B ased on the morphological characteristics of the organism seen in the cytology smear and the bladder tissue biopsy specimen, the patient was diagnosed with an infection caused by Schistosoma haematobium. While the cytology examination was diagnostic for this patient, the clinical team chose to further confirm with a biopsy. The patient recovered on praziquantel therapy with normal urine and three follow-up negative urine cytology specimens. Schistosoma species are among the most medically important trematodes, with the greatest impact on human health. In 2014, the World Health Organization reported 61.6 million cases of schistosomiasis requiring treatment worldwide (http://www.who.int/ mediacentre/factsheets/fs115/en/). The three major species of Schistosoma infecting humans are S. haematobium, S. mansoni, and S. japonicum. The life cycle of all species of Schistosoma is composed of five developmental stages: egg, miracidium, sporocyst, cercariae, and adult worm (http://www.cdc.gov/dpdx/schistosomiasis/index.html). Transmission to humans is via penetration of the skin by the free-swimming cercariae, which depend on the presence of freshwater snails as the intermediate host. The geographic distributions of the different species are dependent on their specific freshwater snail intermediate host: S. mansoni is found in Africa and Latin America, S. haematobium in Africa and the Middle East, and S. japonicum in Asia. Schistosomes have tropism for different areas of the body. The adult worms of S. mansoni and S. japonicum reside in the mesenteric venules, where they lay eggs that are progressively moved toward and deposited in the intestine or the liver, causing gastrointestinal or liver disease, respectively. Alternatively, S. haematobium affects the urinary tract, with the adult worm most commonly living in the venous plexus of the bladder, with eggs deposited in the bladder wall and ureters. Clinically, most patients are asymptomatic but may become symptomatic, especially immunocompromised patients. The acute stage begins shortly after cercarial penetration, with itching and dermatitis followed by fever, chills, diarrhea, fatigue, abdominal pain, hematuria (with S. haematobium), and hepatosplenomegaly. The chronic stage is associated with significant morbidity and mortality due to reaction of tissues to schistosome egg deposition, causing granuloma formation and fibrosis. In the case of Schistosoma haematobium infection, this can lead to squamous cell carcinoma of the bladder (1). Direct parasitological examination of either stool or urine remains the gold standard for diagnosis. The cytology examination of this patient demonstrated the classic oval-shaped S. haematobium egg (typical size, 110 to 170 m by 40 to 70 m) with a terminal spine and a hatching ciliated miracidium. Hatching of the miracidium from the egg is a process rarely seen in routine microbiology specimens. It is hypothesized that different specimen-processing techniques in the cytology laboratory may provide optimal conditions to promote miracidium...
A 26-year-old male with HIV/AIDS and a CD4 count of Ͻ50 cells/mm 3 presented to a routine follow-up visit with darkening of his urine, which had been occurring for several days. The patient was born in Ghana and lived there for the first 10 years of his life. He returned to Ghana in 2013 and recalls swimming in freshwater there. He was compliant with his medications and had had no opportunistic infections to date. As the problem was believed to be related to possible exercise-induced hematuria, no recommendations were made; however, a urine sample was collected for cytology examination to rule out possible malignancy and for urine culture to rule out infection. The cytology examination reported no malignant cells, but an organism was present (Fig. 1A). The urine culture was negative. The patient returned with worsening gross hematuria and was then referred to a genitourinary subspecialist. The results of the computed tomography urogram revealed a 1.0-cm soft tissue nodule protruding into the urinary bladder with foci of calcification, concerning for a bladder mass. Cystoscopy examination showed multiple tan white papules, predominantly at the trigone, and a 1.5-cm mass in the left lateral wall. Multiple tissue biopsy specimens were obtained from the bladder wall and trigone (Fig. 1B), which confirmed the diagnosis, and treatment was initiated. Citation Jing J, Hanna MG, Zhang DY, Szporn AH, Dingle TC. 2018. Photo Quiz: Hematuria in a 26-year-old male with AIDS. J Clin Microbiol 56:e00724-16. https://doi.org/10.1128/JCM .00724-16.
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