Phimosis of foreskin uncovering schistosomiasis of the urinary bladder: a case report

Introduction

Schistosoma (S.) haematobium is a species of trematode endemic to Africa and parts of the Middle East. S. haematobium larvae, called miracidia, infest freshwater snails and, upon maturation into second-stage larvae called cercariae, leave the snails to infest human hosts (1). The cercariae initially penetrate the skin, then migrate to the venous plexus of the bladder where they mature into adults, reproduce, and lay eggs, which are shed in the urine, starting the cycle anew. Schistosomes live an average of 3–10 years in human hosts (2).

S. haematobium infection initially presents as a pruritic rash, followed 1–2 months later by flulike symptoms. Long-term infection has far-reaching consequences: instead of shedding, eggs may become lodged in bladder tissues, causing a granulomatous response which leads to chronic inflammation. This is associated with scarring, ureteral obstruction, repeated infections, and hydronephrosis, and can eventually progress to squamous cell carcinoma of the bladder (1). Anemia, cognitive impairment, and growth stunting are also common among infected children (3).

A 2019 study found the overall prevalence of S. haematobium infection among schoolchildren in Sudan to be 5.2%. However, this was highly variable by school and by province with greatest provincial prevalence in East Darfur (25.23%) (4). Infection was found to be significantly more prevalent in areas without improved latrines; i.e., in areas where open defecation is commonly practiced (4). We present here a case of a 10-year-old male immigrant from Sudan, found to have schistosomiasis. We present this case in accordance with the CARE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-182/rc).

Case presentation

The patient was a 10-year-old male who had immigrated to the United States (U.S.), from Sudan with his family 5 years ago and had last traveled to Sudan in 1.5 years prior to his presentation. He was brought to urology clinic by his mother for consideration of circumcision, as the patient’s parents had desired neonatal circumcision but were unable to do so due to family circumstances. He had been evaluated by his pediatrician and found to have phimosis, at which point he was referred to urology. A thorough interview of both the patient and his mother was conducted with the assistance of an interpreter. Upon interview, it was discovered that the patient had a history of gross hematuria; he experienced small amounts of bleeding at the end of micturition for approximately 5 months prior to presentation as well as occasional abdominal pain. He also reported a history of ongoing intermittent abdominal pain. A retroperitoneal ultrasound was performed, which showed a 3.7 cm mass at the dome of the bladder (Figure 1). A computed tomography (CT) abdomen and pelvis was not ordered as part of the initial workup so as not to potentially delay biopsy. Instead, cystoscopy was performed semi-urgently the following day to rule out bladder tumors such as rhabdomyosarcoma, which has poor prognosis. Complete blood count (CBC) and comprehensive metabolic panel (CMP) were ordered; however, these were not completed. Notably, patient did have a CBC in 2022 after his trip to Sudan that showed eosinophilia, which at the time was attributed to his environmental allergies.

Figure 1 Retroperitoneal ultrasound showing apparent a 3.7 cm mass at dome of bladder (red arrows).

Cystoscopy was performed in the operating room under anesthesia and showed an unremarkable urethra, but the patient was found to have two nodular masses within the bladder, one to the left and one to the right of the midline. Each mass was highly vascularized and measured approximately 2.5 cm (Figure 2). The bladder was otherwise normal appearing, with no calcifications at the ureteral orifices. Using cold-cup biopsy forceps, 6 biopsy samples were taken from the left mass and sent to pathology for intraoperative analysis of frozen section; preliminary pathology report for these frozen sections were consistent with rhabdoid malignancy. Twelve additional samples were taken from the left mass as well as 3 from the right mass and these were sent as permanent pathology in formalin for staining and final diagnosis. A urine sample was also collected for cytological analysis. The biopsy sites were fulgurated using a Bugbee electrode.

Figure 2 2.5-cm, highly vascularized bladder masses to the left (left) and right (right) of the midline.

