TWiP 147 letters

Case guesses:

Erik writes:

Hello TWiPanosomes,

I very rarely write in the guess the TWiP case of the week because I very rarely feel confident in my guesses. However, this week I feel like I just might have the right answer. On initially hearing the symptoms that Dr. Griffin was describing, my mind flashed to dracunculiasis because of its classic manifestation as a skin lesion on the foot. But then the travel history didn’t include trips to the Old World, ruling out that particular parasite. So I started thinking about parasites of Central/South America that might cause skin ulcers. I recalled a little bugger called Tunga penetrans, or the ‘sand flea’, which burrows into the skin causing a lesion or ulcer. But when I read descriptions of the ulcers caused by Tunga penetrans, they didn’t fit Dr. Griffin’s description. T. penetrans ulcers usually have a central black dot, and also they’re not all that big (certainly not 4 centimeters). Then, finally, it came to me. This could be nothing other than cutaneous leishmaniasis. Leishmania can be found in both the Old and New World in tropical and subtropical regions. Manifestations of the disease are the presence of a non-healing, raised ulcer which can easily reach 4cm in diameter. Having been outdoorsy on his trip to Costa Rica (and probably barefoot since he was whitewater rafting), it’s easy to imagine that the patient may have been bitten on the foot by a phlebotomine sandfly carrying the parasite. After a bit of reading, it seems a fairly standard treatment for cutaneous leishmaniasis is amphotericin B, and perhaps an antibiotic to prevent secondary infection of the ulcer.

Hopefully this wasn’t too ham-handed a response. I’m a virologist not a eukaryotic parasitologist. But I love the show! Keep up the good work.

Peter writes:

A cháirde

Sending this from a cold, bright and blustery Dublin, Ireland. High of 6-7 C. I wrote in before Christmas which resulted in the question did James Joyce go to Trinity College Dublin? Vincent correctly said he went to University College Dublin. Not to be out done by my colleagues in UCD, Trinity can boast of other literary greats such as Deirdre Madden, Bram Stoker, Oscar Wilde and Samuel Beckett. Ian Donohue in our department sometimes uses Beckett’s quote “In the landscape of extinction, precision is next to godliness” to great effect during his presentations, including when speaking of his recent paper he wrote with Montoya and Pimm (2018) Planetary boundaries for biodiversity: implausible science, pernicious policies. Trends in Ecology and Evolution 33: 71-73. A thought provoking paper that may interest you.

In my quest for precision in tackling the case studies, I often wish somebody else in our parasitology group would come into the lab, when I am listening to them, so I could avail of their expertise. So today I sent around an email saying ten minutes before coffee break, I would be listening to the case study in the coffee room, if anyone would be around. I was lucky enough to be joined by Gwendoline Deslyper, who does great work investigating the proteins that are produced in the liver during Ascaris infection (http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0004837) and Juliette Piccard, who does exciting work with Maureen Williams, using an Acanthocephala model to answer the question does parasitism interact with warming to modify energy flow in ecosystems? From proteins to ecosystems, hopefully a broad enough spectrum to tackle the case.

During an enjoyable discussion we came to a diagnosis. After ruling out botfly, due to the description of the wound, we settled on a species of Leishmania. This was due to the physical description of the wound and its development, the time it took to appear and develop and that it was painless. The patients travel history to Costa Rica and insect bites also agree with Leishmania. To confirm it is Leishmania and identify it to species level we would carry out PCR. Species identification is important as treatment will be species dependent, as some species found in Latin America may spread to the mucus membrane. Hope we are right but had a lot of fun coming up with our answer.

For a pick of the week I suggest this great piece of science journalism on parasites in the NYT https://www.nytimes.com/2018/01/16/health/toxocara-children-new-york-playgrounds.html

Great to hear about the parasitology heroine Marietta Voge in the last episode and really enjoyed her quote.

Is mise le meas,

Peter Stuart

Trinity College Dublin

Carlo writes:

Hi Twip Trio,

My name is Carlo and I am a long time listener. I’m currently a med-peds resident very interested in infectious disease.

