Dear Doctors TWiP,
My guess for the most recent case study is disseminated strongyloidiasis. A Google search for thumbprint rashes led me to articles about “periumbilical thumbprint parasitic purpura” (“the thumbprint sign”) being a diagnostic criteria for disseminated strongyloidiasis in immunocompromised patients. That led to a Google search for prednisone, which, as I suspected, is indeed an immunosuppressant. Dissemination can occur decades after initial infection, which in her case most likely occurred when she was living in the Dominican Republic.
Although the symptoms listed on Wikipedia don’t match 100%, chronic diarrhoea is on the list, as is a loss of peristaltic contractions, which may explain the decreased bowel sounds. Prognosis is very poor, so I hope I’m wrong, but I’ve enjoyed trying to figure it out.
Thank you so much for everything you do: I’m a big fan!
All the best from Berlin,
Dr. Wink writes:
Dear TWiP Professors,
I am aiming to tie my previous case diagnosis record of one-in-a-row! Here goes…
Profuse diarrhea with dehydration should make you think of cholera. I am going to guess that there are markets of food from the D.R. in Washington Heights; that someone snuck in a product from Haiti into this market; and that our patient ingested a marine food with V. cholera attached to its chiten, imported from Haiti. (The Public Health Service inadvertently re-introduced cholera to Haiti during relief programs. This followed a 100 year absence.)
My second guess is cryptosporidiosis because her steroid therapy for temporal arteritis may make her susceptible to more severe illness.
I don’t get the rash.
The 82 year old woman seems to be presenting a case of Entamoeba histolytica. Her inflammatory diarrhea is possibly due to the parasite’s damaging of the intestine, and as a result, she has been afflicted with weight and appetite loss. E. histolytica can also form skin rashes, and while her liver and spleen may not be enlarged, if the disease is indeed amoebiasis, she should still get this treated as fast as possible to avoid the formation of liver abscesses.
I surmise she contracted the parasitic disease from a careless food worker somewhere in Washington Heights – an area with a population quite high in Dominicans, probably including recent immigrants.
Thank you once again for the informative podcasts.
Hello Team Twip!
In regards to the 82 year old female with the watery stools, I’m at a bit of a loss. The presence of a rash is throwing me off. I’ve heard that ascaris can cause rashes, but with her eosinophils in the normal range, I’d rather lean towards intestinal protozoa over helminths. Giardia can also cause a rash, but that would result in a fatty, smelly stool.
On my list of candidates: Entamoeba histolyitca, Balantidium coli, Cryptosporidia, Isospora, and Cyclospora. I think that the best guess is Cyclospora, but I haven’t heard of it causing a rash. She could certainly have acquired it in the United States, rather than having a very delayed onset if she acquired it in the DR.
hystolitica would be my second favorite of the bunch, seeing as it can cause a rash, but I would have expected to see blood in the stool at least occasionally, and same with B. coli. Isospora seems rather rare, and cryptosporidia is usually asymptomatic in immunocompetent individuals, or at least self limiting.
Honorable mentions: chagas disease can cause megacolon, but that should present with a distended belly and other symptoms. Cholera causes ‘rice water’ diarrhea, but is of course not a parasite. I don’t believe its common in DC anymore though.
To diagnose, check for cyclospora or other cysts/eggs in the stool. I’d also run a stool antigen test for E. histolytica, since the cysts are morphologically identical to other, non-pathenogenic, amoebas.
I’m certainly looking forward to hearing the answer, and I hope the patient fully recovered.
In San Diego, where it DOES get slightly cloudy in the spring.
Dear Twip Trio,
Sorry that I haven’t answered for a while. I just finished my second year in medical school and am about to start my third year. It’s possible that I will even see Dr. Griffin in some of my rotations!
For my diagnoses:
Primary: I am going to guess that this is a case of Strongyloides stercoralis infection. While the patient does not have an elevated white count or an eosinophilia as expected; this may not be necessary if she is being immunosuppresed by the steroid use. Many people can be chronically infected with strongyloides for years and be completely asymptomatic until they lose their ability to fight back and the infection disseminates. The key clue in this case is the “periumbilical thumbprint rash” which when I searched for came up with strongyloidiasis. I would order a stool & ova to confirm. Ivermectin and albendazole could be used to treat.
Secondary: Ascariasis can present similarly to a strongyloides infection and I don’t think it can be ruled out completely by the history. The stool & ova would help confirm if there is co-infection and would help to rule out ascariasis.
