Thanks to you all for this interesting case study with its guesses. I enjoyed the complicated story in this highly functioning person.
It was interesting to me that a lot of the psychiatric comments seemed to come out of psychiatric theory that was prevalent in the 1970s.
The 1970s in psychiatry were a time of transition from psychoanalytic thinking to a more biological approach to psychiatry disorders. Old ways of approaching psychiatric problems persist as newer methods are adopted but progress is being made.
Terms like “folie a deux’ and “matchbox presentations” of evidence were used as evidence of psychiatric disorders in this case discussion. It is not clear that findings like this have any relevance in modern psychiatry. This patient may be experiencing anxiety more than delusions. He seems to have some substance use problems and some post traumatic problems. This guy needs a psychiatric consult.
There were a lot of references to delusions, post traumatic disorder, and substance use disorder. These terms were used like they were already understood. The assumption seemed to be that these terms were self-evident and that precise definitions were not needed. Clearer definitions according to modern psychiatry would be helpful.
Daniel’s sympathetic approach seems to be working at least partially with this patient.
A consultation with psychiatry does not necessarily have to involve the reluctant patient at the beginning. For patients who cannot initially tolerate the idea, the treating physician can get ideas of how to keep things moving to resolve the problems mentioned above. For patients who are more tolerant of a psychiatric evaluation, more direct work can begin.
This may be a very good case to have a psychiatrist join the TWIP team in discussing the case. I would love to hear about how modern psychiatry sees this patient.
Thanks to the TWIP team and to all the TWIX podcasts.
I want to start with saying that I’m not a parasitologist, but the way that your podcast is hosted makes it so easy to want to learn more. I knew as I was growing up that I wanted to work outside, I just didn’t know what I could do. Going to college for a degree in natural resources and later learning about oceanography has made me want to go further and learn more and hopefully in the future, help others gain a better understanding of the sciences. I feel that as it stands I wouldn’t really have a serious need for a hardcover edition of Parasitic Diseases. Currently, my college is growing a lot, we recently got our first three Bachelors programs and I feel that I want to give the book to them in hopes that there might be a better opportunity for a student to find a topic that they might be interested in.
The electrician from Tamil Nadu has a liver mass, which could be caused by several parasitic and non-parasitic causes. With the help of the handy Bible Parasitic Diseases, 6th Ed., we came up with a differential diagnosis.
Echinococcus granulosus is well-known to cause liver cysts. However, it would normally cause jaundice, which the patient did not have. It is also usually asymptomatic, and if symptomatic causes less dramatic symptoms (unless ruptured). The patient also did not report contact with dogs and sheep. Furthemore, we would not expect the doctor to aspirate a suspected hydatid cyst, since puncturing it would be dangerous.
Another possibility is Ascaris lumbricoides that somehow ended up in the liver and caused an abscess, as has been known to happen (https://www.ncbi.nlm.nih.gov/pubmed/10501884) and can be confused with a cyst formed by E. histolytica (https://www.peertechz.com/articles/liver-abscess-secondary-to-ascaris-lumbricoides-case-report.pdf). It can be diagnosed using ultrasound, or by aspirating the lesion. This infection is endemic to the area and consistent with most of the other symptoms, such as pain and fever. However, an Ascaris infection would cause eosinophilia, which makes this less likely. If this was the infection, treatment would be albendazole and likely surgery.
Entamoeba histolytica usually causes amoebic dysentery, but nearly half of cases of extraintestinal infection have no symptoms of colonic infection. Symptoms associated with an amoebic liver cyst are:
Right upper abdominal pain with enlarged liver, and intercostal tenderness, plus fever. Check.
No eosinophilia, often eosinopenia. Check.
Lung involvement is most commonly spread directly from the liver and affects the base of the right lung; pleural effusion is a likely symptom. Check.
The only symptom that doesn’t completely fit is the nausea and vomiting, but that’s common with illness in general, and may be psychosomatic, pain-related, unrelated, or alcohol-related (although in the last case, the patient would probably know what caused it).
It is also logically plausible that he got an E. histolytica infection during the ordinary course of his life. It is found worldwide, and transmission is faecal-oral, which is likely to happen if the general sanitation and hygiene are not great – if not in his house, as his wife is unaffected, perhaps in his clients’. Transmission via soil is also likely. Aspiration of the lesion is common, both diagnostically and as a treatment.
The patient should be given metronidazole, and should stop drinking at least for the duration of the treatment.
