sign in sign up
<<
Home , Parasitic worm

1 Rev Esp Sanid Penit 2012; 14: 62-66 A Bedoya del Campillo, PA Martínez-Carpio, MJ Leal, N Lleopart Diagnosis and treatment of bladder from penitentiary primary care: Case report

Diagnosis and treatment of bladder schistosomiasis from penitentiary primary care: Case report

A Bedoya del Campillo, PA Martínez-Carpio, MJ Leal, N Lleopart

Medical Services. Young Offenders center in Barcelona, Generalitat de Catalunya

ABSTRACT

We describe a case of a patient from Senegal with voiding symptoms and microscopic hematuria diagnosed and treated for bladder schistosomiasis in the medical services of the Youth Prison in Barcelona. According to our information in the Medline database no bladder schistosomiasis cases have been seen in primary care outside endemic areas. Patients can be diagnosed and treated before referral to specialized care for further study of possible complications. Key words: schistosomiasis; bilharziasis; urinary tract ; hematuria; emigration and immigration; primary health care; prisons; infection.

Text received: 09-01-2012 Text accepted: 05-05-2012

INTRODUCTION toms such as asthenia, abdominal pain, intermittent , blood in faeces, and in more advanced cas- Schistosomiasis, or bilharzia, affects over 200 es portal hypertension, hepatic fibrosis and ascites, million people worldwide and is the second most im- may occur. In such cases, diagnosis is mainly estab- portant parasitic after . Cases record- lished through the identification of in the faeces ed in Europe and North America regard immigrant (1-5). However, the species S. haematobium presents patients or in those who have travelled or resided in a special tropism towards perivesical plexus and the countries where such disease is endemic. It is caused urinary system 6-8. Approximately 50% of the cases by trematode of the genusSchistosoma 1-5. recorded in Europe concern immigrants from sub People become infected when larval forms of Saharan African countries, especially from Western the , or cercaria, released by certain freshwater Africa according to the sentinel epidemiological re- snails, penetrate the skin in contact with contami- cord of the European Network for the diagnosis of nated water. Snails are intermediary hosts part of the imported 9. parasite’s lifecycle and which become infected them- Urinary or bladder schistosomiasis depends selves by eggs released with urine or faeces. of the contact with infecting forms of Infection takes place by contact with water in ponds, haematobium (cercaria) which penetrate the skin in rivers or swamps where larval forms of the contact with contaminated water. Many of the cases (cercaria) can be found. Swimming and fishing are published in non endemic countries have been iden- the main activities related to this infection. The spe- tified in immigrants from Nigeria5 , Ghana 4, Gambia cies S. mansoni, S. japonicum, and other less frequent, 7, Mali 6, 8 and other sub-Saharan countries, and less cause the intestinal form of the disease. Adult worms frequently in individuals from Maghreb, the Middle often gather in mesenteric venules, generally asymp- East and other tropical areas 4, 7. When the cercaria tomatically, although in long term symp- penetrates the skin it reaches the circulation and suf- — 62 — Rev Esp Sanid Penit 2012; 14: 62-66 2 A Bedoya del Campillo, PA Martínez-Carpio, MJ Leal, N Lleopart Diagnosis and treatment of bladder schistosomiasis from penitentiary primary care: Case report fers a process of migration, maturing and metamor- Early diagnosis and treatment are essential in phosis. The adult female of S. haematobium selective- curing the disease and avoiding irreversible compli- ly nests around pelvic organs ad releases hundreds cations and sequels. The identification of parasitic of eggs every day, which penetrate the bladder and eggs in the urine, semen or biopsy material is the de- the mucous membrane of the inferior part of ureters finitive method for diagnosing active schistosomia- and are released with the urine. Unlike the intesti- sis. A single oral dose of 40 mg/kg of praziquantel or nal form, urinary schistosomiasis is usually symp- two different doses separated by a 12 hour interval tomatic with an unspecific irritative syndrome, pol- are highly effective in exterminating parasites. After lakiuria, suprapubic pain during urination and other treatment is it essential to conduct thorough explo- symptoms suggesting urinary infection. Intermittent ration of the genitourinary system by the urologist symptoms are usually caused by bacterial overinfec- in hospital. In severe cases, urological controls must tions, mainly by Gram-negative which are be periodic during some years to early prevent the frequently found in parasitic hosts because they nest appearance