Mirroring rarity of ectopic adult Schistosoma haematobium worms in a Sudanese patient

Abstract

Introduction and importance

Schistosomiasis is the second most common endemic disease after malaria. This case highlights the rarity of adult S. haematobium worms in a sub-granuloma area and explores how they may reach this site.

Case presentation

A 25-year-old man presented with hematuria, dysuria, and urinary incontinence, with no prior history of schistosomiasis. Investigations revealed numerous RBCs, pus cells, and S. haematobium eggs in his urine. An abdominal ultrasound showed a thickened bladder wall with filling defects. Cystoscopy revealed two bladder tumors and sandy patches, where multiple mobile worms were found beneath granulomas. The granulomas and worms were completely removed (TURBT). Histopathology confirmed bilharzial granuloma and adult S. haematobium. The patient was treated by empirical regimen postoperatively and reported symptom improvement at follow-up.

Clinical discussion

Schistosomiasis is prevalent in tropical and subtropical regions, particularly in Africa, where over 90 % of cases occur in areas with inadequate sanitation. In Sudan, urinary schistosomiasis was first reported in 1919. The disease manifests in two forms: urogenital, caused by S. haematobium, and intestinal, caused by other species. Adult worms reside in the bladder, and their eggs lead to symptoms such as dysuria and “sandy patches.” Praziquantel has been the gold standard treatment for over 30 years. Granulomas around adult worms are rare due to their location in the peri-vesical plexus and inability to migrate to bladder cavity. The presence of viable adult worms in uncommon sites may be explained by many possibilities such as angiogenesis in chronic inflammation or aberrant vascularity that early led the small adult worm to reach this site and to grow to this size.

Conclusion

This case mirroring rarity of the presence of adult S. haematobium in sub-granuloma area, it's also discuss the different possibilities of how this adult worm reach this rare site.

Highlights

• •Clinical Significance: Atypical adult S. haematobium beneath granuloma in a male.
• •Pathophysiological Mechanisms: Chronic inflammation may enable schistosome migration.
• •Epidemiological Context: Schistosomiasis is a key public health issue in Sudan.
• •Histopathological Findings: Increased angiogenesis signals of chronic inflammation presence.
• •Therapeutic Implications: Praziquantel is effective; cystoscopy confirms diagnosis.

1. Introduction

Schistosomiasis has a long history, dating back to ancient Egypt (circa 3500 BCE) which discovered its antigens in Egyptian mummies. The disease was recognized and documented by ancient Egyptians, who described its symptoms and effects. Later, in the 19th century, the German pathologist Theodor Bilharz identified the parasitic worms responsible for the disease [2,3].

Schistosomiasis is the second most prevalent parasitic disease after malaria affecting endemic nations. Adult S. haematobium worms reside within the pelvic venous plexus. In individuals with chronic, active infections, clusters of viable eggs can be found in the urogenital tissues, leading to severe inflammation. This inflammation may subsequently cause the development of tumors and pseudo polyps within the bladder, often manifesting as hematuria [1].

This case report has been reported in line with the SCARE checklist 2025 [12].

2. Case presentation

A 25-year-old man presented frank hematuria, dysuria, suprapubic pain and urge urinary incontinence, no loinspain, no ureteric cholic pattern, no hx of stone disease or passage. There was no obstructive symptoms, remembering history of skin manifestation, uretheral discharge, recent streptococcal infection, no family history of similar condition or past medical history of schistosomiasis. On examination there was no abnormality detected.

Investigations revealed Uncountable RBCs, significant pus cells and presence of S. haematobium eggs in urine analysis. Complete hemogram (CBC) and renal functions tests (RFT) were normal. Abdominal ultrasound showed thick, irregular wall of the bladder and there was a filling defects, with the possibility of clot or bilharzial granuloma.

Accordingly the patient was planned for cystoscopy plus TURBT. Intra-operatively there was two bladder tumors (? granuloma) near to the ureteric orifices and sandy patches (Fig. 1). TURBT was done for the granulomas, there was sub granuloma strange multiple mobile worms (Fig. 2). TURBT was completed and the worms were removed. Specimens and worms were sent for histopathology. The histopathology confirms bilharzial granuloma and adult S. haematobium worms (Fig. 3, Fig. 4).

Fig. 1.

Intravesicle bladder granuloma.

Fig. 2.

