CASE 16275 Published on 19.11.2018

Rare case of urinary Schistosomiasis in a non-endemic region

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

António Pedro Pissarra, Raquel Madaleno, Bruno Graça, Maria Conceição Sanches

Coimbra University Hospital,Radiology Department; Avenida Central n6 5B 3000-607 Coimbra, Portugal; Email:antoniopedropissarra@gmail.com
Patient

66 years, female

Categories
Area of Interest Urinary Tract / Bladder ; Imaging Technique CT
Clinical History
We present a case of a 66-year-old female who presented to the Emergency Department due to four days of painless hematuria. Initial clinical examination and laboratory results did not reveal any abnormality. A primary neoplasm of the urinary system was suspected and a CT urogram was requested.
Imaging Findings
Non-contrast-enhanced abdominal CT scans revealed the presence of diffuse bladder wall calcification (figure 1a,b), manly involving the bladder anterior wall (figure 1c). There were no other relevant findings on the CT urogram.
Discussion
Background
Schistosomiasis (also known as bilharzia), is a disease caused by parasitic worms called schistosomes. It is very common in tropical and subtropical areas, particularly in the African continent (85% of the cases) and relatively rare in western countries [1]. However, global changes like rise in temperature and the intensification of human activities promote the spread of tropical and subtropical vector-borne diseases worldwide, leading to parasitic diseases outbreaks like Schistosomiasis in developed countries [2].

Clinical Perspective
There are five species of schistosomes (S. haematobium, S. mansoni, S. japononicum, S. intercalatum and S. mekongi) that can cause disease in humans. Human contamination occurs after exposition to infected water, after which the parasites can cause two major forms of schistosomiasis: intestinal and genitourinary [3].
Intestinal symptoms can occur with infection by any Schistosoma species as a result of the deposition of parasitic eggs in the abdominal wall, leading to a granulomatous response that can cause bowel obstruction and blood loss [3].
Urinary tract manifestations occur only after contamination with S. haematobium, which can cause obstruction of the urinary tract, hematuria and nodular bladder wall thickening, representing the deposition of worm eggs in the bladder wall [4]. Eggs are also released in the urine, leading to possible transmission of the disease to others when in contact with infected water, like in public swimming pools [5].

Imaging Perspective
In the chronic phase, deposition of eggs in the bladder wall leads to diffuse nodular thickening with curvilinear calcifications that represent calcified eggs [6]. These findings can be found on cross-sectional imaging and definitive diagnosis is based on findings of ova at microscopic analysis of the bladder wall or urine samples [6].

Outcome
Early diagnosis is crucial, since the chronic inflammatory response and fibrosis secondary to the presence of the parasites within the bladder wall is an important predisposing factor for squamous cell carcinoma [6].
Treatment of urinary Schistosomiasis usually includes 40 mg/kg of antiparasitic Praziquantel. In the future, combination of Praziquantel with other drugs (namely antimalarial) could be used [5].

Take Home Message, Teaching Points
Although still relatively uncommon in developed countries, radiologists should recognize typical imaging findings of parasitic diseases such as Schistosomiasis in order to reach a timely diagnosis and avoid possible complications associated with these diseases.

Written informed patient consent for publication has been obtained.
Differential Diagnosis List
Urinary Schistosomiasis
Tuberculosis
Eosinophilic cystitis
Cystitis post radiation/chemotherapy
Final Diagnosis
Urinary Schistosomiasis
Case information
URL: https://eurorad.org/case/16275
DOI: 10.1594/EURORAD/CASE.16275
ISSN: 1563-4086
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