The Fever Files: What’s a Bladder With You?
The Case
You’re working on the sketchy side of the tracks, in an area where calls for drug overdose outnumber calls for chest pain by about 100 to 1. You’re called to an apartment famous for insect infestations; yet an impoverished group of immigrants calls it home. You tuck your socks over your duty pants and make a note to change out of your uniform before you clock out and wear your civvies home.
It's hot outside today; with the humidity, it’s over 100 degrees. Come to think of it, it’s hot inside as well. There is no AC here, and every window is open, though the muggy, still air makes this effort at catching a breeze seem futile.
A Nigerian woman meets you with her young child, and she tells him to say hello to you. You extend your hand and shake, and you note he is weak and tired. You can tell he’s pale when you look at his lips, nailbeds, and palpebral conjunctiva (the insides of the lower eyelids).
The mother tells you in a heavy accent and perfect detail that since coming to the country six months ago, her son has been more tired and less engaging then usual; he used to be such a happy and playful kid, and she thinks leaving his homeland has saddened him. Regardless, today he felt faint and nearly passed out. That, she says confidently, has never happened before.
You suspect dehydration from the heat, but of course you are thorough and develop a differential. He feels warm, but you bet everyone in the building is likely hyperthemic; you decide to ask a few questions to rule out sepsis. Cough? No. Headache? No. Diarrhea? No. Urinary symptoms? “Yes, he is always bleeding in his pee” she tells you.
The hematuria, she says, has been going on since he came to the country but seems to be getting worse.
You ask a few questions related to their life before immigrating.
T
he mother tells you they lived on farmland, and her son frequently played in pools of water. He has no immunizations other than what they received when they immigrated; she isn’t sure which ones. She is a good historian; she tells you she lost one child during labor, and that her other child, her son, is eight years old. He’s never been sick, except for last year when he had a terrible fever. She worried it was malaria, but the local health clinic tested him for it and ruled it out. They also ruled out tuberculosis and HIV.
Your physical exam is normal—there is no tenderness over his kidneys, abdomen or bladder—and he is slightly febrile and tachycardic, but has a normal blood pressure and oxygen saturation.
You aren’t impressed with your clinical exam, but your gut tells you something unusual is going on. You offer to transport to the local ER, and the mother is grateful. “Every time I take him to the clinic, they give him an antibiotic and send me on my way. No one listens.”
You arrive at a packed ER—there must be 60 patients in the ER, and at least a dozen lined up to triage. You join the queue.
You finally make your way to the front of the triage line. The triage nurse makes a quip: “Oh great, another urinary tract infection—I guess you want a resus bed?” You let the sarcasm slide off you like water off a duck’s back and calmly suggest a workup for tropical diseases might be appropriate for this child. The nurse gives you a stare and softens his stance. “Yeah, ok, I’ll put in for a urine sample and labs.”
Laboratory results show anemia (hemoglobin 7.8 g/dL, reference range 13-15 g/dL) and renal insufficiency (creatinine 1.9 mg/dL, reference range 0.7-1.3 mg/dL). The usual culprits—urinary tract infection, malaria, dengue and typhoid—are excluded.
Because of your heightened concern and careful history, an infectious disease physician is consulted, who recommends ova and parasite testing from stool and urine. The child is discharged home with an appointment for follow up at the pediatric clinic.
Schistosomiasis: A True Case of Mine!
Before you fade away and think this case is too crazy to be true, it’s real—it was a patient brought to my ER by paramedics whom I saw in a rapid assessment zone.
This is a case of schistosomiasis. The fever one year prior in Nigeria is a tip-off: Katayama fever, the acute stage of schistosomiasis, occurs a few weeks after initial infection, but the damage to the body continues long after the fever subsides.
Also known as Bilharzia, schistosomiasis is one of the most common parasitic infections, affecting over 200 million people, mostly children, worldwide; 90% of cases are in sub-Saharan Africa. A type of flatworm, Schistosoma live in human blood vessels where they lay eggs; these eggs can get into feces and urine and contaminate water. The lifecycle is completed when eggs hatch and infest freshwater snails, where they mature into larva and contaminate fresh water. These larvae then penetrate human skin, where they mature into adults.
Eggs that don’t get excreted into the environment can get stuck in organs, like the kidneys and intestines, and cause immune reactions that lead to bleeding and organ damage. Fibrosis of the bladder and ureter can cause infertility in both men and women or, more concerningly perhaps, bladder cancer.
Back to the Case
Your advocacy pays off; one week after the visit to the ED, the public health lab flags a parasitology report showing Schistosoma hematobium eggs in the urine. The pediatrician arranges follow up at an infectious disease clinic, which then leads to a referral to a pediatric infectious disease specialist downtown. There, the child receives treatment with a single curative dose of praziquantel. One month later, his hemoglobin and creatinine have normalized, and no further parasite eggs are found.
Citation:
https://www.who.int/news-room/fact-sheets/detail/schistosomiasis