Viable adult S. haematobium worms.

Fig. 3.

Bladder tissue show densely invested by adult worm of Schistosoma (orange arrow: adult female Schistosoma worm - red arrow: adult male Schistosoma worm), with the surrounding lamina propria show large number of viable ova (blue arrow: Schistosoma egg) with surrounding dense infiltration by mixed acute and chronic inflammatory cells including eosinophils, neutrophils, lymphocytes and plasma cells (green arrow: intravascular adult worm - yellow arrow: lumen of blood vessel (vein)) (magnification ×40).

Fig. 4.

Section show many adult worm intravascular with many eggs on the surrounding tissue with marked inflammatory infiltrate (magnification ×40).

Postoperatively the patient started the S. haematobium empirical protocol thereby and was discharged 24-hour post-surgery. Two weeks later, the patient came back to the clinic for follow-up, he looked well, and reported that his symptoms had improved.

3. Discussion

Schistosomiasis is widespread in tropical and subtropical regions, it is believed that more than 90 % of people who are suffering from schistosomiasis are located in Africa especially in underprivileged areas with limited access to safe water and adequate sanitation [4].

.In Sudan, the first case of urinary schistosomiasis was reported in 1919. Since then, the disease has spread across northern Sudan and other regions, particularly in areas involved in large agricultural and water projects. This expansion has led to increased water-borne diseases like schistosomiasis and malaria, which have become major health concerns in those regions [5].

Infection with schistosomes occurs when cercaria, the larval form of the parasite, is released by freshwater snails and penetrates the skin during contact with infested water. Schistosomiasis has two forms: urogenital, caused by Schistosoma haematobium, and intestinal, caused by S. guineensis, S. intercalatum, S. mansoni, S. japonicum, and S. mekongi [6]. Adult S. haematobium worms are inhabited in the vesicle venous plexus, the passage of its egg clusters through the epithelial layer into the lumen of the bladder is accompanied by bleeding causing hematuria. The eggs then exit the body with urine through the urethra making them detectable in the urine, which is considered the gold standard for diagnosis of urogenital schistosomiasis [7,8]. Deposition of eggs in the bladder can cause other symptoms like dysuria and stress urinary incontinence while the accumulation of calcified tissue of dead eggs forms the classical lesions of schistosomiasis in the urinary bladder which are described as “sandy patches” that tend to bleed upon contact and can additionally induce genital itching and discomfort [9]. Ova deposition can also cause hydronephrosis as a result of blockage of the ureteric orifice by granulomatous lesions which form due to the accumulation of eosinophilic and inflammatory mediators around eggs [9,10].

Praziquantel, an acylated quinoline-pyrazine derivative, has been the gold standard for treating schistosomiasis for more than three decades [11].

There was no evidence of formation of granulomas around the adult S. haematobium which is most properly due its usual location in the peri-vesicle venous plexus and the inability of the adult worm to migrate from outside to the mucosa or bladder cavity, in comparison to the ova which is able to penetrate and migrate from the plexus to the bladder cavity. And the trapped ova might be the nidus that induce immune response and lead to granuloma formation [9].

The presence of the viable adult worm in uncommon site may be explained by increased vascularity in the sub- mucosal area due to many possibilities such as angiogenesis in chronic inflammation or aberrant vascularity that early led the small adult worm to reach this site and to grow to this size …etc.

4. Conclusion

This case mirroring rarity of the presence of adult S. haematobium in sub-granuloma area, it's also discuss the different possibilities of how this adult worm reach this rare site.

CRediT authorship contribution statement

Dr. Alkarem A (urologist) did the surgery within and following up the patient.

Dr. Hegazi A (urologist) assisted in surgery and data collection.

Dr. Hassan A (histopathologist) examined specimens and reported findings.

Dr. Elhassan Y (resident of clinical microbiology at SMSB) assisted in examination and reported specimens.

Dr. Mussab Mohjoub Taha (resident of urology at ABHS) revised, wrote, checked the grammar and, spelling, organized and did submission process.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethical approval

Ethical approval was obtained from the committee at Department of Urology, Atbara Teaching Hospital (A.T.H 00249915013817 – 00201102198960).

Guarantor

Sami Mahjoub Taha Awad.

Funding

No financial support was received from any organization.

Declaration of competing interest

The authors declare no competing of interests.