Volker writes: 

Dear Twix listeners and fans, 

This is a letter to you. There must be many of us, enjoying the science and banter that Vincent and the team bring to us at least once a week. But if you look at Patreon, only 200 of us have already decided to say thank you by giving a small amount each month. 

Are you one of those many listeners who really like TWIX? Are you fortunate enough that you can easily afford a cup of coffee? Maybe you already considered to become a Patreon? Then please, press pause right now and do it. It is really easy. It will not reduce the number of coffees you will drink. It will make a real difference to the TWIX team! Just imagine if Vincent and the others would only consider to do the podcasts but not actually do it. 

Thank you! 

Greetings from climate change hot Germany, 


Case guesses:

Vic writes:

Dear All,

First of all I would like to hazard a guess about this week’s case.  Due to the hint provided by Dr. Griffin as to the effect of treatment with Metronidazole, and a quick browse of the sixth edition of Parasitic Diseases, I believe the retired doctor was suffering from amoebic dysentery caused by entamoeba histolytica.  Gotta watch out for those peanuts laced with fecal matter…

Secondly, I have a quick cruise ship parasite story.  I work as a Port Agent here in Kristiansand, Norway. One of my primary responsibilities is to arrange medical treatment for sick passengers and crew members. So, over the years I have seen most of the viruses and microbes that commonly plague cruise ship passengers and crew members.  However, up until last week I hadn’t had to deal with a parasite.

Last week, I received a request from the medical center on board an incoming ship to take a crew member to the doctor and fill his prescription for Permethrin cream and shampoo.  I went to the “Felleskatalogen”, which is an online resource where anyone can check the availability, price, and usage for all medications sold in Norway, and searched to see if I could get Permethrin.  I saw that it was available, and then I read the description of the usage, which was a bit unsettling.  

I contacted the ship to ask about the crew member I was about to go pick up and transport in my car.  They told me he was a newly arrived, South Asian, man who appeared to have scabies on his hands when he was examined by the medical center.  To say I was a bit sceptical about hauling him around would be an understatement. Also, I heard from the staff that he was in isolation on board, because they were very concerned about a scabies outbreak among the crew.  

After some back and forth, it was determined that the best course of action was to not go to the doctor, but keep the guy isolated and provide him with the cream and shampoo so he could be treated in his cabin.  I assume that there was also a lot of scrubbing, vacuuming, and disinfecting that went along with the treatment. I was not disappointed to hear that I wouldn’t be doing the same scrubbing, vacuuming,and disinfecting in my car.

Love the podcast!  Keep up the great work!



Suellen writes:

First off, I want to thank all three of you for the animated and informative discussion of my email about Toxoplasmosis and indoor riding arenas in TWIP 172. My hypochondria meter is back down to zero, and I’m no longer worried about inhaling Toxo in the indoor arena!

Now for the case study: This was a tough one for me. I came up with two possible diagnoses, based on the symptoms and probable location where our Navy doctor acquired the parasite (Central America or Caribbean): Balantidium coli and  Entamoeba histolytica, but neither of these will produce a rash on the abdomen. Hmm. Back I went to Parasitic Diseases 7th Edition.

Strongyloides can produce a rash . . . but usually is asymptomatic, and our patient clearly had severe abdominal pain, plus diarrhea and bloody stools. So I’m a little stuck on this diagnosis, frankly, due to that rash. Could it be unrelated to the parasitic infection? Perhaps a reaction Could he have BOTH Strongyloides AND B. coli or Entamoeba histolytica? If so, my heart goes out to him! But I have to discount Strongyloides, since metronidazole is not listed as a possible treatment option.

So I’m going with B. coli, even though the rash still puzzles me. I look forward to hearing what the actual diagnosis is! 



Marcus writes:

Dearest doctors, sorry if this got a bit long.

Hope I’m not too late with my guess. I have finally been catching up on my TWiP backlog after finishing exam season. Been looking forward to this for months now.

Though it may be considered a bit dull; my first thought when hearing stomach pain, sailboat, flagyl and parasite was an oldie but a goodie – giardia lamblia! 

This, however, only rarely causes dysentery. This makes amoebiasis seems more likely. Then again, giardia might cause rashes… don’t think enamoeba does…

Normally asymptomatic, amoebiasis is usually caused by entamoeba histolytica or dispar, and transmitted by the fecal-oral route. The risk of this is particularly high in cramped conditions with less than ideal hygiene and shared uncooked food (peel it, cook it or leave it!). Sexual transmission by same route increasingly common. 

Normally causes abdominal pain and diarrhea with some blood and mucous. In some cases more bleeding and fever (amoebic dysentery). The bleed would likely cause the light thrombocytopenia and with infection the left shift.

Normally the amoeba stays in the wall of the colon, but can eat a way through to larger vessels and via the portal system to the liver, where additional damage is caused. Can in rare cases spread further.