Tertiary: Other parasites such as cryptosporidium parvum or cystisospora belli are also possibilities that need to be ruled out. They can both cause diarrhea and can tend to be worse in an immunosuppressed patient; however, I do not believe that they are associated with a specific rash and the patient’s history never mentioned possible contact with fecal contaminated water.
Campylobacter enteritis: Can cause rashes and GI symptoms. Possibly obtained from under-cooked poultry.
Overall, I’d probably give her some IV fluids and electrolyte supplementation and order a stool & ova along with a stool culture.
One question that I have is how tolerant are people to chronic administration to ivermectin? I would expect in this patient, since she already has a history of cognitive decline that the neurotoxicity of ivermectin might be a greater concern.
Hofstra Northwell SOM Medical Student
Class of 2018
Sorry I caught the gap between your TWIP recording and posting last week.
The weather today in Myanmar is 32ºC with 88% humidity.
Not many things cause the described periumbilical thumbprint purpura.
The most likely being a strongyloidiasis hyperinfection.
Anyway, that’s my guess and I’m sticking with it.
At 88% humidity, I’m sticking to everything this week.
Keep up the great work.
Dear Vincent, Dick and Daniel,
Greetings from Caracas, Venezuela, a city where weather is balmy and pleasant most of the year. Our current temperature is 21 °C (annual average temperature 24°C) with no rain for the next couple of days.
As an infectious diseases trained medical specialist working in the tropics, I do enjoy thoroughly all your podcasts, which find not only informative, but most entertaining.
Your last clinical case of an 82 Y/O woman living in Washington Heights NYC, with watery diarrhea and an abdominal rash resembling multiple periumbilical thumbprints, represents a diagnostic challenge even to widely experienced clinicians.
Periumbilical thumbprint purpura is a rare but pathognomonic manifestation of disseminated Strongyloides stercoralis hyperinfection in the immunocompromised host.
The patient has a recent diagnosis of temporal arteritis, a condition that usually requires high doses of corticosteroids for its initial treatment. The latter being a well-known risk factor of disseminated strongyloidiasis. She is from Dominican Republic (presumably from a rural or periurban area), a endemic country where strongyloidiasis is endemic. This parasite has the capacity to produce long-lasting infections due to the mechanism of autoinfection, whereby infective filariform larvae may penetrate the intestinal mucosa or perianal skin, and perpetuate the infection in the host.
Although eosinophilia is a common feature of strongyloidiasis, it is typically absent during the episode of hyperinfection or dissemination. Since disseminated infection entails migration of larvae beyond the pulmonary and gastrointestinal tract; this is often complicated via bacterial gram-negative sepsis due to translocation of intestinal bacteria. Diagnosis is made by the documentation of increased number of larvae in stools, and their occasional finding in samples of sputum, or even CSF.
Lethality rate for disseminated infections may be extremely high (over 80%) unless prompt and effective antiparasitic treatment with Ivermectin is provided.
Again, thanks for your excellent work with TWIP.
Jaime R. Torres, MD.
Dear Twip Team;
It is 105 degrees Fahrenheit at Oklahoma G festival today.
Suspect patient has cryptosporidium infection brought on by immunosuppressive prednisone therapy for giant cell arteritis and New York drinking water? Sorry, but I remember comment by Dixon regarding New York drinking water. (It can’t be that bad, can it?)
Hope you stay cooler than Oklahomans this weekend.
Checking up on on the patient from TWiP 109
Dear TWIP Trifecta
I hope this finds you well and rested after the long Memorial Day weekend. This is just the quickest note to say that I did manage to get to the Bronx Zoo over the weekend and I looked in on the penguins at the Sea Bird Aviary. I couldn’t photograph them because they were all swimming and refused to get out and pose, but here is proof that I was there, because the brown pelicans were cooperative.
Thank you again for your podcast.
Mark writes (case 109)
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.
Greetings from Savannah GA, I am John Mills. I received my bachelors in biology about six years ago and have been working as a GCMS analyst testing soil and water for EPA regulated semi-volatile organic compounds for about four years. Having worked in the chemistry field for quite some time I’ve been interested in returning to the world of biology. Because of my strength in microscopy, I was recently given the opportunity to work for an indoor air quality testing company analyzing asbestos by PLM. Unfortunately this opportunity fell through but it left me with an insatiable appetite for the world of microbiology. This is when I found these podcasts. I started listening to this week in microbiology because at the time it was the subject with which I was most familiar but having listened to all that were available at the time I then tried TWIV. I turned to TWIP to satisfy my need for edutainment. After having listened to all three series TWIP is easily my favorite. There’s something about the quality of interaction the three of you have in TWIP that I greatly enjoy. I think it helps that you all meet in person.
