a urologist, a microbiologist and an infectious disease specialist, will help in the early identification and targeted treatment of schistosomiasis.
Funding None.
Conflict of interest None declared.
References [1]. World Health Organization coordinated strategy. Preventive chemotherapy in human helminthiasis. Geneva: World Health Organization; 2006. [2]. Webbe G. Infection with S. haematobium. In: Jordan P, Webbe G, editors. Schistosomiasis: epidemiology, treatment and control. 1st ed. London: Pitman Press; 1982. pp. 79e104. [3]. Ghoneim MA. Bilharziasis of the genitourinary tract. BJU Int 2002;89(Suppl. 1):22e30. [4]. Stuiver PC. Acute schistosomiasis (Katayama fever). Br Med J (Clin Res Ed) 1984;288:221e2.
Please cite this article in press as: Uysal HK, et al., A rare case of urinary schistosomiasis in Turkey, Travel Medicine and Infectious Disease (2013), http://dx.doi.org/10.1016/j.tmaid.2013.11.002
+
MODEL
Urinary schistosomiasis in Turkey [5]. Soonawala D, Geerts JW, de Mos M, Yazdanbakhsh M, Visser LG. The immune response to schistosome antigens in formerly infected travelers. Am J Trop Med Hyg 2011;84: 43e7. [6]. Mohammed AZ, Edino ST, Samaila AA. Surgical pathology of schistosomiasis. J Natl Med Assoc 2007;99:570e4. [7]. Neal PM. Schistosomiasis an unusual cause of ureteral obstruction: a case history and perspective. Clin Med Res 2004;2:216e27. [8]. Clements AC, Barnett AG, Nyandindi U, Lwambo NJ, Kihamia CM, Blair L. Age and gender effects in self-reported urinary schistosomiasis in Tanzania. Trop Med Int Health 2008;13:713e21. [9]. Shokeir AA. Squamous cell carcinoma of the bladder: pathology, diagnosis and treatment. BJU Int 2004;93:216e20. [10]. Wong-You-Cheong JJ, Woodward PJ, Manning MA, Sesterhenn IA. Neoplasms of the urinary bladder: radiologicepathologic correlation. RadioGraphics 2006;26: 553e80. [11]. Koraitim MM, Metwalli NE, Atta MA, el Sadr AA. Changing age incidence and pathological types of schistosoma-associated bladder carcinoma. J Urol 1995;154:1714e6. [12]. Fenwick A, Savioli L, Engels D, Robert BN, Todd MH. Drugs for the control of parasitic diseases: current status and
3
[13].
[14].
[15].
[16].
[17].
[18].
development in schistosomiasis. Trends Parasitol 2003;19: 509e15. Zheng YL, Amr S, Saleh DA. Urinary bladder cancer risk factors in Egypt: a multicenter caseecontrol study. Cancer Epidemiol Biomarkers Prev 2012;21:537e46. Sousa-Figueiredo JC, Basanez MG, Khamis IS, Garba A, Rollinson D, Stothard JR. Measuring morbidity associated with urinary schistosomiasis: assessing levels of excreted urine albumin and urinary tract pathologies. PLoS Negl Trop Dis 2009;6:526. Palanca BA, Zaragoza QJ, Meseguer BJ, Perez CF, Trullenque EF, Sempere PF. Bladder infection by schistosoma: an uncommon cause of hematuria. Actas Urol Esp 2008;32:253e5. WHO Expert Committee. Prevention and control of schistosomiasis and soil-transmitted helminthiasis. Geneva: World Health Organization; 2002. King CH, Muchiri EM, Mungai P, Ouma JH, Kadzo H, Magak P, et al. Randomized comparison of low-dose versus standarddose praziquantel therapy in treatment of urinary tract morbidity due to Schistosoma haematobium infection. Am J Trop Med Hyg 2002;66:725e30. Renganathan E. An international initiative on praziquantel use. Parasitol Today 1998;14:390e1.
Please cite this article in press as: Uysal HK, et al., A rare case of urinary schistosomiasis in Turkey, Travel Medicine and Infectious Disease (2013), http://dx.doi.org/10.1016/j.tmaid.2013.11.002