My differential for the 27 yo male lawyer with a R foot ulcer who recently came back from Costa Rica is Localized New World Cutaneous Leishmaniasis, Dracunculus medinensis, cellulitis, and pyoderma gangrenosum, and atypical mycobacterium.

Per Parasitic Diseases 6th edition, Leishmania forms “large, painless craterform ulcers”. This is most likely the cause of the ulcer given the description of the ulcer and his recent travel history to Costa Rica. Another parasite that can cause cutaneous ulcers is Dracunculus medinensis, but the travel history is not consistent as it is prevalent in central Africa, the middle east, and India. Less likely to be bacterial cellulitis due to the chronicity and lack of erythema, swelling and systemic symptoms. Also, less likely pyoderma gangrenosum as there was no reported history of inflammatory bowel disease or GI symptoms. Atypical mycobacterium less likely as no recent exposures and no history of immunosuppression.

To diagnose Leishmaniasis, a sample should be sent for culture, microscopy or nucleic acid amplification testing from the margin of an active ulcer that is not obviously superinfected. He most likely has L. panamensis or L. braziliensis.

He should have a nasal and oropharyngeal exam to make sure he does not have nasocutaneous involvement. He may be treated with localized therapy including cryotherapy, thermotherapy, topical paramomycin or sodium stibogluconate.

Looking forward to the next podcast, keep up the great work!

Lucian writes:

Dear TWiPsters,

For this week’s case study, I would suggest Leishmania. From the downloadable copy of Parasitic Diseases, Leishmania infection produces large, painless ulcers that start as a papule. The parasite, transmitted from the bite of a sand fly, is present in the New World, including Costa Rica. 2–8 weeks after being bitten, a papule forms which, as infection progresses, turns into a large craterform ulcer as the intracellular parasite induces cell death. The ulcer can take weeks or months to heal. (All of the above is from the very excellent book).

Based on his current symptoms: a large, painless craterform ulcer with raised edges that has been present for a month that started as a papule following a trip to Costa Rica, I believe the fellow has a Leishmania infection. In addition, the ulcer has not spread to other parts of the body and is not painful, as might be expected from bacterial infection.

Given that Costa Rica is North of the so-called mucosal belt, there is probably no need for systemic therapy. Cryotherapy might be sufficient to resolve the infection.

All the best!

Iosif writes:

Dear Twip Team,

My guess for this case is cutaneous leishmaniasis. Unfortunately, our patient was likely bit by an infected sandfly. Topical paromomycin treatment can be given.

Sincerely,

Iosif Davidov

E-mailing from Kisoro, Uganda

Trudy writes:

Hi TWiPers,

I think the lawyer has cutaneous leishmaniasis. This would be consistent with the fact that he wore sandals and was subjected to lots of insect bites. So, he was most likely bitten by an infected sand fly. As I understand it, there is usually no treatment necessary, as the infection resolves on its own, resulting in life long immunity.

Trudy

Harrison writes:

Hello good doctors. I am a junior studying public health and I love this podcast. This is my attempt at a differential diagnosis for the male patient from episode 146. The painless foot ulcer with raised borders could be bacterial, decubitus, or parasitic. Bacterial foot ulcers might be caused by S. aureus or beta hemolytic streptococci. These infections are common in diabetic patients or ones with reduced circulation in the foot and leg. The diagnosis is usually done clinically and based on the presence of purulent discharge and signs of inflammation. These are painful and do not have predominately raised edges. A decubitus ulcer is caused by prolonged pressure on a small area of the foot. This could have been caused by the patients teva sandals but the prolonged pressure would be from days of wearing and not hours. Lastly I come to the parasitic causes of foot ulcers with raised borders and minimal surrounding erythema. Being that this is a parasite podcast I will use this as my final diagnosis. My first idea would be a parasite that is transmitted by flying insects. Based on the patient reporting that he had many insect bites I think this is new world cutaneous leishmaniasis. According to the 6th edition of Parasitic Diseases and information from the CDC, the disease starts as a small red papule about “2-8 weeks after injection of the metacyclic promastiogotes.” The sand fly is the primary source of infection but I assume other biting insects could cause this (Dickson please correct this if I am wrong). Sand flies become infected when they suck blood from an infected animal or human. Diagnosis is confirmed by PCR or isolation of the organism. The edges of the ulcer can be scraped and then sent to pathology for identification. Healing of the lesion may be spontaneous and require no medication. If there is concern of a mucosal disease Azoles or sodium sitbogluconate my be used. Currently prevention is limited to decreasing the breeding sites of the sand fly and avoiding activities when the flies are active. The use of insect repellent and clothing treated with an insecticide will also offer more protection.