Okay enough for the background and on to the main reason I’ve finally written today.
TWIP has always been fantastically enjoyable but it wasn’t until Daniel joined the team and started doing the case studies that this podcast absolutely changed my life. The inspiration of listening to these podcasts, the void left by the asbestos testing opportunity falling through, the motivation of my wife working on her doctorate in public administration (her fourth degree while I only have one bachelors), and the sensation that I want to make a difference each and every day I go to work, have ultimately encouraged me to go back to school. I am currently seeking a bachelor’s degree in medical laboratory science. Realistically I don’t think I would be doing it without listening to this podcast and it was Caroline’s email from TWIP 109 that finally encouraged me to write in. I am having to reduce my hours at my job so I can start school full time at the beginning of June for some prerequisites and I start my MLS coursework this coming fall. I genuinely can’t wait! I don’t know if I’ve ever been as enthusiastic about something as this.
I recommend this podcast to pretty much everyone I encounter. I never could get this Spring’s anatomy professor to listen. It genuinely has changed my life. Keep up the good work. I suppose it goes without saying I really enjoy the case study segment. I would be interested to see if something could be added to the other podcasts.
Thanks again for all you do.
Seems a bit alarming.
Dear Drs TWIP,
It’s a hazy and HOT 41C / 106F day here in New Delhi, but a much more sane 22C / 72F in the airport transit where I find myself waiting for the 5th and last leg of a milk-run journey to Kathmandu.
Just to get a guess in, I’m going with an ecto-parasite: bed bugs.
Both the sudden appearance overnight and the lack of appearance in flexure surfaces rules out scabies.
Flea bites are smaller and more randomly diffuse rather than large, hard and often linear bites described.
Both bed bug and mosquito bites can appear as raised hard itchy bites, but bed bug bites typically are in areas of of the body in contact with mattress and are therefore more often linear (as described).
Ticks and chiggers more often locate where clothing is tight like a waist band.
You always would want to rule out a food allergy or contact dermatitis (the once-a-week linear abdominal rash . . . has all to often been a high-nickel Boy Scout uniform belt buckle).
Bed bug bites tend to last longer and even look more severe than mosquito bites, which most people can self identify, causing them to be more alarmed.
And after a week of penguin parasites, I’m guessing this is simple bed bugs.
Of course I’m always happy to hear about a new Zebra chase, which makes your collaboration so delightful.
Keep up the good work.
University of the Nations
On the recent TWiP that you criticized the current widespread fascination with food. I, too, have found this disconcerting — yet another sign of the deterioration of the American mind.
With the rise of the Cooking Channel and the other media focus on food. I recalled an anecdote of a patron of a tavern that I ran in Jersey City PG (PreGentrification). The gentleman had been all through the NJ penal system (as luck would have it, often in the company of Hurricane Carter). He related how in prison no matter what program was put on the common room TV, an argument would break out for others almost always wanted to watch something else. The exception was the Galloping Gourmet; every inmate watched this with fascination. He found this especially curious because, though not fancy, there was no fault with the prison fare either in quality or quantity.
I believe the greatest complement I can pay you for your excellent educational service is to plug-in your podcast and expose my emergency medicine colleagues to your entertaining and informative podcast:
Besides writing a monthly article for Emergency Medicine News with my wife Jordana (also an emergency physician), I’m also a novelist. I’d love to send you an autographed copy of my latest medical thriller, “Dr. Vigilante,” soon to be a major motion picture, as a small token of my appreciation for everything you do.
Thank you, and keep up the fantastic work!
All the best,
Alberto Hazan, M.D.
Las Vegas, NV
Author of the medical thriller “Dr. Vigilante” and the preteen urban fantasy series “The League of Freaks”: http://amzn.to/1WJKKH6
Glasgow Romans ate ‘porridge but suffered worms and fleas’
Excavations of a large Roman fort in Bearsden, Glasgow, have provided a rare insight into how Roman soldiers lived at this northern outpost two millennia ago.
“We were very fortunate to discover sewage in a ditch, which was analysed by scientists at Glasgow University and demonstrated that the soldiers used wheat for porridge and to bake bread, and possibly to make pasta.
“It also told us that they ate local wild fruits, nuts and celery as well as importing figs, coriander and opium poppy from abroad, and that they suffered from whipworm, roundworm and had fleas.”
The term June gloom pertains to a coastal California event. During the summer months the fog comes in and doesn’t burn off until about 1100 am. This creates a gray gloomy day until the sun comes out. I really enjoy listening to all of your pod casts.
RN, Infection Control Nurse
“I believe in having an open mind, but not so open that your brains fall out.” Grace Hopper