A 55-year-old man comes to the physician because of weight loss and increased urinary frequency for the past month. He has also noticed blood in the urine, usually towards the end of voiding. He returned from a deployment to Egypt , where he spent 2 years on a mission on the Nile. He has smoked one pack of cigarettes daily for 35 years. Physical examination shows a palpable liver edge and splenomegaly. His hemoglobin concentration is 9.5 mg/dL. A urine dipstick is strongly positive for blood. A CT scan of the pelvis shows bladder wall thickening and fibrosis. Microscopic examination of a biopsy specimen of the bladder obtained during cystoscopy shows squamous cell carcinoma. Which of the following is the most likely underlying cause of this patient's symptoms?

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Eductional Objective: Schistosomiasis, a parasitic blood fluke infection, is common in rural portions of sub-Saharan Africa.  Initial infection is often asymptomatic, but some patients develop chronic hepatosplenic (eg, portal hypertension, hepatosplenomegaly, esophageal varices) or urinary (eg, bladder cancer) complications years or decades later.  The presence of eosinophilia is an important diagnostic clue.

A 55-Year-Old Man Comes to the Physician Because of Weight