Kay Schaefer joins TWiP to solve the case of the German Male with Hematuria, and discusses Tropical Medicine Excursions, which provides patient-oriented training courses for healthcare professionals who wish to improve their clinical skills in tropical medicine and travelers’ health in the endemic regions of Uganda, Tanzania and Ghana.
Still in Uganda but now in a clinic in Entebbe. A boy, less than age 10, who grows up in very limited conditions, dirt floor home with other siblings presents with recurrent right upper abdominal pain, fevers, and first undergoes blood work that shows eosinophilia. He has an abdominal ultrasound performed which shows what looks like a mobile piece of spaghetti in the gallbladder with dilated ducts. He also has a stool examination performed.
A 49 y.o. German male is seen with significant gross hematuria. He reports no travel outside Europe but does report that he visited France twice, 7 years before and 1 year before. He reports swimming in the Solenzara River in the southeastern part of the island, near a busy campsite. He might have gone into the Gravona River in western Corsica near Ajaccio, at a turtle park and near a campsite, and at the Tavignano River. The patient also reported swimming in the Restonica River. He reports never swimming in the Cavu River and using GPS data from his smartphone and camera, he reconstructed his bathing sites precisely and this history was confirmed.
Exam was unremarkable. Complete blood count was unremarkable and did not show eosinophilia.
This complaint triggered cystoscopy and biopsies that were sent for histological analysis. These findings triggered referral to the Tropical Medicine department at LMU Hospital Munich.
Now in the next episode we will have a guest to discuss this case as well as tell us a bit about themselves. I am hoping people will tell us what they think this might be but then perhaps do a bit of research and go into a little more detail.
14 year old boy with a history of slow progressive development of abdominal ascites over years. Appears wasted and malnourished. Afebrile, no history of weight loss or night sweats, no history of TB exposure, HIV negative. Had an older brother who died the year before of apparently the same disease. Had lived early life by the shores of lake Victoria. Currently has really impressive abdomen.
Man in his 20s originally from Mali who comes in with a dermatological complaint about 1 mo after he returned from spending time in Bamako, Mali with friends and family. Reports this has been going on for months and he is getting very frustrated as he is not getting any answers. He relates that this started with itching over a “blackhead” resembling a pimple that was itchy and very small. Over the subsequent months it started to get larger with ongoing itchiness but no pain. No erythema or warmth in the area. Other lesions developed in addition to the first one. There was no drainage from the skin lesions. He started putting triple antibiotic ointment on his lesions that he bought from a pharmacy.
He then went to his primary doctor who prescribed a topical medication and PO antibiotics but this did not help.
He reports that when in Mali he stayed in his house with his parents, siblings, grandmother and other extended relatives – more than 40-50 people under one roof. food made by his family, reports consumption of only cooked meat, no uncooked meat. Ate salads and uncooked vegetables. No contact with any animals, no pets in the home. Denies any contact with any pets or farm animals such as pigs, cows, horses, cattle. Denies swimming in any lakes or ponds. No hiking or outdoor activities. No riding horses.
Was sexually active in Mali with women and is HIV negative.
On examination he has a 10 cm lesion over anterior L thigh, with verrucous and vegetative appearance with yellow crusting over central area and heaped up lesion, not undermined. No erythema, warmth or drainage. Has a similar smaller lesion measuring about 3 cm on R flank. Has a 3rd smaller lesion with some mild crusting and about 2cm over R posterior thigh.
He ends up getting a biopsy that reveals:
HISTOLOGIC FEATURES That ARE NOT DIAGNOSTIC. THERE IS NO EVIDENCE OF any specific organisms. THE EXOGENOUS MATERIAL WHICH COULD REPRESENT SOME TYPE OF FOREIGN BODY IS NOT IDENTIFIABLE AS PART OF A FLY OR ARTHROPOD, NOR IS IT TYPICAL OF A SPLINTER AND ITS PRESENCE IN THE SPECIMEN MAKES IT PROBLEMATIC AS TO ITS SIGNIFICANCE. MICROSCOPIC DESCRIPTION: WITHIN THE DERMIS THERE IS A DENSE DIFFUSE MIXED CELL INFLAMMATORY INFILTRATE INCLUDING MANY PLASMA CELLS AND NEUTROPHILS. THERE IS EXOGENOUS MATERIAL. PAS, GMS, FITE AND GRAM STAINS ARE NEGATIVE FOR INFECTIOUS ORGANISMS.
Additional testing is ordered that leads to the diagnosis.
He is planning on returning to Mali and perhaps sooner than originally planned if he does not get a diagnosis since he thinks the doctors in Mali would know what he has.
From ASTMH2022 in Seattle, Aisha joins the TWiP team to talk about her training and her career, including delivering a baby on an airplane, and they solve the Case of the Heartsick Guatemalan Septuagenarian.