Diagnosis ideally by Antigen-detection or PCR, alternatively by microscopy.

Both bugs are treated initially with flagyl; followed by humatin or furamide to rid patient of remaining protozoa. 

Kind of wish it was giardiasis, since it would allow me to wax poetic on my favourite diagnostic test – the string test. But I’ll have to land on amoebiasis. Either way, the treatment should work.

Still loving the podcast from Levanger Hospital, Norway

Tanto writes:

Clostridium difficile

Courtney writes:

Dear Professors, 

Hello once again from Omaha, Nebraska. I’m writing to you for 3 reasons. 

First of which, the medical history podcast “Sawbones” recently had an episode about Trichinosis  https://www.maximumfun.org/shows/sawbones .  

Secondly, in the previous episode of TWIP (172) Dr. Dickson stated near the end that there are no parasitic bees.. But au contraire, there indeed are. Cleptoparasitic bees are fairly common and they function pretty much like cuckoo birds (these bees are sometimes called cuckoo bees). They go into the nests of other bees, usually closely related species, and lay their eggs. Many times these imposter eggs will hatch before the host, kill the other eggs, and then eat all of the resources. 

Finally, my guess. 

I have to admit when I heard “gastorintestial pain” and “diarrhea” my mind immediately went to cholera. Reason being I was currently reading Pandemic Sonia Shah, a non fiction book discussing pandemics with cholera being the central disease. 

But of course, this case is not cholera. 

So, I googled metronidazole + parasites and that lead me to this NIH article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC89320/.  There it  mentions Giardia and  Dientamoeba Fragilis. While they do have some matching symptoms, there still a few things that don’t quite fit.. Such as the rash and the constipation. 

So I began looking at the tables provided in Parasitic Diseases, finding a disease that was common among fever, diarrhea, and gastritis.  

Trichinellosis is one of the diseases mentioned, but it doesn’t mention anything about constipation or a rash.. But looking at the table again, I see Trichinellosis is associated with leukocytosis.. As mentioned in a previous email, I am not a medicine person, more like an ecologist.   Looking up leukocytosis on wikipedia, I start to see that it does fit with elevated white blood cells and it being shifted left. But, it’s not treated with metronidazole or azithromycin 

So back to the drawing board. 

At this point I wasn’t finding anything that matched up nicely with the symptoms ( had considered babesia and amoebiasis).. Then I started to look at what azithromycin treats in regards to parasites.. Turns out, not a whole lot and even fewer diseases that match our symptoms. 

With this in mind, I think our patient has two infections. I think he has babesia, which explains the fevers and chills and  Dientamoeba Fragilis which would explain the diarrhea and gastrointestinal pain. I chose Dientamoeba Fragilis instead of giardia or Trichinellosis  because these diseases are not treated, or at least per parasitic diseases 7th edition, with either azithromycin or metronidazole.  

All of the symptoms weren’t listed (rash and constipation), but they could be red herrings. 

Thanks for the tricky patient, 

Glenn writes:

Initially I wondered if the patient had amebic dysentery (TWIP 17) in light of the bloody diarrhea and ? response to metronidazole. He could have acquired it during his travels (with a 2-3 week incubation period) or from the other person with “bloody diarrhea” on the boat. On the other hand, there are some additional clues that raise the possibility of typhoid fever (I know it is not a eukaryotic parasite!):

  • The “rose spots” on the abdomen is a classic (but not that common) sign of typhoid fever
  • The patient was initially given azithromycin—although this is active against Salmonella typhi, patients may take several days to respond so the absence of a prompt response does not rule it out. 
  • Typhoid fever is often accompanied initially by constipation, then followed by diarrhea which can be bloody as in this case.
  • “Nuts” may severe as a vector for Salmonella infections (see Guodong Zhang, et al. Prevalence of Salmonella in Cashews, Hazelnuts, Macadamia Nuts, Pecans, Pine Nuts, and Walnuts in the United States. Journal of Food Protection: March 2017, Vol. 80, No. 3, pp. 459-466) and I suppose that—in addition to acquiring an organism during his travels in Central America—the  “bowl of nuts” could well have become contaminated by a carrier.

Honesty alert: I am an infectious disease specialist at a public hospital that cares for a large immigrant population—although we are not “in the tropics” we certainly think of these conditions in our patients who travel from these regions. I recently started listening to your podcasts (including TWIM; TWIP) and have found them an outstanding resource—you really capture of the fun and excitement of ID that made many of us choose the field in the first place. By the way, we have found the Biofire FilmArray PCR based diarrhea panel a terrific diagnostic tool—within an hour it checks for 22 different pathogens including salmonella species and 4 of the common intestinal parasites (E. histolytica; Giardia; Cryptosporidium, Cyclospora). From my point of view, it has revolutionized diarrhea diagnosis and clearly improved our diagnostic acumen.