I enjoyed writing this and I hope that I have correctly diagnosed this infection. Thanks for the bi-weekly education and entertainment.  

All the best,

Harrison Nobles

East Carolina University

Public Health Studies

College of Health and Human Performance

Sara writes:

Dear Podfessors,

As promised in my very first TWIP email last episode I am going to join in the case study guessing. Hopefully this will be the start of a pattern and I can refresh my parasite knowledge on a more regular basis – and hone my detective skills in the process.

Hearing Daniel describe the case of the 27 yo male lawyer I could only think one thing: cutaneous leishmaniasis. Whether this was because of my ignorance of many other suitable parasites or because of my instant recognition of the correct culprit remains to be seen!

The description of a painless ulcer with raised borders which started its life as a papule combined with the travel history and timings led me to decide on a cutaneous New World leishmaniasis as my diagnosis, but in an effort to procrastinate more at work and send a more substantial email I decided to scroll about in my free copy of Parasitic Diseases and regurgitate your own words back to you for the education of other listeners.

The patient mentioned he had been in Costa Rica a month or so prior to consultation with the purpose of enjoying some whitewater rafting. Unfortunately for him, being a fit young man does not exempt you from getting insect bites and as he has confessed to wearing sandals and has presented with a lesion on his right foot, I went ahead and assumed a sandfly (Lutzomyia being the vector species in the Americas) had located the slightly inadequately protected area and managed to inject some metacyclic promastigotes.

To confirm my diagnosis, a sample would need to be taken from the margins of the lesion where the organisms dwell and this could be analysed in a variety of ways – PCR (the current bane of my lab life), microscopy, culturing (difficult in the lab as some past colleagues can attest to), NAAT or histology. A correct diagnosis of the causative species can be very important (the lesions caused by different species are difficult to distinguish) as some may have the potential to cause mucocutaneous leishmaniasis.

Although seemingly the wound remains non-healing for a very long time, cutaneous leishmaniasis can resolve itself eventually (given proper wound care and hygiene), however, treatment options exist and include local cryotherapy with liquid nitrogen/ thermotherapy or systemic treatment with pentavalent antimonials, amphotericin, miltefosine or azole drugs. The choice depends on the severity and location of the lesion(s) and the species involved (species with mucocutaneous potential, identified more often in Brazil, Bolivia & Peru, might merit systemic treatment). For systemic treatment, side effects, resistance and cost (less problematic for returning travellers than patients in poorer local communities) must be carefully considered.

I hope I have done myself justice with this first guess, especially since I was “fortunate” enough to see a cutaneous Leishmania case during my time at university when a friend returning from an expedition in South America came home with a large lesion on her face. Contrary to what you might think, she was less disturbed by her misfortune and more fascinated by the progress and eventual healing of the lesion – a true scientist and parasitology student! She credited the excellent advice and treatment given to her by NHS doctors and nurses in Glasgow for her calm dealings with the parasites, and I have to agree and say the knowledge of tropical diseases here is just remarkably good. Perhaps it is because we like to think of tropical places as the relentless rain rules the world outside our office windows, even if it means having to think of disease-causing parasites?