Of course, we should mention the possibility of non-parasitic liver cysts. Those seem to be usually benign congenital cysts with no symptoms; not likely in this case even as an incidental finding alongside an infection, the pain comes from that area, and they tend to be smaller. Some cystic tumours may occur in the liver, but these don’t explain all the symptoms and are unlikely to appear as a 7x8x3 cm tumour after only a week’s illness. Also, this is TWiP, so we’re expecting a parasitic diagnosis.
We are both happy with the PDF, so if we win the book, please send it to someone completely random and mystify them.
This was a transatlantic collaborative effort between Caitlin, from Waterloo in Canada, and Carrie, from Newcastle upon Tyne, England.
My guess on the case in TWiP 159 is an abscess caused by Entamoeba histolytica. My reasons for this is that it was the first thing I came to think of, and I don’t have time to do any proper research… Echinococcus granulosus can also cause fluid filled lesions in the liver, but I don’t think the clinical presentation fits, and also I’m not sure if it’s present in southern India.
(You don’t need to read this – and I know I’ve asked for this before – but a brief summary of the paper discussed in each episode, with the most important findings and its implications, would be really appreciated!)
Adam, Halmstad, Sweden (where it at the moment is windy, 12 degrees and overcast with occasional showers).
Good afternoon from Perth: WA (Showery, 17 deg).
I’ve been listening to the TWIXes since the beginning but find the virology and microbiology sometimes inaccessible. However the parasitology is absolutely fascinating.
I am a retired electrical/electronic person but a biomedical enthusiast. When I was age 14 and attending a good grammar school in UK I was in the ‘science stream’, but was forced to make a choice between physical sciences and life sciences – and I may have chosen the wrong one. School biology in those days was cutting up frogs and a bit of taxonomy and didn’t seem very interesting – this was before the DNA revolution!
A few years ago I had some immunological issues, and in order to try and understand what was going on I studied a bit and read Bruce Alberts’ great textbook: the microbiology of the cell from cover to cover while on a long course of Prednisone which reduced my need for sleep to 3 hours!
Not being able to compete with the qualified people who normally respond to the diagnostic challenges, I normally don’t think about them but I thought I would have a go this time and suggest the gentleman has one or more hydatid cysts caused by Echinococcus granulosus.
I love the style of presentation that you have achieved that does not talk down to the audience but remains accessible to a general but scientifically literate listenership.
If I win the book (I already have V5) my phone is (61)439 369 406
Best Regards and Thanks for the work you put in
Now that the episode is out I wanted to clarify some points. Firstly, I am male. Secondly, thank you so much for inadvertently giving me two shots at a book off a single submission and doing so during a case where my last guess was not so unreasonable as to make me look totally out to sea. I hope this next one is better and allows me to win without the need for you to extend any unique kindness to me again.
Now for my next guess.
The literature I initially reviewed indicated that the parasites in the region of interest to consider are coccidia, strongyles, Monezia, and Trichuris. The key symptoms for me however were the vomiting without diarrhea, the liver lesion, the decreased breath sounds and the hepatomegaly. Consequently, ecchinoccocus seemed like a stronger option. I believe you mentioned dogs in the proximity and looking to my own experiences visiting family in India can certainly see how Echinococcosis could be readily present. In addition, Echinococcosis is known to have the potential to infect lungs and cause cysts in the liver. Given that vomiting is particularly associated with hepatic sequelae of Echinococcosis underscores the potential of this being correct. It is additionally known this organism has the potential to increase alk phos though the patient’s heavy drinking may be partly responsible for abnormal liver function test results as well. All this in conjunction with your saying this was a relatively straight forward case makes me feel reasonable comfortable about this guess.
Man in his 20s with a liver mass, lives in southern India. Drinks the toddy (palm wine), perhaps to excess. It’s the rainy season. Has a big liver, right pleural effusion, right intercostal tenderness. Eight centimeter solitary cystic liver mass on ultrasound. Dr. G has left many bread-crumbs on the trail.
I first learned about palm wine on TWiV in the context of Nipah virus transmission. It is consumed throughout the tropical world and many different types of palm trees can produce the beverage. In southern India and Sri Lanka it can be called ‘toddy’ and usually contains between 4-7% alcohol, much like American beer. The people who gather the palm sap are called ‘toddy tappers’; a pleasing occupational title. More on this later.
Best to begin with an examination of what this lesion most likely is NOT. Tropical hepatic abscesses may be due to:
- Bacterial or pyogenic. I would expect patient to be sicker, almost septic if he had this. Unique sonographic features can be reviewed in the Bächler reference. The usual culprit is Klebsiella pneumoniae.