Whether I am right or wrong (I always say that “medicine is a humbling experience” so that my errors are all too common!), I very much appreciate your podcasts and will recommend them to our ID fellows.

Keep up the good work and thanks again!

Glenn Mathisen MD

Dept of Medicine

Olive View-UCLA Medical Center

Kendra writes:

Hello TWiP professors! It is currently a sunny 71°F or 21°C in Casper, Wyoming. My guess for the TwiP 172 case study is Giardia lamblia.

Giardia lamblia has a cyst stage which enables it to survive in the environment for long periods of time. These cysts are found in contaminated food and water and are spread by the fecal-oral route. They may also spread by person-to-person contact. The cysts are ingested and undergo excystation releasing trophozoites. Trophozoites are the pear-shaped binucleated flagellated protozoa that emerge in small intestine and live on the surface of villi. They will encyst in the small intestine and these cysts will pass with feces. 

Treatments for giardiasis include metronidazole, nitroimidazoles, and tinidazole. Hydration is also very important. 

Giardiasis can be diagnosed by microscopic observation of trophozoites or cysts, ELISA, nucleic acid amplification test, or direct fluorescent antibody test. 

Differential diagnosis includes: irritable bowel syndrome, tropical sprue, inflammatory bowel disease, cryptosporidiosis, traveler’s diarrhea and lactose intolerance. 

Best regards, 



Parasitic Diseases Sixth Edition

NCBI Giardiasis- Noel Dunn and Andrew L. Juergens https://www.ncbi.nlm.nih.gov/books/NBK513239/

Kevin writes:

A basket of deplorable nuts?

Mixed nuts and mixed guts?

Occam’s pen-knife?

Our case involves a retired man (let us assume over 60 years old) doing volunteer medical work in tropical low-resource nations. He lives on a sailboat (currently docked in the Dominican Republic) and has exposure to various crew/employees that come from the regions where he works (one of whom had bloody diarrhea). Clinical picture is sudden intense abdominal pain, fevers and chills, leukocytosis with left shift, constipation followed by bloody diarrhea.. “Rose spots” described on the trunk. Initially treated with azithromycin without significant improvement followed by metronidazole with prompt resolution of symptoms. 

I’ve got a problem with the concept ‘pathognomonic’, (occasionally spelled pathognomic). One problem is that so-called classic signs or oft recited ‘triads’ of symptoms in reality have fairly low predictive value. Even worse is the tendency for such rubrics to activate ‘System 1 thinking’, where the reflexive associative thought process highlights the most ‘available’ memory and swamps slow contemplation. This is all a rewarming of Kahneman’s ideas described in his 2011 book ‘Thinking Fast and Slow.’ Terms such as ‘rose spots’ may immediately activate the ‘availability heuristic’, resulting in activation of closed circuits in my reptilian brain: rose spots equals typhoid and encourages premature closure. It is often more valuable to employ objective language to describe clinical findings,  rather than using leading terms such as ‘rose spots’. This may encourage diagnostic openness. A cumbersome but more objective alternative might state: ‘ Patient with 10-15 blanching pink papules on the trunk, approximately 3-8 mm diameter.’ Almost completely unrelated to the foregoing and mentioned solely in order to prolong this pedantic excursus, I direct your attention to ‘A Terminal Curiosity’ in my endnotes, where past examinations of medical metaphors has been extended, in this case focussing on flower, vegetable and plant metaphors, inspired by the evocative term ‘rose-spots’. 

Speaking of pedantry, I occasionally tire of Occam’s scholastic razor. For this case I prefer him to be armed with a pen-knife, allowing the multiplication of causes. Our patient’s age, location, constellation of symptoms (those rose-spot again), dysentery, dietary habits (that dirty, dirty bowl of nuts) and resolution of illness with azithromycin followed by metronidazole all lead me to conclude that our sailor has typhoid/paratyphoid fever and amoebic dysentery. Rose-spots can be seen in several infections but typhoid is suggested by his initial constipation, intense pain and thrombocytopenia. Medscape turns a nice phrase in describing typhoid as having “notorious gastrointestinal manifestations.” Azithromycin is an effective second-line antibiotic for typhoid, though our patient did not receive a full course. The rapid resolution of his bloody diarrhea with metronidazole is suggestive of Entamoeba histolytica infection. Several references are noted that discuss a protective or facilitating effect of helminth and other infections on typhoid. Another reference hypothesizes that Salmonella enterica infection protects Entamoeba from oxidative stress. I will also attempt to support my dual diagnosis by invoking Osler’s 1907 text where he describes 100 fatal cases of amoebic dysentery, four of whom had typhoid. The patient who is now presumed cured, should have stool/urine culture to rule out chronic typhoid carriage. Stool microscopy, antigen tests or NAAT should be performed to ensure that he does not have persistent amoebic infection. His nut bowl should be discarded, and his employees (and spouse) tested and treated if necessary. A post-script directed to Professor Despommier: Rose spots have been described in trichinosis (see 1985 KK Pun reference below).

