Introduction
Urinary schistosomiasis caused by Schistosoma haematobium remains a major public health problem in endemic regions, particularly sub-Saharan Africa (Gryseels et al. Reference Gryseels, Polman, Clerinx and Kestens2006). Eggs deposited in the urinary tract cause inflammation, haematuria and, in long-standing infection, an increased risk of squamous cell carcinoma of the bladder (Mostafa et al. Reference Mostafa, Sheweita and O’Connor1999). In non-endemic settings, schistosomal bladder lesions may resemble urothelial neoplasia on cystoscopic examination (Botelho et al. Reference Botelho, Machado and da Costa2010). Migration and travel make recognition of imported infections increasingly relevant (Colley et al. Reference Colley, Bustinduy, Secor and King2014). We describe a Somali university student evaluated at the Department of Urology, Gülhane Training and Research Hospital, University of Health Sciences, Ankara, Türkiye, in whom urine microscopy and cystoscopic findings raised suspicion of schistosomiasis before histopathological confirmation.
Case presentation
At the Department of Urology, Gülhane Training and Research Hospital, University of Health Sciences, Ankara, Türkiye, a 20-year-old man originally from Somalia, who had resided in Türkiye for approximately two years for university education, presented with painless macroscopic haematuria and lower urinary tract symptoms. He reported freshwater exposure while living in Somalia. He had no history of smoking, occupational exposure to known urothelial carcinogens, or previous urological disease. A bladder lesion suspicious for malignancy prompted further diagnostic evaluation. Given his epidemiological background and young age, preoperative parasitological urine examination was requested.
Methods
Urine collection and microscopy. Two urine samples were collected during preoperative evaluation on the same day. The first (50 mL) was obtained at 11:00 and the second (20 mL) was collected from the terminal urinary stream at 13:30. The samples were centrifuged, and urine sediments were examined by direct unstained light microscopy (Olympus BX series, Olympus, Japan).
Cystoscopic and histopathological assessment. Cystoscopy was performed with a 19-Fr RZ cystoscope, with inspection of the bladder mucosa and the suspicious lesion. Findings were evaluated by three members of the urology team (a resident, a specialist, and a professor). The lesion was resected transurethrally and the tissue submitted for histopathological examination.
Results
Urine microscopy. No parasitic structures were identified in the first urine sample. Microscopy of the second, terminal-stream sample showed characteristic terminal-spined eggs morphologically consistent with S. haematobium (Figure 1).
Direct microscopy of urine sediment showing a characteristic terminal-spined Schistosoma haematobium egg (unstained preparation; ×400).
Cystoscopy. An approximately 2-cm sessile, hyperaemic and irregular lesion was seen at the junction of the posterior wall, right lateral wall and dome of the bladder, raising suspicion of malignancy (Figure 2B). Diffuse yellowish granular mucosal lesions consistent with ‘sandy patches’ were also observed (Figure 2A).
(A) Cystoscopic view showing diffuse yellowish granular ‘sandy patches’. (B) Solitary sessile bladder mass suspicious for malignancy.
Histopathology and management. Transurethral resection was performed. Histopathological examination showed eosinophil-rich chronic active cystitis, reactive urothelial changes, and numerous subepithelial eggs morphologically consistent with S. haematobium. Neither dysplasia nor malignancy was identified. The patient was treated with praziquantel and scheduled for follow-up.
Discussion
This case demonstrates that urinary schistosomiasis may present as a tumour-like bladder lesion even when the patient is evaluated in a country where the infection is not endemic. Schistosome eggs deposited in the bladder wall induce inflammation and tissue remodelling, which may produce mass-like mucosal changes that mimic bladder malignancy (Darraj Reference Darraj2022; Gryseels et al. Reference Gryseels, Polman, Clerinx and Kestens2006). In the present patient, a suspicious sessile lesion coexisted with yellowish granular ‘sandy patches’, providing a useful cystoscopic clue.
The negative initial urine examination followed by a positive terminal-stream sample collected later the same day highlights the potential limitations of a single examination. The morphological identification of terminal-spined eggs, interpreted alongside freshwater exposure in Somalia, supported a preoperative diagnosis. Although these findings suggested schistosomiasis, histopathological assessment of the suspicious lesion remained important to exclude concurrent neoplasia. The resection specimen demonstrated eosinophil-rich inflammation and schistosome eggs without malignancy.
The clinical implication is not that a suspicious bladder lesion should be left uninvestigated, but that clinicians should integrate exposure history and parasitological testing into the diagnostic pathway. Recognising schistosomiasis may support appropriate antiparasitic treatment and help avoid unwarranted escalation to more aggressive interventions. Chronic S. haematobium infection is also associated with bladder cancer risk, reinforcing the importance of histological assessment when a suspicious lesion is present (Botelho et al. Reference Botelho, Machado and da Costa2010; Mostafa et al. Reference Mostafa, Sheweita and O’Connor1999).
Conclusions
In this 20-year-old Somali student evaluated in Türkiye, repeated urine microscopy identified S. haematobium eggs after an initially negative sample, while cystoscopy showed both a suspicious bladder mass and characteristic sandy patches. Histopathology confirmed schistosomal inflammation without malignancy. In patients with haematuria and bladder lesions who have lived in or travelled to endemic regions, a focused exposure history, appropriate parasitological investigation and histological confirmation when indicated are essential for accurate diagnosis and management.
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During the preparation of this work, the author(s) used AI-assisted technologies solely for basic spelling, grammar checking, and minor formatting corrections. After using this tool, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.
Acknowledgements
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Financial support
The authors declare that no financial support was received for this study.
Competing interests
The authors declare no conflict of interest.
Ethical standards
The authors assert that the procedures contributing to this work complied with relevant institutional and national ethical standards and the Declaration of Helsinki. Ethical committee approval was not required for this case report according to institutional policy. Written informed consent was obtained from the patient for publication of this case report and accompanying images.