Urine cytology was negative for high-grade urothelial carcinoma and final biopsy results showed no evidence of malignancy. However, the tissue specimens contained numerous parasite eggs of species S. haematobium, with internal miracidium and scattered calcifications with surrounding inflammatory cells and benign, reactive urothelial epithelial cells (Figure 3). Additionally, although the urine sample did not contain live parasites, it was notable for eosinophilia. Upon further investigation, the patient’s family reported that he had gone swimming in a freshwater lake during their most recent visit to Sudan.

Figure 3 Bladder biopsy showing multiple Schistosoma haematobium eggs (blue arrow) and inflammatory cells, predominantly eosinophils (red arrow), in a background of reactive urothelial cells. H&E stain, ×10 (left) and ×40 (right). H&E, hematoxylin and eosin.

The patient was treated with praziquantel 40 mg/kg, divided into two equal doses over 1 day, with plans to repeat treatment in 2–4 weeks to increase effectiveness. He was scheduled for follow-up urine microscopy in 3 months to confirm a successful cure. A CT abdomen and pelvis was not ordered or performed prior to cystoscopy however, after confirmation of schistosomiasis, an examination with CT abdomen and pelvis was ordered to evaluate for parasite burden elsewhere, but patient did not receive this as the patient was subsequently lost to follow-up. CBC and CMP were ordered to assess for anemia, eosinophilia, renal and liver function. Testing for human immunodeficiency virus was also ordered to check for co-infection. However, these tests were not obtained by patient. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s), and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Discussion

Schistosomiasis is a neglected tropical disease, since it is prevalent among impoverished communities in tropical areas and has severe medical and social consequences (3). Ninety percent of new Schistosoma infections occur in Africa, and two-thirds of these are caused by S. haematobium (5). In 2012, the World Health Organization (WHO) advised that countries to which schistosomiasis is endemic should work toward eradication of the disease, and to that end multiple mass drug administration programs were launched, which distribute praziquantel to a large segment of the population. Infection rates have dropped, but mass drug administration is less effective in areas where people are repeatedly exposed (3).

In the U.S., schistosomiasis is extremely rare, and primarily affects patients who have immigrated from countries where it is endemic (6). Troublingly, a study of insurance claims spanning 2013–2019 found that only 21% of schistosomiasis patients in the U.S. received praziquantel, which is the gold standard for treatment (6). This was attributed both to increased drug costs and incorrect prescribed treatment due incomplete knowledge regarding appropriate treatment for Schistosoma infection. This highlights the challenge of practicing medicine in a world where patient populations are increasingly mobile; in order to effectively care for patients, physicians in North America and Europe must work to familiarize themselves with conditions that they would previously have encountered infrequently, if at all. Furthermore, this situation is not unique; a survey of European urologists found them to be significantly less knowledgeable regarding diagnosis and management of tropical urological diseases compared to their African counterparts (7). As untreated infection can lead to serious health issues, prompt, appropriate treatment is essential.

Although schistosomiasis is rare in the U.S., the potential consequences of untreated infection are grave, and include scarring, repeated urinary tract infection, and squamous cell carcinoma of the bladder. While the patient in this case was lost to follow-up and a cure could not be confirmed, he was treated appropriately with praziquantel. This case emphasizes the critical importance of taking a thorough history, particularly when working with patients from areas where “rare” infections are endemic. Neither the patient nor his mother volunteered information about his hematuria until asked directly. Had the question gone unasked, the patient would have gone untreated.

Conclusions

Although schistosomiasis is rare in the U.S., it is important to consider it as a differential diagnosis for hematuria in patients who have a history of immigration from an endemic region. As the worms can live for years in a human host, lack of recent travel abroad does not preclude infection. Treatment with praziquantel is gold standard to achieve a cure. A thorough patient interview is a key component of diagnosis. This case report provides a further data point for presentation and management of schistosomiasis both in the U.S. and within pediatric populations.

Acknowledgments

The abstract of this case report was presented at the 43rd Annual Meeting of Surgical Infection Society (SIS), Miami, Florida, USA, June 5–7, 2024.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-182/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-182/prf

Funding: This work was supported by the Frank Stranahan Foundation for Oncological Research.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-182/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s), and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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