CLINICAL CASE
Urinary tract infection from
Schistosoma haematobium: a case
in Cuernavaca, Morelos, Mexico
Francolugo-Vélez VA,1 Zarzosa-Alguiar J.2
• Abstract
Schistosomiasis, also known as Bilharziasis or
Bilharsiosis, is a disease that can cause hemorrhagic
cystitis and be associated with bladder cancer.
Schistosomiasis is caused by Schistosoma haematobium.
It is more frequent in Africa and the Middle East and
is highly contagious for humans in the larual stage
miracidia phase of the platyhelminth worm.
Clinical case: The patient is a 24-year-old Nigerian man
presenting with mild hematuria of 1 year progression.
Kidney microlithiasis in the middle calyx of the right
kidney and bladder polyps were revealed by 64-slice
computerized tomography. Cystoscopic biopsy reported
acute and chronic cystitis with hemorrhage and
epidermoid metaplasia, a lesion following Schistosoma
haematobium egg deposition. Patient was treated with
praziquantel.
Key words: Schistosoma haematobium, hematuria,
Mexico.
1 Urologist. Sanatorio Henri Dunant, Professor at the Universidad Au-
tónoma del Estado de Morelos. Mexico.
2 Pathologist. Hospital Carlos Calero Elorduy, ISSSTE. Cuernavaca,
Morelos. Mexico.
• Resumen
La Esquistosomiasis, llamada también Bilhariasis o Bilhar-
siosis, es una enfermedad que puede causar cistitis hemo-
rrágica y asociarse a cáncer vesical. La esquistosomiasis es
causada por Schistosoma haematobium, es más frecuente
en África y en el medio Oriente y es de alta contagiosidad
para el ser humano durante la  fase larual del platelminto.
Caso clínico: Masculino de raza negra, de 24 años de edad
originario de Nigeria, con hematuria discreta de un año
de evolución. La urotac reveló  microlitiasis renal en el cá-
liz medio del riñón derecho y tumoraciones vesicales. La
biopsia por cistoscopia reportó cistitis aguda y crónica con
hemorragia y metaplasia epidermoide, lesión consecutiva
a infección por huevos de Schistosoma haematobium. Se
administró tratamiento con prazicuantel.
Palabras clave: Schistosoma haematobium, hematuria,
México.
Corresponding author: Dr. Víctor Alfonso Francolugo Vélez. Pericón
esquina Angélica 5º piso-502. Colonia Miraval. Cuernavaca, Mor.
Telephone and Fax: (777) 314 0555. Email: urovafv@netfm.com.mx
Rev Mex Urol 2010;70(3):187-192 187
 Francolugo-Vélez VA, et al. Urinary tract infection from Schistosoma haematobium: a case in Cuernavaca, Morelos, Mexico
• Introduction
Schistosomiasis, originally known as Bilharziasis (or
Bilharsiosis) is a parasitic disease produced by the
platyhelminth worm of the class Trematoda, genus
Schistosoma (commonly known as blood-flukes and
bilharzia) and is relatively common in developing
countries, especially on the continent of Africa1 and in
central rural zones of Egypt and China.2
It dates from ancient times, as bilharzia eggs have
been found in mummies and hematuria (principal
symptom) has been registered in ancient papyri from
Kahun in Egypt.
In 1851, Theodor Maximilian Bilharz discovered
parasites in portal circulation and associated them with
being causal agents of cystitis. 1-3 Pirajá da Silva first
described the pathogenic agent in 1908.1 In 1911, Ferguson
was the first to report the high frequency of bladder cancer
and its etiological relation to urinary bilharziasis.3
There are 5 species of Schistosoma parasites that
produce schistosomiasis in humans and each of them
has its respective clinical manifestations: 4,2
• Schistosoma mansoni and Schistosoma
intercalatum cause intestinal schistosomiasis.
• Schistosoma japonicum and Schistosoma
mekongi cause the Asian variety of intestinal
