Case report
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A Rare Parasitic Infection Diagnosed in a Traveller in India: Urinary Schistosomiasis- A Case Report |
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Bhaskar Das, Natasha Mittal, Gurdeep Singh, Tanuj Paul Bhatia 1. Consultant Microbiologist, Department of Microbiology, Sarvodaya Hospital and Research Centre, Faridabad, Haryana, India. 2. Consultant Pathologist, Department of Pathology, Sarvodaya Hospital and Research Centre, Faridabad, Haryana, India. 3. Consultant Pathologist, Department of Pathology, Sarvodaya Hospital and Research Centre, Faridabad, Haryana, India. 4. Consultant Urologist, Department of Urology, Sarvodaya Hospital and Research Centre, Faridabad, Haryana, India. |
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Correspondence
Address : Dr. Bhaskar Das, D1, 807, Summer Palms, Sector-86, Faridabad, Haryana, India. E-mail: drbhaskarinnet@gmail.com |
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ABSTRACT | |||||||||||||||||||||
Schistosomiasis is prevalent in tropical countries but it is rare in Indian subcontinent. Basically two major forms of schistosomiasis are there- intestinal and urogenital which are caused by five species of schistosomes. Urinary schistosomiasis is caused by Schistosoma haematobium (S. haematobium). Though this infection is endemic in Africa and Middle-east, population movement from endemic zones has resulted in detection of such cases in non-endemic developing countries. Detection of egg of S. haematobium is the gold standard test for diagnosis of schistosomiasis. Histopathological examination of urinary bladder is an alternative diagnostic method. Here, we report a case of urinary schistosomiasis in a 12-year-old Nigerian traveller who was presented with terminal haematuria. Patient had history of bathing in fresh water ponds and rivers. Ultrasound abdomen and cystoscopy revealed nodular lesions on the wall of urinary bladder. Diagnosis of schistosomiasis is made by detection of egg of S. haematobium in urine sample and biopsy of urinary bladder. Patient was treated with oral Praziquantel. | |||||||||||||||||||||
Keywords : Bilharziasis, Terminal haematuria, Urinary bladder | |||||||||||||||||||||
INTRODUCTION | |||||||||||||||||||||
A 12-year-old Nigerian boy presented to our hospital with history of intermittent painless terminal haematuria for last six months. The frequency of haematuria was one to two episodes per week and each time haematuria episode was associated with pain in right side of lower abdomen. History of fever or weight loss was negative. Past history revealed patient was suspected to be a case of urinary bladder malignancy in his country, but could not be confirmed with definitive investigations. Physical examination revealed no gross abnormality in any organ system. Blood count and renal function test were normal. USG whole abdomen revealed soft tissue density lesion measuring 2.9×1.5 cm arising from posterior wall of urinary bladder extending upto right vesicoureteric junction along with another small isoechoic nodule measuring 1.9 mm arising from lateral wall of urinary bladder. Cystoscopy was done which revealed nodular lesions in base and dome of bladder and tubercle like lesion in lateral wall of the bladder. Resection biopsy was taken in view of suspicion of malignancy in his home country for pathological examination. Urine routine examination was done which showed 4-6 pus cells/high power field, 2-4 RBCs/ high power field, 1-2 epithelial cells/high power field and scanty eggs of Schistosoma haematobium (S. haematobium) with characteristic ‘terminal spine’ (Table/Fig 1). Ziehl Neelsen stain of urine was done to rule out urinary tuberculosis, which was negative. Aerobic bacterial culture of urine was sterile. Further detailed history revealed patient had habit of bathing in fresh water ponds and rivers, which might be the source of infection in this case. The diagnosis of urinary schistosomiasis was confirmed in resection biopsy of urinary bladder which also showed egg of S. haematobium along with acute inflammatory infiltrate composed of neutrophils and eosinophils in the mucosa and no feature of malignancy was there (Table/Fig 2). Stool routine examination did not reveal egg of S. haematobium. Patient was treated with oral Praziquantel 25mg/kg body weight in a single day in two divided doses and to repeat three courses at two weeks of interval. Urine sample became negative for egg of S. haematobium after three days of first dose of the drug. Patient was asked to review after three months for urine routine examination, but till now the patient has not turned up for review. | |||||||||||||||||||||
DISCUSSION | |||||||||||||||||||||