Anyways, that’s my guess and Leishmania musings. Apologies for the lengthy email, but I’d like to leave you with a few last thoughts:

–      Thanks to the TWIM-team for confirming my suspicions that what you pronounce as “sonometer” indeed means centimetre – really helps with the case guesses!

–      Thanks to the listener who wrote in with a female heroine – I had never heard of her before and now I have! – and thanks to you for making her your episode hero. I look forward to seeing her and other cool heroines in PD soon!

–      Finally, I also look forward to Vincent convincing his wife to come on one of the podcasts to talk about her career and life balance etc., it would be great to hear from her. Add my voice to those calling for an appearance.

Many thanks and until the next case,

Your faithful listener and new correspondent Sara in Glasgow

Sara Elg

Centre for Virus Research,

Glasgow

Suellen writes:

I have not taken a shot at the case studies in a while, but now that I’m all caught up on TWIV I thought I’d try my luck with this one — the case of the 27 year old NY lawyer with the open sore on his foot.

I spent a good deal of time with my Parasitic Diseases 6th Edition PDF, and the most likely candidate I could find was cutaneous leishmanaisis. However, the description of the disease does indicate that the papule should be around 1 cm, not the 4 cm that is reported in the case, and that there should be more than one ulcer. So I might not be correct in my diagnosis.

Still, the description given in PD6 does seem pretty spot on: “The typical lesion seen in cutaneous leishmaniasis is a nodule that enlarges into a painless ulcer with an indurated border,” so I’ll go with that.

Also want to add that I really enjoyed this past episode — I enjoy them all, but this one was especially fun because around the 48th minute or so Daniel and Dickson started totally geeking out over malaria as only two totally dedicated parasite fans could do. I listened to that part twice, it was so great.

I have to give all of the TWIX podcasts props for helping me decide to change careers at this rather late point in my life. After spending almost 30 years as a database administrator, I decided to take a sabbatical and try something new. I’m studying phlebotomy at the moment, and hope to get a job in a hospital or health care facility after I get my certification. I am lucky enough to not need a big income, but I do want to do something that interests me. So keep those podcasts coming, keep geeking out over parasites, and keep inspiring people like me to try something new!

Melissa writes:

Hello hosts of the TWIP universe.

Here is my guess for the TWIP 146 case study about the 27 year old lawyer with the 4cm ulcer on his right foot:

I was not sure if I was going to send in a guess for this episode, but when I was looking through the PDF of Parasitic Diseases at the photos, I came across a photo of a white fibrous circle on someone’s big toe and I remember one of the clues we got was “white, fibrous coating” on the ulcer.  I glanced down at the caption and it said Tunga penetrans. This got me thinking, so I opened up CDC’s site and searched for “Tunga.”  A couple clicks later, and I’m reading about how the female flea burrows into the skin of the host to feed on blood and leaves its posterior sticking out.  During this time, the female is producing more eggs and expands in size, which would cause the ulcer to get larger.

CDC says that Tunga penetrans is found in tropical and subtropical regions of the world, which would include Costa Rica.  Normally, in those regions, the flea is found in areas with sand.  If the patient went white water rafting, I can see the shores of the river being the perfect place for the flea to be introduced to his foot, especially since TEVA sandals don’t offer much side and top of feet protection.

Treatment for this is to surgically remove the flea.

I can’t remember if you do listener picks on TWIP, but while browsing the CDC page, I noticed that they have case studies: https://www.cdc.gov/dpdx/monthlycasestudies/2017/index.html

For any of your other listeners who can’t get enough case studies, they may want to take a look at the case studies that CDC posted (the answers are also provided, so there is no waiting for the next podcast).

Sincerely,

Melissa

Melissa Ly

Associate Biosafety Officer

University of California, San Diego

David writes:

Dear and estimated professors,

As always I listen with great joy to your program.  If the world is a stage, the twip podcasts combines comedy in the friendly interaction between the hosts (e.g. where Dickson gives thanks to the small people) with the tragic reality of parasitic infections.  Last year I seemed to experience a consistent lag in processing the podcasts, and consistently was too late to write in.  When I missed yet another case with my favorite eosinophilia (because it has a self limiting range of causes and I sort of have a decision chart worked out by now), I decided to assign the next case a higher priority.

