A 7-year-old male, recently adopted from Ethiopia, presented to the pediatrician with hematuria shortly after immigration to the United States in January of 2016. Adoptive parents noted hematuria for about 2–3 weeks, observing gross blood at either the beginning or the end of the urinary stream. Over the past few days, the coloring had been getting lighter (only faint pink). He had no fevers, abdominal pain, dysuria, nocturia, suprapubic pain or flank pain. Adoptive parents noted that he seemed to urinate frequently but did not show signs of constipation.
Little was known about his medical history, other than he had good growth and development and had been treated for an infection “with 5 shots” before adoption. He also had a negative tuberculin skin test before immigration. Adoptive parents requested additional health information and received paperwork stating “acute renal failure,” with masses noted on a renal and bladder ultrasound (US). His family history was not available.
On initial examination, the child had a temperature of 36.4°C, heart rate of 84 beats per minute, respiratory rate of 18 breaths per minute and blood pressure of 113/64 mm Hg. He had an overall normal examination, with a soft, nontender, nondistended abdomen, no hepatosplenomegaly or mass, no suprapubic tenderness and no costovertebral angle tenderness. He had a normal-appearing uncircumcised penis with healthy foreskin and bilaterally descended testes without masses or edema.
Urinalysis showed 6 red blood cells per high powered field and 108 white blood cells per high powered field and negative protein, leukocyte esterase and nitrites. Urine culture did not show any significant growth. A complete blood count was normal with a white blood cell count of 7.1 thousand cells/μL, with differential of 49% neutrophils, 41% lymphocytes, 4% monocytes, 3% basophils and 3% eosinophils.
Renal and bladder US showed thickened bladder with debris and multiple mass-like lobulated areas (Fig. 1). Kidneys were normal without scarring or hydronephrosis.
He was referred to the Infectious Disease and Urology Clinics. A repeat renal and bladder US done 1 week later confirmed multiple bladder masses similar to the prior examination without hydronephrosis. Given the persistence of the mass-like lesions, cystoscopy and biopsy of lesions were performed to rule out malignancy.
For Denouement see P. 980.
(Pediatr Infect Dis J 2020;39:980–981)
Continued from P. 979.
Biopsies of the bladder masses obtained via cystoscopy revealed reactive uroepithelium with granulation tissue and severe chronic active inflammation. Numerous parasite eggs with occasional calcification and rare terminal spine were also noted, consistent with bladder schistosomiasis (Fig. 2). Microscopic sections showed increased numbers of neutrophils, as well as rare dead larvae. The findings of granulation tissue and parasite eggs within the bladder were concerning for chronic schistosomiasis infection, which can be complicated by squamous cell carcinoma of the bladder.1 However, while there was some squamous metaplasia noted in the urothelial epithelium, no evidence of malignancy was found.
Definitive diagnosis of schistosomiasis includes finding Schistosoma eggs in the urine or stool via microscopy, which can then be used to identify species and quantitate the parasite burden. The patient’s urine on examination of ova and parasites was positive for Schistosoma haematobium. Further investigation into his health screening in Ethiopia before coming to the United States revealed a concern about “bilharzia,” the term used for schistosomiasis in the Middle East.
