TWiP 133: Tape test

May 13, 2017

rhoptryDaniel and Vincent solve the case of the Woman With Anal Area Discomfort, and discuss the multiple functions of a clathrin adapter protein in formation of rhoptry and microneme secretory organelles of Toxoplasma gondii.

Hosts: Vincent Racaniello and Daniel Griffin

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Case Study for TWiP 133

Seen while working in remote mountain makeshift mobile clinic in Dominican Republic, on Haitian border. Traveled 3 h by pickup truck, remote mountain town, womens centers. Set up makeshift mobile clinic in this center. Mother concerned about 6 yo girl, failure to thrive compared with sister, protuberant belly, frequent abdominal discomfort, going on over 1 year. No surgeries, no meds, first time ever seeing medical person. Mother and sister are family. Three children in family. Father does timber work. Very impoverished region, living in dirt floor home, drinking untreated water from local stream, go to bathroom outside, could be contamination. Diet: carbohydrate, plantains, rice, beans. On exam: lungs clear, heart fine, belly protuberant, liver and spleen not enlarged, some edema. Mother said noticed long motile worm in girls feces. Firm belly, not painful to her.

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Music by Ronald Jenkees

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2 comments on “TWiP 133: Tape test

  1. Michael Martin, MD May 21, 2017

    Dear Gamesters of TWIPskelion (Vincent, Daniel, and Dickson in absentia):

    I listened with both amusement and interest to the last TWIPcast, concerning pinworms, and I thought I would send in a general pediatricians perspective.

    I remember hearing from an older colleague when I was but an intern: “Rectal itch? Vermox (mebendazole). Vaginal itch? Vermox.”
    “Shouldn’t I do a paddle test first?”, I asked.
    “Waste of time. The test costs $15 and the Vermox is a quarter.”

    I was confronted with reality this past winter when I had a family who all had pinworms. They had tried several rounds of pyrantel pamoate without success. I tried to prescribe mebendazole (Vermox), which was denied by the insurance company because the pills were now $500 each, and anyway, not available currently in the U.S. They suggested albendazole, which cost a measly $200 a dose. I have since learned that a new mebendazole (EMVERM) will be available, but I have no idea of its price point.

    I must admit, I sometimes make a leap to the diagnosis, as I did in this case, so I was glad that one reader sent in a proper differential diagnosis of rectal itching. I have spent a professional lifetime trying to make sure I at least consider other diagnoses so as to avoid premature closure, a dangerous cognitive bias.

    The case this week also made me jump to a conclusion. As I was listening to the podcast, I concluded that the child had Ascariasis. I was unsure whether the place (the Dominican Republic) was relevant, but that poverty and the lack of modern facilities for the disposal of waste were.

    One further anecdote. When I was first in practice, a mother rushed into the office, hysterical at having discovered a large worm in her toddler’s diaper. I figured it was probably Ascaris, but as she had the worm in a bottle, we sent it to the lab for more expert identification. The report was not Ascaris lumbricoides as we expected, but Lumbricus terrestris, the common earthworm. The solution to the case was the 4 year old sibling, who thought it would be funny to put a worm in his brother’s diaper.

    I wager 100 quatloos that I will continue to listen to TWIP.

    • profvrr Jun 20, 2017

      Missed this great comment! We recorded TWiP 135 today but we’ll read it on TWiP 136.