We are consulted about a rash. A male in his mid 60s originally from Hong Kong with PMH of T2DM, Hypertension, BPH, Hepatitis B infection, COPD (not on home o2), current smoker, ESRD with right chest cath on dialysis (MWF) presented to the ED c/o progressive SOB and DOE for 1 week. 2 weeks prior the patient missed 1 session of hemodialysis. Progressively worsening SOB, DOE, orthopnea began to develop starting one week ago with an associated productive cough with white sputum. Last dialysis was session was 3 days PTA. Pt also began developing nausea and vomiting for 3 days x12 times last week. Pt also started developing diarrhea. Pt has states to have a notable generalized pruritic rash for 3 months that has been worsening. He reports he has been seen by dermatology and was told that the rash is due to certain allergies from food and has been using an unknown cream for 1 month that does not relieve his symptoms. Pt recently admitted for management of bleeding permacath and acute hypoxic respiratory failure likely 2/2 COPD requiring intubation and vent support. Denies recent travel, recent antibiotic use, or sick contacts…but his nephrologist reaches out and is concerned about a certain diagnosis as he says three other patients that come for dialysis have recently been diagnosed with a certain diagnosis.
On exam ee has a diffuse symmetrical rash and is scratching the while time. On careful examination there are small linear scabbed areas between his fingers.
Man in his early 70s with PMH sig for HTN, DM-II, HLD, BPH is admitted to the hospital after coming from Guatemala to visit his son. He feels faint with standing and is noted to have a HR in the 40s and does not feel well when he stands. He is also noted to have diarrhea, but this has been going for an unclear period of time. On EKG he is noted to have a RBBB.
PMH HTN, DM-II, HLD, BPH PSH neg
Social -no toxic habits reported, reports living in Guatemala City but grew up in the rural areas. Enjoys fruit juice
Exam: slow heart rate, orthostatic
A number of blood and stool tests are collected and he is referred to a tertiary care center for implantation of a cardiac pacemaker. At the tertiary care center the patient is seen by an Infectious Disease Specialist and a number of tests are ordered by the Infectious Disease Consultant but they are canceled by Cardiologist who writes in their note “no concern for an infectious process”. Now one of the tests collected at the first hospital returns with an interesting result that is later confirmed by a second test.
An adult female resident of Hawai’i presented to the emergency department (ED) with several days of fever, abdominal pain, urinary hesitancy, and generalized itchiness. white blood cell [WBC] count 14,000 cells/mL) without eosinophilia. Urinalysis suggested a urinary tract infection and she was treated for acute UTI and discharged home.
The following day she returned to the ED because of worsening abdominal pain, bilateral hip and leg pain, dizziness, diffuse hyperesthesia, and allodynia (Pain from stimuli which are not normally painful) (worse on her feet and legs.) Urine culture from her initial ED visit grew normal urogenital flora. Her leukocytosis increased and she now had eosinophilia (WBC count 15,500 cells/mL; absolute eosinophil count 574). Laboratory evaluation was otherwise unremarkable. CT scans of the brain, abdomen, and pelvis were normal.
She was hospitalized and her allodynia worsened despite treatment with analgesics. She also developed a sensation of “electric eels swimming through [her] body. Electromyography and nerve conduction studies were normal. The patient underwent a lumbar puncture and CSF examination was notable for eosinophilic meningitis with 138 WBCs and 13% eosinophils (absolute eosinophil count 18).
Claire joins the TWiP team to discuss her training and experience as an infectious disease physician, and her transition to science communication, then we solve the case of the Honduran Male with Seizures.
Woman in 20s, spent time in Kenya 6 months prior, vomited up a worm. 0.5 cm in length. Sent to lab. Was moving. Earlier that day she went out with friends to sushi place, ate fish. Developed horrible abdominal pain, then vomited.
42 yo Spanish speaking male, originally from capital city of Honduras. Admitted to hospital after seizure. Grew up in Honduras, 20 year history of seizures. Now in NYC area. Treated with carbamazepine, 2x a day. Has not filled scrip for 3 months. Fast heartrate, o2 sat fine, no fever. No surgery, no toxic habits. Unremarkable physical exam. Undergoes blood work and head imaging. CBC normal, normal diff, slight elevation in blood glucose. Imaging of head reveals non-specific coarse calcification. Eats regularly.
Two women, 80s and 50s. Former had 9 children, lives in Ghanian village with large lagoon, many mosquitoes. Concerned about chronic swelling of left leg, groin area for much of her life. Walks barefoot. 50 yo with 4 children, both legs started to swell, cold, mosquito bites. With time left leg becomes hard, swollen, disfigured. Has gone to hospital for ulceration. Common problem in her village, mostly women but some men. Problems getting access to medications.