- tuberculous, always think TB, it it a ‘great imitator’. Only 7.5% of Ghosh’s series had this.
- fungal, very uncommon (Ghosh 2014 case series of 200 patients), only 1.5% had fungal abscess. Candida did it.
- Misc: culture negative, indeterminate, malignancy
- parasitic / helminthic. Hydatid cyst is a concern. It is usually associated with eosinophilia, which is inconsistent with our patient, who is eosinopenic. Hydatid cysts often have unique sonographic features which distinguish them from other types of abscess. One of the highest prevalence locations of echinococcosis in India is in Tamil Nadu (REF Rao,S), where our patient lives . Classic teaching forbade aspiration of these lesions for fear of cyst rupture and subsequent intra-abdominal daughter cyst formation -however, recent thinking is that hydatid cysts can be safely drained percutaneously (Polat reference). Our patient’s laboratory and radiograph data make this diagnosis unlikely.
Ascaris associated liver cysts have been described (Javid ref) and are not rare. The sonographic appearance of these cysts are quite characteristic and not consistent with our toddy tippler.
Now, to a statement of what this lesion most likely IS.
The bread crumbs on this trail lead directly to PD6 —specifically pages 160-163 (A quality book I just discovered to be stitch-bound in signatures, a quality anachronism perhaps as rare as anchovy sauce these days) . The ‘intercostal sign’ is the dead give-away. Amoebic abscess in India and Sri Lanka is overwhelmingly found in males who consume large quantities of palm wine (toddy). Speculations as to the mechanisms of susceptibility of palm wine drinkers can be reviewed in Kumanan’s article. Case series report a male:female ratio of 13:1 in amoebic liver abscess. Hypotheses as to why E. histolytica forms abscesses in this group range from host factors, liver damage by alcohol, contamination of the beverage etc. I suggest that the rainy season detail is a red herring since the case series in Sri Lanka by Kannathasan showed that amoebic liver abscess incidence peaked in during the dry season. It is important to note (as PD6 emphasizes) that antecedent dysentery is seen in less than 50% of liver amoebic abscess patients. Our patient also has an elevated alkaline phosphatase, an indicator of biliary tract or liver damage and is common in amoebic abscess patients (lab findings exhaustively reviewed by Jain). Patient’s pleural effusion may represent extension of the liver abscess or perhaps is an inflammatory reaction producing a sterile effusion. Pleural effusion (almost always right sided) can be seen in 30% of patients. Diagnosis is through a combination of sonographic findings and serology. Aspiration of the amoebic cyst can be diagnostic via antigen testing or nucleic acid amplification testing – note that organisms are seldom seen in the aspirate. Treatment may be conservative, especially in lesions less than 7cm in diameter i.e. a 72 hour course of metronidazole with drainage performed if response is poor… (as outlined by Kale). Extra-intestinal amoebiasis, specifically liver abscess is a serious matter with some case series reporting a mortality of 2.5%. Pharmacologic treatment of the abscess in the simplest cases may be metronidazole for 10 days, followed by treatment with a luminal agent. Treatment must be individualized for more complex cases or mixed bacterial/amoebic infection.
In the interest of sparing the moderators and listeners a pedantic exegesis on anchovy sauce, I refer you to the terminal references below.
Thanks to all TWiP hosts and participants for perpetually enlightening listening.
Page 160, PD6, “Extraintestinal amoebiasis.” The text emphasizes the very important fact (and one which caused much early confusion: see 1902 British Medical Journal ref), that up to 50% of patients with amoebic liver abscesses do not have antecedent colitis/dysentery.
page 163 PD6: management of liver abscess
Amoebic Liver Abscess and Indigenous Alcoholic Beverages in the Tropics, T. Kumanan, 1 V. Sujanitha, 1 S. Balakumar, 2 and N. Sreeharan 1 J Trop Med. 2018; 2018: 6901751.
Review article from Sri Lanka.
Epidemiology and factors associated with amoebic liver abscess in northern Sri Lanka
Selvam Kannathasan BMC Public Health. 2018; 18: 118.
Clinical and biochemical profile of liver abscess patients, Vineet Jain*, et al. International Journal of Research in Medical Sciences Jain V et al. Int J Res Med Sci. 2017 Jun;5(6):2596-2600 www.msjonline.org
Amoebic Liver Abscess and Indigenous Alcoholic Beverages in the Tropics, T. Kumanan et. al. Journal of Tropical Medicine Volume 2018, Article ID 6901751, 6 pages https://doi.org/10.1155/2018/6901751
“As most of the studies clearly point out, ALA almost always occurs in males with a history of drinking indigenously brewed alcohol beverages in a poor socioeconomic background.”