I must admit that the tell tale signs of the athletic youngster’s infection after a visit to Costa Rica also made me feel quite confident that the case is one of cutaneous leishmaniasis.  I read through the introductory section in parasitic diseases and the following chapter on CL, and this only reinforced my first hunch. What a great reading, and what a wicked parasite, manipulating the human immune system with foul trickery!  You even managed to insert the Cuban diaspora of emigrants who fled first to Ecuador (I believe) to go over land through Columbia and Darien (which is really a jungle), only to be blocked on the border of Costa Rica with Nicaragua by the devious power of geopolitics.

Concerning treatment, I am not quite sure how I should interpret the text (I have no formal medical background after all).  Would it be enough to keep the wound clean?  Or did you freeze the ulcer with liquid nitrogen?  Finally – I did not read this, but I am curious: does it make any sense medically to use anti inflammatory drugs to keep the immune system in check?

Saluting you from a windy Jinotepe, Nicaragua,

Warm regards,

David

Louis writes

Dear esteemed TWIP hosts,

First of all, thank you for the informative and interesting podcast which serves as a highlight to my commute.

This week’s podcast appears to have proposed a case that, strangely enough, a parasite enthusiast without special training might be able to diagnose. Based on the description of an ulcer on the patient’s foot, it appears our patient has contracted Cutaneous Leishmaniasis from the bite of a sandfly while rafting in Costa Rica. The depressed ulcer with raised edge and lack of pain are strong indicators of CL, though a definitive diagnosis through isolation of the organism or PCR is recommended.

In this patient’s case, an accurate species-level diagnosis (using nucleic acid amplification testing) is important, since L. braziliensis is a likely culprit. For Old-World Leishmaniasis, local treatment may be indicated, but L. braziliensis, found in the New World, has a 2-10% chance of metastasizing to the patient’s mucocutaneous junctions and forming the dreaded Mucocutaneous Leishmaniasis, even after the original ulcer heals. As such, a systemic therapy would be indicated to ensure the patient doesn’t develop ulcers around the mouth or worse.

If any of the above sounds familiar, most of it is paraphrased from the free downloadable version of Parasitic Diseases.

Thanks again for all you do,

LouisP.S. It is unclear from Parasitic Diseases whether the ulcer associated with CL is painful. This may be a good clarification to add in the next edition.

Jaime writes:

Dear TWIP paladins, or should I say “The Three Amigos of Parasitology”,

Greeting from Caracas where, perhaps as a compensation to our current worsening economic and political climate, weather this time of the year is the closest it could be to perfection (blue clear skies, average temperature 18C with a highest of 24C and a lowest of 13C).

Again, thanks for the fantastic job you perform in producing such an entertaining and informative podcast, which has a vast and loyal global audience. Even for an Infectious Diseases and Tropical Medicine Specialist like me, each episode brings plenty of useful information and challenges our clinical skills, particularly when Dr. Griffin deftly presents interesting clinical cases from remote or unique geographic locations.

In regard with your last case of a 27 Y/O male lawyer with a painless ulcer gradually developing on his right foot one month after whitewater rafting in Costa Rica, the diagnosis appears to be straightforward.  The first diagnostic consideration should be cutaneous leishmaniasis. However, since there are no specific morphologic features that are pathognomonic for cutaneous leishmaniasis, the differential diagnosis in a patient with this type of exposure may include, among others: staphylococcal skin infection, cutaneous neoplasm, pyoderma gangrenosum, sporotrichosis, chromomycosis, cutaneous tuberculosis, atypical mycobacterial infection, syphilis, yaws, and loxoscelism.  A definitive diagnosis can be accomplished by identification of the causative parasite. A Giemsa-stained scraping or punch biopsy taken from a cleaned lesion provides an adequate sample. Identification is also performed by culture, or PCR.

