Case guesses:

Wink writes:

Dear TWiP team,

I missed you Dixon! You would have asked about sandbox play. Paul emphasized outdoor exposure, and for a 4 year-old that might include playing in the sandbox or dirt and putting his fingers in his mouth. Baylisascaris is the most feared agent here because it effects the nervous system. Toxoplasma gondii wouldn’t cause pulmonary edema with an intact immune system. But I looked up Toxocara canis and I saw that it can cause myocarditis, so I’m going with that!

Daniel, you may be interested to know that one of your listeners was one investigator who showed atovaquone’s efficacy for toxoplasmosis and P. carinii, as we called it then.

[Torres RA, Weinberg WG, Stansell J, Leoung G, Kovacs J, Rogers M, Scott J. Atovaquone for salvage treatment and suppression of toxoplasmic encephalitis in patients with AIDS. Clinical Infectious Diseases, 1997; 24:422-9.

Dohn MN, Weinberg WG, Torres RA, et al. Oral atovaquone compared to intravenous pentamidine for Pneumocystis carinii pneumonia in patients with AIDS. Annals of Internal Medicine, 1994; 121:174-180.]

Wink Weinberg

David writes:

Dear Twip folks!

After hearing the symptoms of the 4 year old child from “Paul” on Twip 109, I make the reserved diagnosis of Babesiosis.

The symptoms are consistent with previous cases of babesiosis; the increased respiratory rate, increase in liver enzymes, even the the pulmonary oedema. The child was also stated as being “depressed”, which I took to mean fatigued, suffering lethargic “flu-like” symptoms. Furthermore, Paul stated that the symptoms manifested themselves in spring in a North Eastern region of the USA and that the child was actively outdoors. With temperatures warming up following winter, the Ticks responsible for transmitting the disease would be waking up for another year.

No other members of the extended family appear affected like the 4 year old child – again, fitting with the 4 year old being the unfortunate recipient of a one-off tick bite spreading the Babesia.

The reason my diagnosis is reserved is due to the lack of anemia or jaundice reported in the child. Although jaundice doesn’t necessarily manifest in cases of Babesiosis, I was under the impression that anemia is a normal symptom.

I think the raw fish consumption is a red herring.

I’ve seen that pulmonary oedema can occur in cases of ascariasis and schistosomiasis, but I ruled these out due to the lack of eosinophilia. But here’s my wildcard: Toxoplasmosis. Not a tropical disease per se, so in fitting with the disease occurring in North Eastern USA. But the kicker is that active T. gondii infections have also been associated with pulmonary oedema. Perhaps the stated “depression” was meant literally and provides evidence of a psychiatric disorder resulting from toxoplasmosis…

Keep up the great work guys, I look forward to the next installment of your insightful show.

David Smith

Final Year PhD Student,

John Dalton Lab,

Dept. of Parasitology,

School of Biology,

Medical Biology Centre,

Queen’s University Belfast,

Belfast, UK.

Johnye writes:

I’m putting myself out there for the universe to know how little I know about parasites and emergency medicine. 13C and cloudy. JB

The patient is described as:

A previously healthy 4 y/o M, presenting, in the “spring time”, “depressed and lethargic with a little bit of increased (inc) RR”; afebrile.  “Relatively acute” onset; not eating as well as usual with perhaps some weight loss, but “not significant[ly]”. No diarrhea. Radiograph looks like “pulmonary edema.” No known ill contacts. Dietary hx positive raw fish consumption by child and family; no raw frog meat.


o   Was there vomiting? What did his stools look like; had there been any changes in frequency or color?

o   Interval between eating raw fish and onset of sx?

o   Was this the first time the child had had raw fish? Did he eat at the same time as everyone else?

o   Source of fish; usual place or new source?

o   Other vital signs esp O2 saturation in in room air and a description of his respiratory effort.

o   Was there anything that helped child look or feel better?

o   What had caregivers tried?

o   Did the family have an explanatory model? Had these sx ever been seen before in other children or adults?


Elevated white count due to a relative lymphocytosis; nl RBC and Hct; no eosinophilia

Other labs:

o   Blood drawn for markers of inflammation?

o   U/A

o   Stool or rectal guaiac

Radiograph: “Looks like pulmonary edema.”

o   I don’t really know how to interpret that. I would need to discuss with radiology and perhaps pulmonology.

o   Is that pediatric specific or an adult comparison?

o   Does it mean fluid accumulation in the lungs, associated with inc RR, dyspnea, hemoptysis, edema, abnormal breath sounds? Pulmonary edema isn’t something I would expect to get back as a reading in an otherwise healthy child without a significant cardiac history. I really don’t know what to make of the study in the context and manner presented.


Takes vitamins; no surgeries (and presumably no hospitalizations).


  •    Immunization hx: ___
  •    Lead level: ___
  •    Last PPD: ___

Travel Hx:

No reported travel outside the Bronx or contact known contact with recent travelers within extended family and community.  Plays outdoors.