schistosomiasis.
• Schistosoma haematobium causes urinary
schistosomiasis 5 and is most frequent in Africa,
the Middle East and the Mediterranean.1
The disease is the result of the granulomatous
response of the definitive host to the Schistosoma egg
and pathophysiology is related to the life cycle of the
parasite. Parasite eggs hatch upon contact with fresh
water, releasing free-swimming miracidia. The miracidia
infect the Bulinus snail which acts as an intermediary
host. Here the miracidia undergo asexual reproduction
and are transformed into cercariae which are the
larval form of the parasite that is capable of infecting
mammals. Cercariae are released into the water as
free-swimming organisms with tails. They attach to
humans and penetrate the skin (penetration can take
place after only 10 seconds of contact of human skin
with contaminated water). They lose their tails during
penetration and become schistosomulae that then enter
into the circulatory system. 6
Schistosomulae migrate to portal blood in the liver
and mature into adults. After fertilization, females reach
the bladder plexes through the portal system.
Adult worm: The adult worm is from 10-15 mm
in length and 2 mm wide. It releases its eggs in
blood vessels adjacent to the bladder. The eggs pass
188 Rev Mex Urol 2010;70(3):187-192
through the bladder wall and exit the body in urine.
Adult worms can live in the body from 2-18 years. The
worms themselves do not cause inflammatory vascular
reaction. Pathology is the result of the progressive
immune response. 7
Egg: Parasite eggs cause the first disease
manifestations. They are rarely taken into account and
are the cause of later chronic Schistosomiasis.
Principle damage is the formation of granulomas
caused by the immunological response to the eggs
and the parasite. Inactive schistosomiasis may occur
after adult worms have died and viable eggs are not
presented in tissue or urine, resulting in the so-called
bilharzial granulomas found in the bladder wall and
containing calcified eggs.7
When viable eggs are released in fresh water they
hatch, producing a miracidium embryo. It swims
towards the Bulinus snail and penetrates its tissue
where it transforms into the larval form of the parasite,
infesting the snail, and the cycle is repeated.
Clinical manifestations: The acute form is called
Katayama syndrome or fever and it is rarely identified
since it occurs 3-9 weeks after infection. It is characterized
by fever, lymphadenopathy, splenomegaly, eosinophilia,
urticaria, dermatitis in the penetration zone, headache
and general malaise.
Chronic form due to the presence of eggs in
the bladder wall, ureter or genital organs and its
accompanying inflammatory granulomatous reaction
occurs at 2-7 months after infection. It is characterized
by discontinuous hematuria with bright red blood that
can be accompanied by dysuria, frequent urination,
reduced bladder capacity, pain in the lower back, pelvic
pain and urinary incontinence. Bladder ulcerations
may present and it is possible for this disease to lead to
epidermoid bladder carcinoma.
Diagnosis: Diagnosis is made through the study of
urinary sediment in the search for eggs. Urine should
be collected between 11:00 and 14:00 hours, considered
to be the hours in which there is maximum parasite
expulsion.8 Infection is classified as mild when there are
less than or equal to 50 eggs per 10mL and serious when
there are more than 50 eggs per 10mL.5 Recount of the
amount of eggs in urine sample enables the severity of
the infection to be evaluated.
Analysis of the same urine sample determines
