Case 39-2003: A Woman with Gross Hematuria
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《新英格兰医药杂志》
To the Editor: Gross hematuria in a 33-year-old woman with a bladder-wall mass, described by Heney and Young (Dec. 18 issue),1 should raise the suspicion not only of tumors but also of parasitic infestation with Schistosoma haematobium and its sequelae. Determining whether there was a history of travel to sub-Saharan Africa, an area where this infection is endemic, would be important. Schistosomiasis is still a major helminthic infection and an important public health problem in many nonindustrialized countries.2
Urinary tract disease is characteristic of infection with S. haematobium.3 Hematuria may be the first sign of established disease and is common in both the early and the late stages of disease. The adult worm may live in the walls of the urinary bladder for decades, and the antigens from the eggs induce a chronic granulomatous inflammation in the host. This chronic inflammation can be misdiagnosed as bladder cancer, though, as correctly pointed out by the discussant in the Case Records, S. haematobium may later play a role in causing some types of bladder cancer. Thus, urinary schistosomiasis would be an important element in the differential diagnosis, given this patient's presentation.
Parthak Prodhan, M.D.
Natan Noviski, M.D.
Massachusetts General Hospital
Boston, MA 02114
pprodhan@partners.org
Priya Mendiratta, M.D.
Greater Lawrence Family Practice Program
Lawrence, MA 01842-0389
References
Case Records of the Massachusetts General Hospital (Case 39-2003). N Engl J Med 2003;349:2442-2447.
Chitsulo L, Engels D, Montresor A, Savioli L. The global status of schistosomiasis and its control. Acta Trop 2000;77:41-51.
Ross AGP, Bartley BP, Sleigh AC, et al. Schistosomiasis. N Engl J Med 2002;346:1212-1220
To the Editor: It is curious that in Case 39-2003, despite quite a long list of alternative names for the lesion that the authors call "inflammatory pseudotumor," the term "inflammatory myofibroblastic tumor" is not mentioned. The recently published World Health Organization classification of soft-tissue tumors1 uses the latter term in order to emphasize that this lesion is currently considered to be a true neoplasm, with a component of inflammatory cells, rather than a reactive condition. Continued use of "inflammatory pseudotumor" might therefore be considered inadvisable, not only in view of the updated classification and its implications for the definition of entities and for medical communication, but also because it is a misnomer that implies a reactive condition. In fact, it is a neoplastic proliferation with an established, albeit small, risk of metastatic spread.
David A. Wright, M.R.C.P.
St. Thomas' Hospital
London SE1 7EH, United Kingdom
wrightplc@aol.com
References
Fletcher CDM, Unni KK, Mertens F, eds. Pathology and genetics of tumours of soft tissue and bone. Vol. 5 of World Health Organization classification of tumours. Lyons, France: IARC Press, 2002.
The discussants reply: In response to Dr. Wright's letter: different lesions may have differing names, and even different behavior, when they occur in different sites within the body. The lesion in this case must be classified on the basis of its location in the bladder. Thus, comments related to its behavior should be based on what is known about lesions with these morphologic features in the bladder. To the best of my knowledge, the great majority of authorities on bladder pathology consider this lesion benign (in the bladder) and do not classify it with neoplasms of the bladder. The terminology, in the bladder and elsewhere, has varied, but the term used in the clinicopathologic conference has been widely used in the literature and happens to be the preferred term at the Massachusetts General Hospital.
We are indebted to Dr. Prodhan and colleagues for emphasizing the importance of schistosomiasis in the differential diagnosis of hematuria in many parts of the world. Consideration of the possibility of travel to places where schistosomiasis is endemic would have been prudent in our discussion. Schistosomiasis is not primarily contracted in the United States, since the intermediary host, the freshwater snail, is not found in this country.
Robert H. Young, M.D.
Niall M. Heney, M.D.
Massachusetts General Hospital
Boston, MA 02114
Urinary tract disease is characteristic of infection with S. haematobium.3 Hematuria may be the first sign of established disease and is common in both the early and the late stages of disease. The adult worm may live in the walls of the urinary bladder for decades, and the antigens from the eggs induce a chronic granulomatous inflammation in the host. This chronic inflammation can be misdiagnosed as bladder cancer, though, as correctly pointed out by the discussant in the Case Records, S. haematobium may later play a role in causing some types of bladder cancer. Thus, urinary schistosomiasis would be an important element in the differential diagnosis, given this patient's presentation.
Parthak Prodhan, M.D.
Natan Noviski, M.D.
Massachusetts General Hospital
Boston, MA 02114
pprodhan@partners.org
Priya Mendiratta, M.D.
Greater Lawrence Family Practice Program
Lawrence, MA 01842-0389
References
Case Records of the Massachusetts General Hospital (Case 39-2003). N Engl J Med 2003;349:2442-2447.
Chitsulo L, Engels D, Montresor A, Savioli L. The global status of schistosomiasis and its control. Acta Trop 2000;77:41-51.
Ross AGP, Bartley BP, Sleigh AC, et al. Schistosomiasis. N Engl J Med 2002;346:1212-1220
To the Editor: It is curious that in Case 39-2003, despite quite a long list of alternative names for the lesion that the authors call "inflammatory pseudotumor," the term "inflammatory myofibroblastic tumor" is not mentioned. The recently published World Health Organization classification of soft-tissue tumors1 uses the latter term in order to emphasize that this lesion is currently considered to be a true neoplasm, with a component of inflammatory cells, rather than a reactive condition. Continued use of "inflammatory pseudotumor" might therefore be considered inadvisable, not only in view of the updated classification and its implications for the definition of entities and for medical communication, but also because it is a misnomer that implies a reactive condition. In fact, it is a neoplastic proliferation with an established, albeit small, risk of metastatic spread.
David A. Wright, M.R.C.P.
St. Thomas' Hospital
London SE1 7EH, United Kingdom
wrightplc@aol.com
References
Fletcher CDM, Unni KK, Mertens F, eds. Pathology and genetics of tumours of soft tissue and bone. Vol. 5 of World Health Organization classification of tumours. Lyons, France: IARC Press, 2002.
The discussants reply: In response to Dr. Wright's letter: different lesions may have differing names, and even different behavior, when they occur in different sites within the body. The lesion in this case must be classified on the basis of its location in the bladder. Thus, comments related to its behavior should be based on what is known about lesions with these morphologic features in the bladder. To the best of my knowledge, the great majority of authorities on bladder pathology consider this lesion benign (in the bladder) and do not classify it with neoplasms of the bladder. The terminology, in the bladder and elsewhere, has varied, but the term used in the clinicopathologic conference has been widely used in the literature and happens to be the preferred term at the Massachusetts General Hospital.
We are indebted to Dr. Prodhan and colleagues for emphasizing the importance of schistosomiasis in the differential diagnosis of hematuria in many parts of the world. Consideration of the possibility of travel to places where schistosomiasis is endemic would have been prudent in our discussion. Schistosomiasis is not primarily contracted in the United States, since the intermediary host, the freshwater snail, is not found in this country.
Robert H. Young, M.D.
Niall M. Heney, M.D.
Massachusetts General Hospital
Boston, MA 02114