Schistosomiasis is endemic to over 90 countries, including many in Africa. Per 1 report, schistosomiasis affects up to 60% of African children, with the youngest age of infection noted to be at 6 months of age.2 Schistosomiasis is caused by the digenean trematode Schistosoma; there are 5 different species of Schistosoma that can cause human disease, with Schistosoma haematobium in particular causing urogenital disease. Infection typically occurs after contact with the intermediate host, the water snail, while bathing or wading through freshwater streams. Larvae released from the water snail are able to penetrate human skin within seconds of contact, mature into adult worms in the liver, and then migrate to the urogenital tract. There is encapsulation of the egg by the bladder via granuloma formation.3 Infection with S. haematobium will cause dysuria, frequency, and hematuria typically at the end of voiding, and complications can occur if eggs are released into the blood stream, potentially leading to hepatic, pulmonary, or neurologic dysfunction.1
A urinalysis with red blood cells is typical of infection. Although not found in our patient, peripheral eosinophilia, often >400 cells/μL, will often be seen on complete blood count.4 However, eosinophilia is not a strong predictor of evidence of Schistosoma infection and was noted in only 8% of cases in 1 study.5
The treatment for schistosomiasis includes 2 doses of praziquantel at 40 mg/kg divided twice daily for 1 day. Often after treatment, no further evaluation is needed; however, in rare cases, where there is residual infection, a second treatment course is required.4 Within 2 months after praziquantel treatment, our patient’s US showed improvement in bladder wall thickening and masses and he no longer had symptomatic hematuria. Four months after treatment, a peripheral eosinophilia (37%) was noted, which was thought to be due to significant parasite death. Nine months after therapy, urine ova and parasites remained negative, and the patient remained asymptomatic. Peripheral eosinophilia declined slowly over the next few months. He is currently followed yearly by urology with repeat renal and bladder ultrasounds to monitor the bladder masses. At most recent evaluation 3 years after treatment, there remained 2 lobulated masses within the bladder that were shrinking in size.
This case emphasizes the importance of appropriate screening for refugees and adoptees coming into the United States. An excellent resource to identify what screening and initial testing is needed is the American Academy of Pediatrics Immigrant Health Toolkit. Currently, the American Academy of Pediatrics at minimum recommends a tuberculosis test, hepatitis B surface antigen screening, complete blood count with differential, lead screen for those 6 months to 16 years old, syphilis testing for those over 15 years of age, HIV testing, and 3 separate stool examinations for ova and parasites.6 For those that live in endemic countries, hepatitis C should be screened as well. If there is any concern for abuse before adoption, testing for sexually transmitted diseases should also be included. All prior records that can be attained should be brought to the initial pediatrician visit. A full physical examination, including skin and genital examination, should be done. Additional screenings, including hearing, vision, dental and developmental, should be performed as appropriate for the adoptee’s age.7 Adoptees and refugees should also be brought up to date as appropriate for vaccinations. In addition, the mental health of international adoptees should be evaluated, as many may need additional help adjusting to a new environment.8
This case highlights the importance of prompt evaluations of refugees and international adoptees on arrival into the United States, and the appropriate urgent referrals for any acute symptoms. Pediatricians and specialists should be aware of endemic diseases in other countries, and early recognition of such diseases may be able to halt chronicity and prevent further disease complications.
1. King CH, Mahmoud AF. Kasper D, Fauci A, Hauser S, et al. Schistosomiasis and other trematode infections. In: Harrison’s Principles of Internal Medicine. 2014.19th ed. New York, NY: McGraw-Hill;
2. Mutapi F. Changing policy and practice in the control of pediatric schistosomiasis. Pediatrics. 2015;135:536–544.
3. Bamgbola OF. Urinary schistosomiasis. Pediatr Nephrol. 2014;29:2113–2120.
4. Summer AP, Stauffer W, Maroushek SR, et al. Hematuria in children due to schistosomiasis in a nonendemic setting. Clin Pediatr (Phila). 2006;45:177–181.
5. Dawson-Hahn EE, Greenberg SLM, Domachowske JB, et al. Eosinophilia and the seroprevalence of schistosomiasis and strongyloidiasis in newly arrived pediatric refugees: an examination of Centers for Disease Control and Prevention screening guidelines. J Pediatr. 2010;156:1016.e1–1018.e1.
6. American Academy of Pediatrics. Immigrant health toolkit: Section 2. “Medical screening and treatment recommendations for newly arrived immigrant children.” Page 3.Available at: Aap.org/en-us/Documents/3_AAP_MedicalScreening.pdf
. Accessed April 14, 2020.
7. Veronnie FJ; Committee on Early Childhood Adoption and Dependent Care. Comprehensive health evaluation of the newly adopted child. Pediatrics. 2012;129;e214.
8. Juffer F, van IJzendoorn MH. Behavior problems and mental health referrals of international adoptees; a meta-analysis. JAMA. 2005;293:2501–2515.