Leishmania is a parasite with a complex life cycle involving wild animal reservoirs and vectors. The common species of Leishmania spp., in Costa Rica belong to the subgenus Viannia: L (V.) panamensis is the most frequent and occasionally, L. (V.) braziliensis. Common vectors are Lutzomyia lephiletor and Lutzomyia ancistrura [Telmophage insects, as I learned thanks to TWIP 138…]. The principal reservoirs of the infection in the country, according to studies, include sloths (Bradypus griseus and Choloepus hoffmani) and a rodent (Heteromys desmarestianus).

A nice rhyme provided by a recent review article may be useful to promote greater awareness of cutaneous leishmaniasis among care practitioners unfamiliar with the subject. It goes as as follows:

 

A global traveler begins to unpack

And on his leg finds an ulcerated plaque.

The possibilities are many,

Numbering far more than 20.

Leishmaniasis is a lurking issue,

So the savvy physician tests the tissue.

 

Pentavalent antimonial drugs have been the mainstay of treatment for more than 50 years, remaining the most popular treatment. Two antimony compounds, sodium stibogluconate and meglumine antimoniate, often lead to clinical cure in less than 1 month. However, these drugs are far from ideal because of the inconvenience of obtaining them, emerging parasite resistance, long treatment course, parenteral route of administration, and serious side effects and toxicity.

Finally, the Tropical Medicine Committee of the Pan American Association of Infectious Diseases (API), which I happen to coordinate, would be much interested in making the PDF version in Spanish of the sixth edition of Enfermedades Parasitarias by Dickson D. Despommier, Daniel O. Griffin, et al., available to our affiliates. Although it is currently downloadable for free at the Web page of Parasites Without borders, we would like to know whether or not is also necessary to ask for a formal authorization from the organization, in order to upload it, with the due credits and acknowledgements? By the way, I call your attention to a minor, but very evident mistake in the cover and first page of the book.  The correct spelling in Spanish is “Sexta Edición”, not Sexta Edoción as it mistakenly appears.

Looking forward to enjoying your next TWIP episodes,

Jaime Torres

Tropical Medicine Institute of Caracas

Universidad Central de Venezuela

David writes:

Dear Hosts,

I believe the 27-year old lawyer from New York is suffering from cutaneous leishmaniasis brought on by an infection with Leishmania – most likely L. panamensis or possibly L. braziliensis. In Costa Rica, there is an apparent absence of L. mexicana which is typically the causative agent of New World cutaneous leishmaniasis (https://www.ncbi.nlm.nih.gov/pubmed/7330931), and most cases in Costa Rica appear to have been stemmed from L. panamensis. In the New World, cutaneous leishmanisis is spread by sandflies in the Lutzomyia genus.

The man’s growing, red, ulcerating, nontender lesion with a raised border and white coating match the image of a cutaneous ulcer spurned, and the timing of the infection – with the ulcer appearing a month after exposure to sandfly bites – fits the diagnosis as well. The treatment for cutaneous leishmaniasis has been highly debated by researchers and doctors alike, and typically topical paromomycin has been issued to those who suffer from cutaneous lesions.

Thank you once again for the informative and entertaining podcasts.

Sincerely,

David P.

Gretchen writes:

Dear twipome,

First of all, thanks for taking the time that you put into edutainning all of us.  You and the other TWiX podcasts make my time working an assembly line bearable.

I just finished listening to the most recent episode, and there was an error that I simply can’t overlook. Don’t worry it was in an email, not anything y’all said. The emailer who described the Dax character in Star Trek got the process a bit muddled.

Dax is the Symbiont (“parasite”) that moves to a new host, only at the end of its current host’s life. And it’s not really a parasite, once it is implanted in the Trill host they integrate into the central nervous system, and the host can’t live without them. The Trill are the humanoid alien species that these Symbionts coevolved with. On the Trill home world the Symbionts can breed and live without a host for an extended time. In Star Trek: Deep Space 9 Jadzia is the Trill host that carries the Dax Symbiont and is known as Jadzia Dax.