of bladder cancer, whose risk keeps in- in urinary tissues already damaged by the Schisto- creasing after the patient’s recovery. In women, ad- soma. Macroscopic or microscopic hematuria (very ditional gynecological studies are needed 3, 7. Recov- usual) is often terminal, intermittent and recurrent ery from the active disease is confirmed by the dis- 3-8. At this stage, the bladder becomes affected with appearance of viable eggs in the urine three months an edematous mucosa with granuloma, polyps and after the administration of praziquantel, although ulceration. Biopsies usually show abundant eosino- new therapeutic cycles may be needed to eliminate phils and the Schistosoma eggs 4. Asymptomatic car- the parasitic worm. Residual unviable eggs may re- riers present altered bladder emptying and reactive main in the bladder and continue being eliminated hypercontraction of the urinary bladder 10. for months, or even years 12. After several years of undiagnosed and untreat- The objective of this paper is to describe and ed urinary symptoms the so called bilharzian urop- discuss a case of bladder schistosomiasis identified athy occurs, with a characteristic granulomatous and treated by the medical services of the Young inflammatory response with irreversible fibrosis Offenders facility of Barcelona. This is the first re- secondary to the that takes place ported case of outpatient diagnosis and treatment of against the eggs placed on the walls of the urinary this disease before being derived to a hospital in a bladder. At this stage the most common damages are non-endemic country. sclerosis, bladder stones, calcification and hyper- trophy of bladder walls. Cytology and cystoscopy, together with imaging (ecography, computerized CLINICAL CASE tomography, intravenous urography and retrograde urethrography) are important tools in identifying This is the case of a 20 year old patient, male, coexisting damage of the urinary system, like steno- black, from Senegal who has been living in Spain for sis, sclerosis and granulomatous nodules at different five years now. He was admitted to our facility in levels. Cases of renal colic may also occur as well February 2010. In the initial medical examination it as pyelonephritis, pyelonephrosis, hydronephrosis, was established that the patient suffered a state of kidney stones and affectation of the urethra, semi- delirium of mystical content, so he was derived to nal vesicles, prostate, vas deferens, epididymis and psychiatry where he was diagnosed from paranoid testicles 3, 6-8. Female genitals are more frequently af- schizophrenia. He also reported the use of cannabis. fected than the male’s, mostly involving the ovaries, Later we underwent a general blood test, according Fallopian tubes, the uterus and the vagina, apart to the prison admission protocol, which included a from the urinary system. In countries where schis- complete blood count (CBC), serum biochemistry tosomiasis is endemic it is considered a common and serology for hepatitis A, B, C, HIV and syphilis. cause of infertility 3. In Africa, urethral stricture is The CBC revealed a value of hemoglobin of 14.2 g/ one of the most severe complications which usually dl and 300 / μl. The rest of analytical pa- jeopardize the vital prognosis. We must also take rameters showed no alteration. The patient initiated into account the probable development of bladder psychiatric treatment with risperidone, olanzapine, squamous cell carcinoma. Over 30% of patients de- biperiden and quetiapine. veloping this type of cancer in endemic areas have A few days later he consulted for pain of the a history of urinary schistosomiasis 3, because the glans during erection. The examination revealed that parasitic eggs are highly carcinogenic 11. he presented a cutaneous bridge between the glans — 63 — 3 Rev Esp Sanid Penit 2012; 14: 62-66 A Bedoya del Campillo, PA Martínez-Carpio, MJ Leal, N Lleopart Diagnosis and treatment of bladder schistosomiasis from penitentiary primary care: Case report and the penis skin in the balanopreputial sulcus, to- DISCUSSION gether with a short frenulum. This is why intercon- sultation with the urologist in our reference hospital African countries where this disease is endemic was pursued, after which he was awaiting surgical are among the poorer and more underdeveloped treatment. He later consulted for a clinic of dysuria countries worldwide, with high child mortality rates, and frequent or urgent urination without a febrile a low and very limited healthcare and syndrome or macroscopic hematuria. Empirical healthiness resources. In this context a high percent- treatment with amoxicillin clavulanate 875/125 mg age of the native population becomes infected with was then initiated for a 10 day period, after which Schistosoma during