The patients described by Kumanan are usually from low socioeconomic backgrounds….the palm wine is contamined with E histolytica via poor hygiene and improper sanitary food handling.–> “open air defecation, poor hand washing practices, unwashed utensils at these taverns, and the consumption of unboiled drinking water.” They were unable to culture E histolytica from toddy….the question is the association between ALA and toddy ingestion causal OR incidental? The alcohol content of toddy is 4.5-7%. like the average American beer…. Detailed pathophysiological theories as to how alcohol facilitates ALA
Clinical, Laboratory, and Management Profile in Patients of Liver Abscess from Northern India
Soumik Ghosh, et. al. Journal of Tropical Medicine Volume 2014, Article ID 142382, 8 pages http://dx.doi.org/10.1155/2014/142382
case series. 200 consecutive cases of liver abscess: Majority of them were from lower socioeconomic class (67.5%) and alcoholic (72%). The abscesses were predominantly in right lobe (71%) and solitary (65%). Etiology of abscess was 69% amoebic, 18% pyogenic, 7.5% tubercular, 4% mixed, and 1.5% fungal. Solitary abscesses were amoebic and tubercular whereas multiple abscesses were pyogenic…Conclusions. The commonest presentation was young male, alcoholic of low socioeconomic class having right lobe solitary amoebic liver abscess. Appropriate use of minimally invasive drainage techniques reduces mortality. Overall mortality was 2.9%
Percutaneous drainage of hydatid cyst of the liver: long-term results
KY Polat, HPB (Oxford). 2002; 4(4): 163–166.
Open access. “Previously surgical operation was the only accepted treatment for hydatid liver cysts. Recently percutaneous management has become more preferable because of its low morbidity rate and lower cost.”
Africa, Indonesia, Indian Subcontinent, Phillipines, Southeast Asia, Caribbean, South America….palmyra (fan palms), date palms, coconut palms…Various names: matango, mbuh, tumbu liquor, white stuff, toddy…only 4% alcohol, mildly intoxicating, sweet.,,,In Tamil Nadu, this beverage is currently banned, though the legality fluctuates with politics.
Listeners to TWiV (TWiV 504: Flying foxes and barking pigs) will be familiar with palm wine in relation to the Nipah virus outbreaks in Malaysia and Bangladesh related to date palm sap which is used in the production of tari (West Bengal name for date palm wine).
Nipah Virus Transmission from Bats to Humans Associated with Drinking Traditional Liquor Made from Date Palm Sap, Islam M, Sazzad H, Satter S, Sultana S, Hossain M, Hasan M, et al., Bangladesh, 2011–2014. Emerg Infect Dis. 2016;22(4):664-670. https://dx.doi.org/10.3201/eid2204.151747
The spectrum of hydatid disease in rural central India: An 11-year experience,Siddharth S Rao, et al, Annals of Tropical Medicine and Public health, Year : 2012 | Volume: 5 | Issue Number: 3 | Page: 225-230
Epidemiological Aspects of Liver Abscesses in Children in the Western Cape Province of South Africa, M. K. Hendricks et al. Journal of Tropical Pediatrics Vol. 43 April 1997, Of a total of 84 childhood hepatic abscesses over a 10-year period, 51 per cent (43 patients) were primary pyogenlc, 30 per cent (25 patients) amoebic, 2 per cent (two patients) Ascaris, and 17 per cent (14 patients) were culture negative.
The Animal Parasites of Man, Fantham, Stephens, Theobald, 1920
“Lung abscesses generally arise by the bursting of a liver abscess through the diaphragm into the right lower lobe of the lung, sometimes also through conveyance of amoebae by means to the blood-stream (Banting).
A Discussion On Dysentery Andrew Duncan, W. J. Buchanan, Leonard Rogers, Patrick Manson, W. G. Rockwood, J. H. Musser, Edward Henderson, James Cantlie, Inspector-General Turnbull and F. M. Sandwith
The British Medical Journal Vol. 2, No. 2177 (Sep. 20, 1902), pp. 841-852
available free online read at JSTOR (registration required) SECTION III, BY L. Rogers, Prof. Pathol. Med. Coll. Calcutta: Tropical or Amoebic Abscess of the Liver..”Alcohol then seems to be an important predisposing cause of the disease
Ascaris-induced liver abscess.Javid G1, Wani NA, Gulzar GM, Khan BA, Shah AH, Shah OJ, Khan M.