I know this email is a bit rambling, but if we hold you to quality and accuracy standards in what you say, I believe it is only fair that we licensees hold each other to the same standards.

The weather here in Mentor, Ohio is an unseasonably warm 60F with a chance of rain later.

Thanks again for the podcasts,

Gretchen K.

Be nice to Dixon.

Dave writes:

Hi everyone,

I love TWiX, especially TWiP. Perhaps a bit surprising since my background is in Electrical Engineering (lasers, electronics, and such). My only (single) biology class was in High School and, as I recall, it consisted almost entirely of memorizing Genus-Species names of seaweed. Not a great incentive to continue, at least for me. How I wish one of you would have taught that class instead! I then went on to study the physical sciences at CalTech, where, frankly, there wasn’t a lot of time or opportunity to branch out from your major. But now many decades later I am making amends. Keep up the great work.

Anyway, today I saw an article about a Canadian couple that contracted Hookworm while vacationing in the Dominican Republic. After their return and eventual diagnosis, they found that Health Canada would not give them access to Ivermectin.

“In terms of treatment, the couple was told they could take a drug called Ivermectin, Stephens said. Their doctor sent Health Canada a request for the medication, as it’s not licensed in Canada, which included their case files and photos of their feet. Stephens said they were expecting to receive the drug this week, but they received some unfortunate news from their doctor on Tuesday.”

“We found out that Health Canada had denied our request to receive the medication saying our case wasn’t severe enough. At that point, that’s when we freaked out a little,” she said.”

“Instead, Zytner’s mother had to drive to Detroit and pay CAD$88 to pick up the medication for the couple. Zytner and Stephens said they took the medication for two days.”

WTF? You can’t get Ivermectin in Canada? I give it to our dogs every month in California.

Regards,

Dave

Palo Alto, CA

Noah writes:

Dear TWiM Crew,

This is my third time writing in. I adore your all of your work. When I was struggling to wrap my head around the enormous world of microbiology, you were there for me. I have just graduated with my BS in Microbiology and Cell Science. I am hoping to receive your book because I have applied to join the Peace Corps to work as a health extension volunteer in Cambodia. This decision was in large part because of Dickson. I love hearing tales and anecdotes from the raconteur’s storied career, and I hope to be able to accomplish a fraction of what he has accomplished in his. I have equal respect for Dr. Racaniello, and the rest of the crew, but the stories stand out, and I think it’s awesome that Dr. Despommier practically bootstrapped himself into a new career in Urban Agriculture once the world had deemed its T. spiralis problems to be relatively solved.

That said, a couple of my professors have been less than enthusiastic about my choice to volunteer for the peace corps. The commitment is two-to-three years, but in this time they say I should continue to be working away in a lab and apply to grad schools. I do not want to join the Peace Corps at the cost of my career in science. I am the sort of person who obsesses over the biochemistry of my lab work and wants try to conceptualize every problem in abstract algebra in case there is some algorithm to optimize the process that nobody else has thought of, so I need my scientific outlet. Do you guys know how I can do science in the field and keep my career moving forward on all fronts? If you were my boss, and I were going into the “bush,” is there anything that you would want to know that I could tell you? In the meantime, I am applying to bench jobs, but should I also apply to run the flow cytometer in the core lab facilities? It pays really well, but I doubt I would have the opportunity to contribute to any papers as an author in that capacity.

Also, Dr. Despommier said that with contemporary molecular methods he could have accomplished so much more over the course of his career. I know he also said that there was not much funding for Trichinella spiralis, but it is super interesting to me to know the sorts of hypotheses that he would jump at the chance to interrogate if he woke up one morning and were suddenly 24 again in the Information Age.

Grateful for any and all of your thoughts, Noah

P.S.: When I was first listening, imagine how disappointed I was when I went to R2208 ARB and Dr. Condit was nowhere to be found.