Image quiz: A bladder biopsy from a child with hematuria

Clinical Context

[[Figure 1]]. Is an H&E stained section of a bladder biopsy taken from a child who presented with hematuria. The patient spent a few months at a refugee camp by the Nile in Ethiopia before arriving in the USA.

Figure 1: H&E stained bipsy of the bladder

Question

What is your diagnosis?

Answer to Image quiz

The diagnosis is Schistosomiasis

[[Figure 1]] featured a section from a fibrotic area of the bladder wall infested with eggs of Schistosoma haematobium highlighted by the arrows in the demarcated image below [[Figure 2]]. This parasitic infection is endemic to the Nile Valley from Ethiopia and Sudan and Egypt. Ancient archival material proves the prevalence of this disease there since the dawn of recorded history. The earliest case of human Schistosomiasis diagnosis (confirmed by immunologic ELISA method) was found in the mummified body of an Egyptian adolescent dating back to more than 5,000 years ago[[1]]. In a study by Miller et al., 15 out of 23 mummies tested showed evidence of schistosomiasis[[2]]. Apparently, hematuria, likely due to schistosomiasis, was so prevalent in ancient Egypt that in a papyrus dated to the Pharaonic era, a palace physician expressed concern if an adolescent boy reaches puberty and reported no blood in his urine; similar to the concern encountered in females reaching adolescent age with no sign of blood or mensuration!

Figure 2: A representative section from bladder mucosa with arrows pointing to Schistosoma eggs in a fibrotic background. Note the terminal spine (arrowhead) that help separate Schistosoma Haematobium from S. Mansoni and S. Japonicum

Schistosomiasis (also known as Bilharzia) is one of the most prevalent parasitic diseases. Schistosoma haematobium is the prevalent species in Africa and the Nile valley. Schistosoma Mansoni is encountered – in addition to Africa- in South America, while Schistosoma Japonicum occurs in Japan, China and South East Asia. The eggs of these parasites are helpful in designating the species at the microscopic level. Schistosoma haematobium eggs are oval and show a terminal spike. Schistosoma Mansoni eggs are also oval but show a lateral spike. The eggs of Schistosoma Japonicum are smaller, round and show a very small lateral spike or no spike.

Author's contribution

None.

Compliance with ethical principles

Not required.

Conflict of Interest

There are no conflicts of interest.

Financial support and sponsorship

Nil.

• References

• 1 Deelder AM, Miller RL, de Jonge N, Krijger FW. Detection of schistosome antigen in mummies. Lancet 1990;335:724-5.
• 2 Miller RL, Armelagos GJ, Ikram S, De Jonge N, Krijger FW, Deelder AM. Palaeoepidemiology of Schistosoma infection in mummies. BMJ 1992;304:555-6.

Publication History

Received: 09 January 2021

Accepted: 13 January 2021

Article published online:
14 July 2022