A 24-year-old man comes to the office due to hematuria. For the past 2 days, he has been passing bright red blood at the end of micturition. He has mild dysuria, but no fever or abdominal pain. He travels throughout Africa frequently and returned from a rafting trip in central Africa 3 months ago. The patient followed medical advice regarding vaccinations and medication prophylaxis. His past medical history is otherwise insignificant. He drinks 2-3 cans of beer on the weekend and does not use tobacco or illicit drugs. The patient has one sexual partner, with whom he uses condoms consistently. He works as a sales representative.
His temperature is 36.1 C (97 F), blood pressure is 120/70 mm Hg, and pulse is 68/min. Cardiopulmonary examination is normal. The abdomen is soft and nontender without organomegaly. The external genitalia are unremarkable. On rectal examination, the prostate is normal in size and nontender.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Question

A 24-year-old man comes to the office due to hematuria.  For the past 2 days, he has been passing bright red blood at the end of micturition.  He has mild dysuria, but no fever or abdominal pain.  He travels throughout Africa frequently and returned from a rafting trip in central Africa 3 months ago.  The patient followed medical advice regarding vaccinations and medication prophylaxis.  His past medical history is otherwise insignificant.  He drinks 2-3 cans of beer on the weekend and does not use tobacco or illicit drugs.  The patient has one sexual partner, with whom he uses condoms consistently.  He works as a sales representative.
His temperature is 36.1 C (97 F), blood pressure is 120/70 mm Hg, and pulse is 68/min.  Cardiopulmonary examination is normal.  The abdomen is soft and nontender without organomegaly.  The external genitalia are unremarkable.  On rectal examination, the prostate is normal in size and nontender.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_986b_ed2f_853d_89fd3e51aaf0_MD0002_00 This young man with terminal hematuria (blood at the end of micturition) has a history of extensive travel to a schistosomiasis-endemic area; his laboratory studies are notable for eosinophilia, hematuria, and leukocyturia without bacteriuria or glomerular casts. These findings are consistent with Schistosoma haematobium infection. In contrast to acute schistosomiasis syndrome or Katayama fever (more frequent in travelers with no immunity), chronic schistosomiasis most commonly occurs in patients who live in endemic areas or have frequent exposure to contaminated fresh water. Symptoms depend on the infection site (Table). Genitourinary schistosomiasis (due to S haematobium) can present with dysuria, urinary frequency, bladder outlet obstruction, or terminal hematuria. Disease largely occurs due to a granulomatous immune reaction to the deposits of schistosomal eggs in the tissues. In patients from endemic areas, diagnosis is made by identifying and quantifying eggs in the urine or stool; in travelers, serology is best due to lighter disease burden and higher test sensitivity. Chronic infection should be treated with praziquantel. (Choices A and B) Ultrasound and CT can help evaluate features of hepatosplenic schistosomiasis but would likely not be helpful in this patient. Cystoscopy to exclude other causes of hematuria would be necessary if other testing is negative. (Choice C) A peripheral blood smear could help diagnose malaria. Although renal impairment and hemoglobinuria may occur in severe Plasmodium falciparum infection, this patient's presentation is not consistent with severe malaria, which normally presents within a month of exposure. (Choice E) Renal tuberculosis can present with hematuria; however, the diagnostic test of choice is identification of Mycobacterium tuberculosis in the urine via culture or polymerase chain reaction testing. Educational objective: Chronic schistosomiasis most commonly occurs in patients who live in endemic areas or have frequent exposure to contaminated fresh water. Symptoms of genitourinary schistosomiasis include dysuria, urinary frequency, bladder outlet obstruction, and terminal hematuria. __________ References: Diagnosis and management of schistosomiasis (http://www.ncbi.nlm.nih.gov/pubmed/21586478) Urinary schistosomiasis: review (http://www.ncbi.nlm.nih.gov/pubmed/25685452)

A 24-Year-Old Man Comes to the Office Due to Hematuria