childhood and suffers urinary the patient presented a remission of the symptoms. symptoms for years without receiving treatment. Two months later, the patient was admitted to In severe manifestations, of over 20 years, some pa- the prison’s infirmary due to a psychotic decompen- tients die due to obstructive uropathy and many due sation. During such episode the patient consulted to bladder cancer. Bladder squamous cell carcinoma the clinician in charge of the unit for a new clinic is the main cause of mortality by urinary schistoso- of frequent and urgent urination and nocturia. A miasis, especially in patients between 30 and 40 years sample of urine was examined by means of a test old 12. In our case, the lack of calcification in the x- strip revealing macroscopically normal urine with ray examination as well as the lack of macroscopic hematuria ++ and proteinuria +. This time the hema- hematuria and the short period of infection due to turia was evaluated in the context of the geographi- the patient’s age, suggest a good prognosis. cal origin of the patient by considering the previous Until now it is still accepted that urinary schis- episode of urinary symptoms that had remitted with tosomiasis is a rare disease in developed countries, antibiotics. with Schistosoma haemato- but throughout recent years many publications by bium was considered a first diagnostic alternative. Spanish experts have reported new cases diagnosed Throughout the medical interview he reported that in our country 3, 6-8, 12, 14, and 15. It does not seem likely he had lived in his country until 15 and that as a child to be casual if we take into account that according he used to swim in the river. to data by the Statistics National Institute the num- As to confirm the diagnostic suspicion a urine ber of sub Saharan African immigrants established 12, 13 sample was obtained at noon after exercise . In in Spain is about 200,000. A systematic review of the our case our patient had run around the courtyard. Medline database confirms that bladder schistosomi- The sample was sent to the laboratory with the in- asis is becoming more common in our country and dication that the diagnostic orientation was blad- therefore it must be suspected in all urologic or mic- der schistosomiasis. The parasitic study of the urine tional symptoms specifically affecting this group of revealed the presence of Schistosoma haematobium patients 3, 6-8, 12. Moreover when macroscopic or mi- eggs, therefore confirming the diagnosis. croscopic hematuria is identified, the first diagnostic Conventional abdominal radiographies were suspicion must be schistosomiasis 3-8, 12. taken and no bladder calcifications or other altera- It is hereby proven that diagnosis and treatment tions were found. The patient did not present any can be easily conducted at an outpatient level as long digestive symptoms or alteration of the faeces or as the epidemiology and the clinic of the disease are the bowel rhythm. Nevertheless, in view of the high considered. Hospital diagnosis and treatment entail probability of coexisting parasitism by Schistosoma an important delay, a delayed treatment and a less ef- mansoni due to the geographical origin, this parasite ficient management of healthcare resources. was tested in the faeces, with a negative result. It is also worth highlighting two different as- Treatment consisted of a 3g single dose of oral pects. On the one hand we must note that if in a uri- praziquantel, whose request was arranged by means nary parasitism the diagnostic suspicion is not re- of the pharmacy department as a foreign drug. A ported to the laboratory and the sample is not sent in new urine test was requested for a date 3 months the appropriate conditions (24 hour urine, or urine after the completion of treatment as to confirm the at noon after exercise) the results of the sediment eradication of the eggs. A new visit to the urology and the culture can be easily negative, or mistaken service of our reference hospital was also arranged as with urinary infection by Gram negative bacteria. to study potential damage of the urogenital system Even if the eggs are large and easily recognizable if secondary to this disease. parasitism is low and hence there are few eggs there is a risk of a false diagnosis of the primary disease. On the other hand, the lack of eggs in urine does not — 64 — Rev Esp Sanid Penit 2012; 14: 62-66 4 A Bedoya del Campillo, PA Martínez-Carpio, MJ Leal, N Lleopart Diagnosis and treatment of bladder schistosomiasis from penitentiary primary care: Case report rule off the disease. If in our case the results of urine BIBLIOGRAPHICAL REFERENCE sediment had been negative we would have not been able to completely rule off the diagnosis since some- 1. Ross AG, Bartley PB, Sleigh