the presence of proteinuria or hematuria and urinary
cytology can reveal the presence of tumor cells.
An enzyme-linked immunosorbent assay (ELISA)
test in Gimvi, India, has been reported that uses
antigens derived from S. haematobium and S. mansoni
 Francolugo-Vélez VA, et al. Urinary tract infection from Schistosoma haematobium: a case in Cuernavaca, Morelos, Mexico
Image 1. Bladder level URO-CT study. Arrows show two small
tumors; the one at the bladder dome measures approximately 8.6
mm.
adult worms. It has been pointed out that patients that
excrete schistosomiasis eggs in urine, test positive for
ELISA titers. 2
Eosinophil cationic protein (ECP) measurement in
urine will be much higher, the greater the urinary tract
invasion, since it can combined with both bladder and
upper urinary tract lesions.2, 9,10
In the United Kingdom there are a variety of serological
methods for diagnosing schistosomiasis. The Hospital
of Tropical Diseases in London uses an ELISA with raw
Schistosoma mansoni, soluble egg antigens (SEA), with
97% specificity and 96% sensitivity (S mansoni).11
Simple abdominal X-ray can show fine, more or
less continuous, lineal calcifications in the bladder
wall, total bladder wall calcification, porcelain bladder
or calcification of the distal segment of the ureter.
Ultrasound (US) has been shown to be useful in the
diagnosis of Schistosomiasis haematobium infection
of the urinary tract by revealing data such as thick
mamelonated bladder wall, sessile or pedunculated
bladder polyps or pyelocaliceal dilatation with
irregular cavities. Unfortunately only severe pathology
can be visualized and mild bladder lesions cannot be
detected with this method. 9 Excretory urography can
localize ureteral stricture and identify hydronephrosis
as consequences of this type of parasite.
Cystoscopy is carried out in cases in which egg
recount is not conclusive and enables a biopsy sample
to be taken in order to rule out neoplastic degeneration.
Image 2. Arrows signal three tumors in the bladder, showing filling
defects.
As concluded by da Silva,12 cystoscopy is an important
procedure for detecting schistosomiasis in cases of
hematuria and other bladder affectations in the study
of disease from S. haematobium, particularly in cases
in which non-invasive semiological evaluation has not
been able to establish diagnosis.
Control studies should be carried out every 6 months
and should be complemented with bladder biopsy
in cases in which alterations of the bladder mucosa
have been observed. Immunological studies should be
repeated and when necessary new treatment should
be administered with cystoscopy follow-up. 12
Treatment of choice: Praziquantel is active for all
clinical forms and disease stages at a single dose of 40
mg per kg of weight.
• Case presentation
The patient is a 24-year-old black man born in Nigeria.
He has been studying at the university level for 3 years
in Cuernavaca, Morelos, Mexico with a scholarship from
his native country. He had no previous medical history
of importance.
Patient sought medical attention in July 2008 for
mild, colicky pain in the upper left abdominal quadrant
that also presented occasionally upon deep breathing.
Nausea of 15-second duration presented once or
twice a week. Patient had no urinary discomfort but
occasionally presented with mild hematuria when
beginning to urinate, a symptom which had a 1-year
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 Francolugo-Vélez VA, et al. Urinary tract infection from Schistosoma haematobium: a case in Cuernavaca, Morelos, Mexico

