Case guesses:

Mark writes:

Dear Twip Trio:

You have me very stumped with this case.  Patient lacks eosinophilia which makes parasite more likely a protozoan infection.  Renal failure, hepatic tenderness, normal liver transaminases, but increased LDH, profound hypoprothrombinemia, anemia can be symptoms of malaria, as splenomegaly. Patient’s high lactic dehydrogenase may be a result of hemolytic anemia.  WBC is low or normal in malaria.

Regarding ketotic smell of breath.  Patient probably has insulin dependent diabetes mellitis.  Now malaria can cause hypoglycemia and also in rare instances pancreatitis, and pancreatitis may cause diabetes or a deceased production of insulin, so that body relies on alternative pathways for energy that lead to ketosis?

This is a far stretch. More likely, ketosis could be related to binge drinking of palm wine and other alcoholic beverages which could cause  alcoholic ketoacidosis?  Don’t believe ketosis is related to parasites.

I have more questions than answers and am probably wrong but I am guessing plasmodium falciparum for this interesting case. I look forward to the answer for what is afflicting the young Indian gentleman and his outcome after diagnosis and treatment.

If patient has malaria, treatment options depend on susceptibility.  India is kind of in grey zone as far as chloroquine susceptibility.

Patient may have a serious case of malaria if he has malaria because he has renal failure. Recommendation per CDC is IV quinidine gluconate plus clindamycin or doxycycline or tetracycline.

Don’t know how available these medications are in India, but I have seen Dr Reddy products in my pharmacy.  Dr. Reddy is a large international drug manufacturer based in India.  

Temperature today  in Oklahoma is 85 degrees Fahrenheit. It is Spring but feels like early Summer.  Global warming seems real where I live.


Ruben writes:

Dear Twip-Experts,

As I heard the case, I was immediately struck with patient’s severe eosinopenia since I knew that visceral leishmaniasis may be accompanied by eosinopenia.

However, I suspected that Daniel is unlikely to present the second visceral leishmaniasis case in a row. Another person (say, from another podcast) could have done something like that but not Daniel, who comes across as a really decent and caring person.

That thought left me with a loud and clear diagnosis of severe malaria with the cerebral syndrome caused by Plasmodium falciparum. There is a small chance that it is caused by P.vivax but it is far less typical and the treatment is going to be the same. I learned a bit about malaria from Victor and Ruth Nussenzweig during my tenure at an associate professor at NYU and Courant Institute of Mathematics in the nineties.

Severe form of malaria can develop very quickly and may lead to death. The clinical features of severe malaria listed below match all the symptoms and test results described by Daniel and include: jaundice/bilirubin, kidney dysfunction, anaemia, fever and impaired consciousness. The latter may transition into a coma.

The most intriguing feature, eosinopenia, is also found in severe malaria. According to some authors the eosinopenia is not due to underproduction in the bone marrow, but rather is the result of acute inflammatory response. Furthermore, eosinopenia may be associated with severity of malaria and it was found that eosinophilia associated with an Ascaris coinfection is protective against cerebral malaria.

Treating this patient is tough as he may be about to slip into a coma. The patient needs to be treated with the IV infusion of antimalarials and possibly anticonvulsants and antipyretics. The may be treated with parenteral artemisinin derivatives, such as artesunate, artemether,  alpha,beta-Arteether, – an ethyl ether derivative of artemisinin for at least three days to see progress. Quinine is another option but it may be dangerous. I hope that with Daniel’s help the patient dodged the fatal outcome.

 As a disclaimer I have to say that I everything written above may be utter nonsense since I am a physicist/mathematician and never studied biology, medicine, or parasitology properly.

Keep up your great work, it is a lot of fun for all of us.



Ruben Abagyan, Ph.D.


University of California, San Diego

Skaggs School of Pharmacy & Pharmaceutical Sciences

San Diego Supercomputer Center

La Jolla, CA

Brett writes:


After listening to you guys for the past 3 years I figured it was finally time I write in. I’m in the last month of my getting my bachelors in cellular and molecular biology and  am frantically trying to finish a project in my lab. Which brings me to why I started listening to your lovely podcast, it’s an Avian Parasitology Lab at San Francisco State University!!! We’re focused on avian malaria but my project looks at diversity and prevalence in the islands off of Papua New Guinea. I had no prior knowledge of parasite when I joined the lab and TWIP has helped me immensely over the years! THANK YOU!!!

So, let’s see if I’m close at all with my diagnosis…

My Guess:

This could be a double infection (or triple!). Of course my initial thoughts go to Malaria (i admit i am biased for that) but I don’t feel like that would explain the dry cough and decreased urination. But Ah HA! this is where i think i land my breakthrough. Could this be a schistosome infection? Perhaps with malaria? And finally the last option, Visceral Leishmaniasis.

My logic is as follows:

Schistosoma japonicum- Although normally found in China and the Philippines, I think could of come into the northern part of India and possibly contaminated the water he drank. Especially, if just after the rainy season, fecal contaminants (or possibly even the snails themselves) were flushed into a drinking source. I couldn’t find any literature on whether the Oncomelania (the snail intermediate) is in India, but it is in China.

Plasmodium falciparum- The fever, chills, vomiting, and general body ache in India will always make me think Malaria. The acute and virulent nature of this make me think it’s falciparum.