AC, Olds GR, Li times serology or bladder biopsies are needed. Once Y, Williams GM, et al. Schistosomiasis. N Engl J discarded, other differential diagnosis with a similar Med 2002; 346 (16): 1212-20. clinical presentation could be considered, especial- 2. Cocharan M, Almeda J, Vinuesa T Valls ME, ly urinary , kidney or urinary cancer, Mejías T, Jou P, et al. Esquistosomiasis importada acute glomerulonephritis and urinary stones 12. Ac- por viajeros españoles: estudio clínico-epidemio- cording to our information, the Medline reference lógico de 80 casos. Med Clin (Barc) 1997; 108: on imported schistosomiasis in Western countries 721-5. mostly comes from hospitals, almost always from 3. Donate MJ, Pastor H, Giménez JM, Carrión the services of urology and pediatrics. In the Span- P, Segura M, Salinas AS, et al. Esquistosomia- ish case, a recent publication (2009) targets pedia- sis vesical, aportación de un caso y revisión de tricians reporting that we are facing a pathology la literatura española. Actas Urol Esp 2006; 30: more and more common in our environment and 714-9. that upon clinical suspicion a thorough interview 4. Scarlata F, Giordano S, Romano A, Marasà L, is essential to avoid more aggressive and expensive Lipani G, Infurnari L, et al. Considerazioni su complementary examinations 6. The last recom- un caso di schistosomiasi urinaria. Le Infezioni in mendation, from 2010, targets urologists: “In view Medicina 2005; 259-64. of the high prevalence of urinary schistosomiasis in 5. Sheehan GJ, Sekla L, Harding GK. Urinary schis- sub Saharan countries and its ulterior clinical and tosomiasis: a report of four cases and a review. epidemiological implications, in all cases of micro- Can Med Assoc J 1984; 131: 1361-4. scopic or macroscopic hematuria in a sub Saharan 6. Morales D, Molina J, Martínez Ortiz A, Martínez immigrant it is mandatory to rule off bilharzias as Artola V, Beristáin X. Hematuria intermitente. the most common cause” 7. Esquistosomiasis vesical. A propósito de un caso. Anales Sis San Navarra 2009; 32 7. Álvarez Maestro M, Ríos González E, Domínguez CONCLUSION García P, Vallejo Herrador J, Díez Rodríguez J, Martínez-Piñero L. Bladder schistosomiasis: case It is worth being aware of the fact that the diag- report and bibliographic review. Arch Esp Urol. nosis and treatment of bladder schistosomiasis can 2010 Sep; 637: 554-8 be conducted by primary care services since this 8. Borrell A, Queipo JA, Beltrán JF, Chocote F, is where the patient is most likely to consult first. Escoms F, Pastor F. Infección vesical por esquis- Therefore the close association between painless tosoma: una causa inhabitual de hematuria. Actas microscopic or macroscopic hematuria and Schisto- Urol Esp 2008; 32: 253-5. soma haematobium in patients from endemic areas, 9. Grosbusch MP, Mühlberger N, Jelinek T, Bisoffi mostly from sub Saharan Africa, must be taken into Z, Corachán M, Harms G, et al. Imported Schis- account. Nevertheless, although the diagnosis and tosomiasis in Europe Sentinel Surveillance Data treatment are feasible in the first assistance level it TopNetEurop. J Travel Med 2003; 10:164-9 is highly recommended that specialized examina- 10. Watanabe K, Muhoho ND, Mutua WR, Kiliku tion be conducted as to evaluate potential compli- FM, Awazawa T, Moji K, et al. Assessment of voi- cations. ding function in inhabitants infected with Schis- tosoma haematobium. J Trop Pediatr 2011; 57 (4): CORRESPONDENCE 263-8. Publicación electrónica 28 abril 2010. 11. Abdulamir AS, Hafidh RR, Kadhim HS, Dr. Angel Bedoya del Campillo Abubakar F. Tumor markers of bladder cancers: Serveis Medics the schistosomal bladder tumors versus non- Centre Penitenciari de Joves de Barcelona schistosomal bladder tumors. J Exp Clin Cancer Carretera Masnou Granollers, Km.13.425 Res 2009; 28: 27. 08430 La Roca del Valles 12. Juliá FX, Pepió JM. Inmigración en atención pri- [email protected] maria. Curso autoformativo en la atención prima- ria de la salut. Barcelona: Institut d’estudis de la Salut. Generalitat de Cataluña; 2003; p. 51-5. — 65 — 5 Rev Esp Sanid Penit 2012; 14: 62-66 A Bedoya del Campillo, PA Martínez-Carpio, MJ Leal, N Lleopart Diagnosis and treatment of bladder schistosomiasis from penitentiary primary care: Case report

13. Bichler KH, Savatovsky I. EUA guidelines for the 15. López-López AI, Cao-Avellaneda E, Prieto- management of urogenital schistosomiasis. Eur González A, Ferri-Ñíguez B, Maluff-Torres A, Urol 2006; 49: 998-1003. Pérez-Albacete M. Esquistosomiasis: una parasi- 14. Navarro-Cabañas G, García-Sánchez N, Rubio- tosis urinaria cada vez más frecuente. Actas Urol Rubio R, Izaguirre-Zugazaga C, Clavel-Parrilla Esp 2007; 31: 915-8. A, Seral-García C. Esquistosomiasis urogenital: un diagnóstico sencillo. An Esp Pediatr 2006; 64: 282-4.

— 66 —