World J Surg. 1999 Nov;23(11):1191-4.
A total of 510 cases of liver abscess were seen over the 10 years between 1987 and 1997. The etiologies of the abscesses were amebic 20, infected hydatid cyst 15, stone-related 59, ascariasis related 74; 10 patients had subacute bacterial endocarditis, and 3 had pneumonia. In the others no source of infection could be found
Tropical Liver Abscess, Yeoh, K, et.al. Postgrad Med J 1997; 73: 89-92
Open access. A case series of 41 consecutive liver abscess patients in Singapore. 65% pyogenic, 15% amoebic, 5% TB, 15% indeterminate. The authors note the decline in incidence of amoebic abscess compared to a case series 10 years previous to this study- then amoebic abscess topped the list.
“Outcomes of a Conservative Approach to Management in Amoebic Liver Abscess.” Kale, S et al. Journal of Postgraduate Medicine 63.1 (2017): 16–20. PMC. Web. 5 Oct. 2018.
Multimodality Imaging of Liver Infections: Differential Diagnosis and Potential Pitfalls
Pablo Bächler, et.al. RadioGraphicsVol. 36, No. 4, May 27 2016 Open Access
Patients with amebic liver abscess are usually adult and male (10 times more common in men than women)….Aspiration is generally unnecessary in patients with amebic liver abscess (48) but should be considered in individuals in whom the diagnosis is uncertain (where pyogenic abscess or bacterial superinfection of the amebic liver abscess is a concern), in patients who have a failed response to metronidazole therapy (persistent fever or pain after 4 days of treatment), and in patients with large abscesses at high risk for rupture (especially rupture into the pleura or pericardium)…At imaging, amebic liver abscess is classically unilocular, although septa may be present in 30% of cases (50). About 70%–80% of lesions are solitary and are located in the right hepatic lobe, typically near the liver capsule, and may be indistinguishable from a unilocular pyogenic abscess (50)….The mature hydatid cyst consists of three layers (11,54): (a) the endocyst (inner or germinal layer), the living tissue that surrounds the fluid-filled central hydatid cavity; (b) the ectocyst (middle layer), an acellular laminated membrane secreted by the germinal membrane; and (c) the pericyst (outer layer), a thick fibrous capsule corresponding to the host response of the liver parenchyma.
SOME REFERENCES CONCERNING THE ANCHOVY SAUCE / ANCHOVY PASTE CONUMDRUM:
I discourage clinicians from analogizing findings using culinary comparisons, such as, the swelling was the size of an almond, the tumor was the size of a lemon, beefy-red granulation tissue, anchovy sauce pus……The comparisons become vague or uninterpretable in a cross-cultural context. How many listeners have anchovy sauce in their fridges? Or for that matter have ever seen a bottle of the stuff. It’s probably even more unlikely in Tamu Nidal. !–see Kapoor reference below. Additionally, if you look at Google Images of anchovy sauce versus anchovy paste you will see big difference in color and consistency. Most photo’s of amoebic pus aspirate look pinkish, but some references say it is chocolate colored. There is something absurd about the whole topic of anchovy sauce, I just can’t get enough of the stuff.
Surgeons Do Not Cry ,Ting Tiongco 2008
“We read about ‘current jelly stools’ in newborns with intestinal instussusception. And nobody in class, including our old doddering professor, had ever seen a currant, Heck, we didn’t even know it was a berry….It was very funny when the textbook described the contents of an amoebic liver abscess as ‘anchovy sauce like’ and all of us in class tried hard to imagine what anchovy sauce looked like….”
“One of the most familiar objects on the table is the bottle of anchovy sauce. It is always the same sort of bottle — with an angular body and a long, narrow neck. The first man to put up anchovy sauce was Burgess..” 1912, Thomas Russel, System, the Magazine of Business.
You can still purchase a bottle on Amazon.com: anchovy sauce, 190ml, $9.00
Oxford Textbook of Medicine: Infection David Warrell, Timothy M. Cox, John Firth, Estée Török OUP Oxford, Oct 11, 2012 —page 662 has a fine photo of a stainless steel tray filled with anchovy sauce pus.
Hlabisa case book in HIV & TB medicine Dr Tom Heller
Amoebic abscesses produce a semi-liquid “anchovy-sauce” coloured material
Encyclopedia of Parasitology: A-M Springer Science & Business Media, 2008 -860 pages
“The center of the abscess is formed by brownish, semi-liquid fluid which is said to resemble ‘anchovy paste.'”