The thing bugging me through all of this case study was the eosinopenia. Wouldn’t either schistosome or plasmodium infection lead to an increase in eosinophils?

I asked the Professor in charge of my lab, Dr. Ravinder Sehgal, and gave him the symptoms I could remember off hand. He agrees with my P. falciparum diagnosis but think schistosomes would only be caught if he was swimming in the contaminated water. But another Ah HA moment! He suggested that it could be Visceral Leishmaniasis as this would explain the swelling of the spleen and liver as well as the weird blood cell counts.

To confirm one of these I would run an ELISA for both Leishmania and Schistosoma japoicum, as well as do a blood smear and giemsa to see if one could find Plasmodium. This could all also be done using PCR, but a blood smear can be done quickly and cheaply.

You all have been a great inspiration to me over the years and although I’ll be moving to Ann Arbor, Michigan for a Masters in Molecular Cellular and Developmental Biology, I’ll still be in contact with my lab to discuss the latest TWIP!

Keep up the wonderful work and sorry for the horribly long email,

Brett from SF State


David writes:

Dear TWIPstars,

I started out late for this one, and again, I am preparing for failure.  I still have to listen to the latest TWIV episode, but I know failure is an inherent part of the learning process.  One cannot make an omelet without breaking eggs, and anyone who ever learned a second language will confirm it takes many mistakes before some fluency arises.  The same goes for the science of life.

The case you presented was seemingly simple, but I went back and forth and can’t come up with a definite and certain diagnosis.

The jaundice, bilirubin levels and enlarged lvier indicate that liver and bile are affected.  I dived into the liver flukes.

Fasciola appeared at first glance to be the most reasonable option, being passed by freshwater snails, but it does not seem to present itself in India.  The geographical is way off, otherwise this would have been my preferred option.

Another parasite that kept coming back in my research was clonorchiasis, but then the man should have eaten raw fish, and there is no mention of it.

I tried a symptom checker, and liver cancer or bile duct cancer topped the list, which again are associated with cholorchiasis and Opisthorchis Viverrini (the latter one presenting in SE Asia, not North India).  But as the case was considered a “fun case”, I also hope the diagnostic was not so gloomy.

My guess is therefore Ascariasis, as it is also associated with fever, jaundice, and can present hepatomegaly in some cases.

I guess I really miss a point.  Especially the darkening of the skin was a symptom I did not encounter for any parasite.    I eagerly await the moment that TWIP108 goes live.   Thank you so much for stimulating my curiosity continuously.

Waiting for rain in hot and humid Nicaragua,

Yours sincerely,


PS I called your efforts relentless in an attempt to complement you.  I would certainly be happy if I was labeled relentless in my efforts, but I may well miss the finer intricities of the English Language, not being a native speaker.

P writes:

Hi: I really enjoy listening to your expertise and continually learn from it.

Concerning the case study for #107 I am guessing protozoa with an emphasis on e histolytica based on several symptoms including the jaundice since it is known to invade the liver.

Caleb writes:

Greetings Doctors,

I was curious about where I could find a 6th edition of the Parasitic Diseases book. I had a 4th edition of the book but I gave it to my father-in-law who is a Neuropsychiatrist, who through my talking about your show had become extremely interested in parasites. He always tells me that if he were to be able to go back, he would have become a Infectious disease Doctor instead of a neurologist. I have found copies of the 5th edition on Amazon, but I would love to have an updated version of the book.

I love all of your shows and tell everyone I know about them whenever I get the chance.


Caleb Hubbard

Ph.D. Student: Medical and Veterinary Entomology

Anthony writes:

Large-Scale Range Collapse of Hawaiian Forest Birds under Climate Change and the Need 21st Century Conservation Options


Hawaiian forest birds serve as an ideal group to explore the extent of climate change impacts on at-risk species. Avian malaria constrains many remaining Hawaiian forest bird species to high elevations where temperatures are too cool for malaria’s life cycle and its principal mosquito vector.  . . .”

# # #

“…  malaria parasites of birds have played an essential role as a model in human malaria studies.”

To lose (any more) unique birds of Hawaii in itself would be tragic.  The mosquito challenge because of climate change is something that many people will soon see, too.  Perhaps the study of an avian disease and the insect vector will be as useful now as it was for Sir Ronald Ross.

Thank you.

Caroline writes:

Hello everyone.

I just wanted to send a note to Daniel thanking him for calling out the importance of a laboratory in twip 108. I’ve worked in a medical laboratory for 17 years and we are definitely the under-recognized profession. I’ve had physicians ask me if we “actually needed a degree for that”? All certified Medical Technologists or Clinical Laboratory Scientists (unless they are grandfathered) must have a bachelor’s degree and have completed a clinical year in a hospital-based training program (which includes chemistry, toxicology, hematology, blood bank, microbiology, and immunology). Most are ASCP certified. Some have Master’s degrees. MTs work under pathology, microbiology and chemistry doctoral staff. Medical technologists are supported by many highly skilled support staff such as MLTs, lab assistants, and phlebotomists.

So thank you Daniel.

I have included a link with a pretty accurate explanation of the Medical Technology profession.

Twip is my favorite but I love all 4 Twix!

Caroline, MT(ASCP)

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