Fam Hx:

Reported as negative, presumably non-contributory; no one ill, no known exposure to infectious diseases.

  •    Any possible exposure to chemical toxins from adult work environments brought into home?

Social Hx:

Lives in an extended family and community in the Bronx.

  •    Is his community primarily composed of individuals from a particular country or region of the world? Where do they typically buy their foods?

Child Care:

Unknown if at home with family member during the day, or in a center or home childcare setting, or playgroups.

Pet Exposure: Unknown

PE: How “depressed and lethargic” was child? How arousable?

Systems I would want more detail about:

  •    Oropharynx:  
  •    Conjunctivae  
  •    Lymphadenopathy:
  •    Neck supple?
  •    Work of breathing: Any retractions, grunting or nasal flaring; comfortable in room air?
  •    Abdomen: Any other abdominal signs: bowel sounds; tenderness; guarding; masses?
  •    Skin: Rashes, perfusion, “not jaundiced”.

So from the history and physical exam, I’m clueless.

Next step: Call the ID fellow for a stat consult, please.

Based on Google and UpToDate searches (I don’t have the current Red Book at home.), there are 3 taxa of pathogenic parasites transmitted through raw or poorly preserved fish, nematodes or round worms; cestodes or tapeworms; and tremadoes or flukes

Anisakis spp. and Gnathosoma spp. are nematodes;

Diphyllobothrium spp. is a cestode;

Clonochris sinesis;  Opisthorchis spp; Heterophyes spp; Paragonimus spp.

Based on history and findings presented:  

Anisakis doesn’t seem likely; while vague abdominal sx may be present for weeks, more pronounced, severe sx occurs when the gut wall is penetrated and the worms enter the peritoneal cavity and the development of peritoneal signs on physical examination.

Gnathostoma has the potential to cause “creeping eruption” and may reach the eye or CNS. “When someone eats the parasite, it moves through the wall of the stomach or intestine and liver. During this early phase, many people have no symptoms or they may experience fever, excess tiredness, lack of appetite, nausea, vomiting, diarrhea, or abdominal pain. Initial phase 2 – 3 weeks, but may have manifestation weeks or years later.” CDC

Not high on my list, but possible, given sx at what might be a still early stage.

Diphyllobothrium latum: “the fish or broad tapeworm; most infections are asymptomatic, complications include intestinal obstruction and gall bladder disease caused by migration of proglottids (each segment in the strobila of a tapeworm, containing a complete sexually mature reproductive system…”Diagnosis is made by identification of eggs or segments of the tapeworm in a stool sample with a microscope…” but may take weeks before eggs or proglottids can be seen or found. CDC

“A fish tapeworm, from raw fish that harbors viable plerocercoid larva. Infection usu asymptomatic but diarrhea and fatigue may occur. Ova or proglottids in stool

Tx with praziquantel or niclosamide (?not available in US)” Both drugs may be used in children.

This is a strong favorite of mine.

Opisthorchis liver fluke infections and Clonochris sinesis

“The acute symptoms of O. felineus infection consist of high-grade fever, malaise, anorexia, diarrhea or constipation, dull pain and discomfort in the upper right quadrant of the abdomen, arthralgia, lymphadenopathy, and urticarial skin rash.

Diagnosis of liver fluke infection in this outbreak was confirmed by identifying ova in stool…”

Not likely.

If pushed, and the ID fellow has not returned the page, I would say Diphyllobothrium a likely dx and treat with praziquantal 5 – 10 mg/kg x 1dose, and repage the ID fellow, or call the ID attending or call Dr. Dan! No indication of megalobalstic anemia, but would follow MCV, along with stool for O & P x 3 until neg.

Interestingly there is a Pediatric Praziquantel Consortium actively working on an “orally disintegrating tablets (ODTs) or fast dispersible tablets, administered as a single dose, to treat children aged 3 months to 6 years” for schistosomiasis.

This was not quick, and more difficult, without the comforts of a more complete physical, history, lab studies, conversation with the radiologist. Hopefully my diagnosis and treatment, if incorrect, would not have caused any harm.

Looking forward to the analysis and answer. Hope Dr. Despommier is back for the discussion and can weigh in.

Johnye Ballenger, MD Primary Care

Mark writes:

Dear Twip trio and Paul:

My guess is pleuropulmonary paragonimiasis.  Though patient ate raw fish, and not crustaceans, he could have been infected with paragonimus via contamination of eggs on fish handlers hands. Peripheral eosinophils may not be evident in a small number of pleuropulmonary paragonimus cases and lymphocytosis with T cell predominance may be a symptom of paragonimus infections. If patient has paragonimiasis treatment is with prazequantel.

One symptom I don’t understand is the high respiratory rate.

I am probably wrong in my guess, but thank you for interesting case.


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