BTW: This book has some very beautiful line drawings and photomicrographs.
Culinary Medicine—Jalebi Adhesions, Kapoor, V.K. Indian J Surg (2016) 78: 68. https://doi.org/10.1007/s12262-015-1404-7
Culinary terms have been used to describe anatomy (bean-shaped kidneys), pathology (strawberry gall bladder), clinical signs (café-au-lait spots), radiological images (sausage-shaped pancreas), etc. While Indian cuisine is popular all over the world, no Indian dish finds mention in medical terminology. In intra-abdominal adhesions, sometimes, the intestinal loops are so densely adherent that it is difficult to make out proximal from distal and it is impossible to separate them without injuring the bowel resulting in spill of contents—resection is the only option (Fig. 1). Jalebi, an Indian dessert, has a single long tubular strip of fried batter filled with sugary syrup so intertwined that it is impossible to discern its ends; if broken, the syrup spills out—the best way to relish it is to chew the whole piece (Fig. 2). Because of these similarities between them, I propose to name dense intra-abdominal adhesions as ‘jalebi adhesions.’
I really hope that I am not too late, but I have recently been told about your podcast by a coworker due to my, admittedly, sick love of parasites. I am new to this mutualism, so I apologize for my tardiness.
For this case study, with the intercostal tenderness and liver coming down, it sounds similar to an Echinococcus infection. Being that this species tends to aim at the liver as well as the lungs, the lesion and tenderness around those areas sound like the effects of a potential granuloid cyst. The symptom of vomiting and feeling overall ill also help facilitate a possible appearance of Echinococcus granulosis.
I am no doctor, I only have a bachelor’s in biology but I do love parasites and finding your podcast has been filling me with glee, so thanks for that!
Wish you all the best,
On TWiP #113, there’s a discussion of chickens and toxoplasmosis. Some speculation on how chickens contracted the disease followed. The suggestions that the birds might consume contaminated material and/or mechanical vectors certainly seem reasonable. In addition, chickens eat mice and so can become infected directly.
On Amazon there’s a listing for
Molecular study of Toxoplasmosis in biting lice Menacanthus straminus: Pathological changes in infected chickens with lice Menacanthus stramineus & its role in transmission of toxoplasmosis
where it appears the author claims that mites are vectors. I’ve not read the book and so can’t say much more. I’ve not purchased it because $53 for an unknown quantity is more than I can pay — especially for one with typos in the title.
On a separate — but related — note, I don’t remember a discussion of T. gondii in milk.
Detection and survival of Toxoplasma gondii in milk and cheese from experimentally infected goats.
Perhaps milk from infected cows are a source of human infection in India.
Could be interesting to cover some of the lesser known tick borne pathogens since it’s that season again
Deer tick – the Band
I don’t remember tick paralysis having been discussed on TWiP.
S Afr Med J. 1958 Feb 22;32(8):201-2.
Tick paralysis or poliomyelitis.
This topic recently was in the news:
Down the Shore, everything isn’t alright.
In the Parasites without Borders Youtube, Professor Despommier talks about how Hookworms limited the economic recovery of the South after the Civil War.
It would seem though that by the same reasoning the Southern slave economy never would have developed in the first place.
“. . .children typically received no shoes at all. Thomas Jefferson, for example, did not begin issuing shoes to enslaved children until they were ten years old. . . . In the nineteenth century, enslaved shoemakers continued to produce country shoes, while other shoes, called “brogans,” were imported from the North. Wooden-soled brogans quickly developed a reputation for being so uncomfortable and ill-fitting that former slaves, interviewed in the 1930s, recollected casting them off, preferring to go barefoot.”
Slaves must have expended effort at a level that would impress an elite athlete. It would seem that the health of those who were forced to work on plantations was not impaired by parasites. Might there have been some item in the diet or something else that might have eliminated or controlled hookworms?
Test the experts?
Perhaps it might be interesting to hear Professor Despommier and Doctor Griffin tell what caused the dermatitis in the picture. I’ll then send a followup image with the answer.
Background. There’s no foreign travel/residence or domestic activities in forests or in/around bodies of water. I live in the Heights neighborhood of Jersey City and rarely leave the block.
What produced the problem could/should have been obvious to me. Unfortunately, after consultation with Doctor Google, with search results pointing to Disney Rash, I made a mental wrong turn.