Image 3. One of the bladder tumors during cystoscopy. Image 5. An image of tumor tissue in which the body of one of the
parasites is seen at its edge.

progression. Renal US reported an approximately 5 mm
calculus in the mid-calyx of the left kidney.
Simple kidney tomography results were doubtful
in regard to the presence of the calculus seen with the
previous US. Urinalysis reported some bacteria, 1-2
erythrocytes per field and protein traces. URO-CT was
ordered and revealed non-obstructive microlithiasis in
the mid-calyx of the right kidney of approximately 3 mm
as well as multiple bladder polyps (Images 1 and 2).
Posterior cystoscopy showed yellowish tumors and
they were biopsied. They were located at the midline
from the dome toward the trigone with a distance of 1-2
cm between them. Upon cut, a parasite body was seen
(Images 3, 4 and 5).
Patient reported that he bathed in a river close to his
home in Nigeria. First symptoms appeared at 8 years of
age, manifested by dermatitis on the thorax and back
with pruritus and small ulcerations.

Image 4. During biopsy this image of a parasite appearing was captured. The smaller image in the box was obtained from the Internet 5
showing a female parasite enveloped in the gynacophoric canal of the male parasite.

190 Rev Mex Urol 2010;70(3):187-192

 Francolugo-Vélez VA, et al. Urinary tract infection from Schistosoma haematobium: a case in Cuernavaca, Morelos, Mexico

Schistosomiasis was suspected and patient was

given a single dose of 40 mg per kg of weight of
praziquantel. Biopsy histopathological report confirmed
diagnosis of acute cystitis and chronic hemorrhage with
epidermoid metaplasia as a consequent lesion of S.
haematobium (Image 6).
A month and a half after treatment, repeat cystoscopy
and laboratory exams were carried out to detect eggs
or parasites in urine. Urine cytology was negative for
malignant cells and there was no evidence of parasites.
Patient experienced intense headache and an
episode of lipothymia as secondary effects of treatment.
Cystoscopy revealed pale mucosa with reddened zones
and small granulomas without tumor. Biopsy was taken
of this tissue and histopathological study reported three
5-7 mm light brown, slightly softened, malleable fusiform
fragments. Microscopically, chronic inflammatory Image 6. Schistosoma haematobium egg.
process with lymphocyte and plasmatic cell formation
with intermediary cytoplasmic histiocytes was
observed. No parasites were identified. Diagnosis was:
subacute and chronic cystitis with no observation of
malignant neoplastic elements.
in schools (24%) and the evaluation of 4 techniques for
Two more studies were carried out in March and
detecting S. haematobium pathology or morbidity was
October 2009 with normal results and no hematuria.
focused on: US for bladder pathology, reactive strips
for microhematuria, interrogation for macrohematuria
• Discussion or macroscopic urine examination. It was concluded
More than 200 million people in the world in tropical that more cases of the same degree of pathology were
regions suffer from schistomsomiasis.11 Its urinary detected by US in children than in adults and that
presentation is caused by Schistosoma haematobium reactive strip was superior to interrogation.14
which is endemic in 54 cities of Africa. Studies on school- There is a lack of knowledge and information in
age children show high prevalence of S. haematobium the population about schistosomiasis. Only 0.78% has
infection. Humans can become infected by coming knowledge of the disease and 16 out of 133 children (in
into contact with contaminated water. The worms Mina, Nigeria) reported having blood in urine for which
install themselves in the vesical plexus and pelvic veins they sought medical attention.8 It has been documented
where females deposit from 20-290 eggs per day. The that there is a greater infection frequency in children
lower urinary tract, ureters and seminal vesicles are than in adults.5
the most affected organs. Lesions are characterized by In a retrospective study by the University of Cairo in
granulomas caused by tissue response to eggs. 13 Egypt, carried out over a 37-year period (1970-2007) on
Schistosoma haematobium is the most common the analysis and time tendency of 9843 patients with
cause of hematuria in endemic cities.5 In women the bladder cancer caused by schistosomiasis, it was found
uterus, cervix and vagina are most commonly affected. that the disease was more common in men with a mean
Principal symptoms are hematuria, dysuria, lumbar pain, age of 46.7 years. The most common histological type
bacterial infection data, dysmenorrhea, leukorrhea, was squamous cell carcinoma. There was muscle layer
abdominal pain and intermenstrual bleeding. 13 invasion in advanced stage cases and therefore the
Identification of S. haematobium infection cases principal line of treatment was radical cystectomy. 3
meriting treatment is generally based on microscopic It was noted in this study that patients treated
detection of eggs in urine in endemic populations, from 2003-2007 showed a significant reduction in
especially in children. From data of 45 studies that bladder cancer frequency that was associated with a
included 74 schools and 28 communities, detected reduction in egg frequency of this parasite, reduction
microhematuria prevalence was evaluated. Its presence of squamous cell cancer and an increase in transitional
was found to be slightly lower in communities (16%) than cell carcinoma. Mean age of patients was 60.5 years.

Rev Mex Urol 2010;70(3):187-192 191

 Francolugo-Vélez VA, et al. Urinary tract infection from Schistosoma haematobium: a case in Cuernavaca, Morelos, Mexico
There was also a reduction in prevalence among men
from 5.4-3.3%.3
In the present case, cystoscopy was very important
since this disease has been demonstrated in patients
who are not living in endemic populations but who have
been in them. Results, even after a second treatment,
have shown the continued presence of granulomas
and viable eggs in 33% of patients, despite negative
urine tests. 3 In addition, the possibility of therapeutic
failure with praziquantel exists, underlining the need
for research on new alternative therapeutics.6 Control
cystoscopy must be carried out every six months or
every year. This is still pending in the present case, but
the patient is currently asymptomatic.
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