Schistosomiasis also known as Bilharziasis is water borne parasitic disease caused by the Platyhelminth worm of the class Trematoda and genus Schistosoma (1). It is endemic in tropical and subtropical countries mainly in Africa and eastern Mediterranean region. It affects 200 million people and poses threat to 600 million people in more than 76 countries. The infection can also be seen in countries where it is not endemic because of the increase in traveling (2). Schistosoma haematobium, one of the Schistosoma species infects the urinary tract. Urinary schistosomiasis manifests as haematuria, usually appears at the end of micturition, termed ‘terminal haematuria’. The complications include ulceration, granulomatous inflammation and fibrosis (3). Schistosomiasis is one of the oldest known parasitic infestations; however it was first described by German scientist Theodor Bilharz during autopsy. Adult worms are dioecious, parasitise venous systems and produce non-operculated eggs (4). Out of so many species of schistosomes, five primary ones infect man. There are two major forms of schistosomiasis- intestinal and urogenital schistosomiasis and five species of schistosomes has been implicated. Urinary schistosomiasis is caused by S. haematobium and intestinal schistosomiasis by S. mansoni, S. japonicum and S. mekongi. S. intercalatum causes rectal schistosomiasis (1). The parasite is excreted via urine and faeces into fresh water and the miracidia infects its intermediate host, the fresh water snails, where they develop into cercaria. The cercaria stage is released from snails into water and penetrates human skin, when comes in contact and then enters subcutaneous tissue, then blood stream and migrate to the lungs, then to liver. After six weeks, the mature worms mate and the adult worms migrate into the venous plexuses of the genitourinary system. The viable adult worms deposit eggs in the tissues of intestine, urinary bladder, prostate and other organs that induces granulomatous host response with formation of polypoid lesions. The inflammation may manifest as well circumscribed granulomas or as diffuse cellular infiltrate. In urinary schistosomiasis, the urinary bladder, lower ends of ureters and seminal vesicles are affected and is manifested by haematuria and urinary excretion of eggs [1,2,5,6]. Schistosomes are characterised by the types of egg produced: a) eggs with lateral spine e.g., S. mansoni; b) eggs with terminal spine e.g., S. haematobium and S. intercalatum; c) eggs that are round and minutely spined e.g., S. japonicum and S. mekongi (1). Literature search for urinary schistosomiasis has shown a very low rate in South-east Asian and South Asian countries. In India an endemic focus of urinary schistosomiasis was confirmed in Gimvi village of Ratnagiri district, Maharashtra, probably by a new schistosome species. As the eggs were oval shaped and were present in urine of patient, but as no species of Bulinus snail, the ntermediate host of S. haematobium is existing in India, so a new schistosome species that is Schistosoma gimvicum name has been proposed (4),(7),(8). Routine examination of urine is the gold standard test for the diagnosis of urinary schistosomiasis by detecting egg of S. haematobium. Histopathological examination of urinary bladder specimen for eggs of S. haematobium is an alternative diagnostic method (3). The treatment of urinary schistosomiasis is oral Praziquantel, a pyrazinoisoquinolone derivative, which is a safe and effective drug against all Schistosoma species (3),(9). This case report is important as the parasite S. haematobium has not been reported in India. But because of globalisation and more frequent travels, there are chances of detection of more cases in India, whether any Indian visits prevalent countries or any foreigner visits India from such countries. So, we as clinicians should upgrade our knowledge regarding such rare diseases and one should keep in mind such diseases as differential diagnosis while treating patients with similar symptoms and history of travel. | |||||||||||||||||||||
CONCLUSION | |||||||||||||||||||||
We have reported a case of urinary schistosomiasis caused by S. haematobium with typical characteristics of egg in urine sample along with characteristic histopathological features. Though urinary schistosomiasis is endemic in Africa and Middle-east countries, the disease can be encountered in developing countries like India with increasing population who are frequent traveller. So, to diagnose such a rare disease in this part of world one needs a very strong suspicion of the disease and observation capabilities in patient’s samples. | |||||||||||||||||||||
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TABLES AND FIGURES | |||||||||||||||||||||