A 26-year-old man comes to the office due to several months of dysuria and increased urinary frequency. He also has blood in his urine at the end of urination. A month ago, he finished 7 days of oral antibiotics for urinary tract infection, but his symptoms did not improve. The patient has no other medical issues and takes no medications. He emigrated from Ghana 2 years ago and works in a chemical fertilizer factory. The patient smokes a pack of cigarettes daily and occasionally drinks alcohol. He is married and has no children. Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 76/min. No abdominal mass or suprapubic or costovertebral angle tenderness is present. Genital examination is normal. Laboratory results are as follows: A dipstick urinalysis shows 1+ blood but is otherwise negative. Which of the following is the best next step to establish the diagnosis in this patient?

Question

A 26-year-old man comes to the office due to several months of dysuria and increased urinary frequency.  He also has blood in his urine at the end of urination.  A month ago, he finished 7 days of oral antibiotics for urinary tract infection, but his symptoms did not improve.  The patient has no other medical issues and takes no medications.  He emigrated from Ghana 2 years ago and works in a chemical fertilizer factory.  The patient smokes a pack of cigarettes daily and occasionally drinks alcohol.  He is married and has no children.  Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 76/min.  No abdominal mass or suprapubic or costovertebral angle tenderness is present.  Genital examination is normal.  Laboratory results are as follows:  A dipstick urinalysis shows 1+ blood but is otherwise negative.  Which of the following is the best next step to establish the diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: This young patient who emigrated from Ghana has urinary symptoms, terminal hematuria, and peripheral eosinophilia, raising suspicion for urinary schistosomiasis. Schistosomiasis is a parasitic blood fluke infection that affects more than 200 million people worldwide. The greatest prevalence is in sub-Saharan Africa. Schistosomes live in specific types of freshwater snails, and humans in endemic areas are often infected as children when bathing in contaminated freshwater. Although five different species of schistosomes cause human infections, urinary schistosomiasis is typically due to Schistosoma haematobium. Patients with urinary schistosomiasis are usually asymptomatic initially, but chronic infections are marked by bladder inflammation and scarring with resultant dysuria, urinary frequency, and terminal hematuria. Peripheral eosinophilia is seen in 30%-60% of cases, and anemia is common due to chronic blood loss. Diagnosis requires the identification of eggs using urine sediment microscopy. Treatment with praziquantel is usually curative. (Choice A) Chronic urinary schistosomiasis can cause bladder wall irregularities and ureter scarring, which may be seen on abdominal ultrasonography; however, these findings would only be suggestive of schistosomiasis, not diagnostic. This patient requires the identification of eggs by microscopic examination of urine. (Choice B) Chronic schistosomiasis can be associated with bladder cancer, which usually presents with intermittent, gross, painless hematuria that is present throughout micturition. This patient with terminal hematuria, peripheral eosinophilia, and dysuria first requires an evaluation for schistosomiasis using urine sediment microscopy. If this test is negative or his symptoms continue after treatment, an evaluation for bladder cancer using cystoscopy with biopsy (the gold standard) would be prudent. CT cystography is unlikely to be used. (Choice C) Expressed prostatic secretion culture is used to diagnose chronic bacterial prostatitis, which may present with dysuria and urinary frequency. However, this patient from Ghana with peripheral eosinophilia is more likely to have schistosomiasis. (Choice D) Abdominal radiography may diagnose urinary bladder calculi, a potential cause of dysuria and hematuria. However, peripheral eosinophilia is not typically associated with bladder calculi. Educational objective: Schistosomiasis is a parasitic fluke infection most commonly seen in sub-Saharan Africa. Chronic urinary schistosomiasis can cause dysuria, urinary frequency, terminal hematuria, and peripheral eosinophilia. Diagnosis is typically made by identifying parasite eggs by urine sediment microscopy.

A 26-Year-Old Man Comes to the Office Due to Several