Thanks to the glam(orous) positive TWiP-lococci for their relentless non-commercial dissemination of non-fake news.


According to Medscape, typhoid has “notorious gastrointestinal manifestations”…These include diffuse abdominal pain and tenderness and, in some cases, fierce colicky right upper quadrant pain. 

An excellent website for all things skin: https://www.dermnetnz.org/topics/typhoid-fever/

-What are rose spots?   Rose spots describe the rash that occurs in up to 30% of people infected with Salmonella typhi. Characteristically, rose spots are seen in untreated typhoid fever.

-Rose spots usually occur between the second and fourth week of illness.

-Groups of 5-15 pink blanching papules (little bumps) appear on the anterior trunk.

-The papules range in size from 2 to 8 mm.

-They are usually distributed between the level of the nipples and umbilicus, but can also be found on proximal extremities and back.

-Each lasts 3 to 5 days.

-are the result of bacterial emboli to the dermis (can be seen in shigella and non-typhoidal salmonellosis

highest risk for typhoid is in south Asia…

Rose spots and trichinosis–report of a case. Pun KK. Clin Exp Dermatol. 1985 Nov;10(6):587-9.

PD7 tells us: for E. histolytica infection it only takes one cyst…

Enteric bacteria boost defences against oxidative stress in Entamoeba histolytica, Hugo Varet, Scientific Reports, volume 8, Article number: 9042 (2018)

“Therefore, the gut microbiota may significantly influence the host’s immune response and/or E. histolytica’s virulence….Escherichia coli protect E. histolytica from oxidative stress….We found that E. coli, S. enterica and E. faecalis (but not L. acidophilus) protected E. histolytica against OS…”

Modern Medicine: Its Theory and Practice, in Original Contributions by American and Foreign Authors, Volume

Sir William Osler, Thomas McCrae, Lea brothers & Company, 1907

“In the tropics, where amoebic dysentery is so common and frequently…a chronic disease of long standing, concomitant occurrence with typhoid fever, cholera, or tuberculosis, is not so very uncommon. In the writer’s series of 100 fatal cases of amoebic dysentery in soldiers there were 4 cases of concomitant infection with typhoid fever, in 1 of which death occurred from a perforation of the ileum. “

Estimated annual global typhoid & paratyphoid cases: 21 million

Salmonella serotypes Typhi ( S. Typhi) and Paratyphi A, B, and C, are the best described serotypes that cause typhoid fever (TF) and paratyphoid fever, respectively (WHO fact sheet)


Co-infection with malaria and typhoid is very common…Out of the 350 blood samples analysed, 190 (54.2%) were positive for malaria, 173 (49.4%) were positive for Salmonella enterica serovar typhi, while 127(36.2%) were positive for both typhoid and malaria.

Interaction between Salmonella and Schistosomiasis: A Review, Hsiao A, Toy T, Seo HJ, Marks F (2016) PLoS Pathog 12(12): OPEN ACCESS

Review of the phenomenon of dual infection, focussing on sub-Saharan Africa. “Those who are infected by both organisms experience reduced immunological functioning, exhibit irreversible organ damage due to prolonged schistosomiasis infection, and become latent carriers of Salmonella enterica serotypes Typhi and Paratyphi and S. Typhimurium. The sequestration of the bacteria in the parasite leads to ineffective antibiotic treatment because the bacteria cannot be completely killed, and lingering infection may then lead to antimicrobial resistance”

Coinfection with an Intestinal Helminth Impairs Host Innate Immunity against Salmonella enterica Serovar Typhimurium and Exacerbates Intestinal Inflammation in Mice, Libo Su, ASM; Infection and Immunity, Published online August 12, 2014. OPEN ACCESS

Enteric Helminths Promote Salmonella Coinfection by Altering the Intestinal Metabolome Lisa A. Reynolds, et al, The Journal of Infectious Diseases, Volume 215, Issue 8, 15 April 2017, Pages 1245–1254, OPEN ACCESS

…in mice, helminth infections impair host resistance to infection with Salmonella enterica serovar Typhimurium and other infections…In humans, helminth infections correlate with increased severity of tuberculosis, higher Plasmodium burdens during malaria, impaired immunity to Vibrio cholerae, and greater incidence of human immunodeficiency virus (HIV) infection…Typhoid–caused by Salmonella enterica subsp enterica…The full name of a serotype is given as, for example, Salmonella enterica subsp. enterica serotype Typhimurium, but can be abbreviated to Salmonella Typhimurium. The helminth in this paper: Heligmosomoides polygyrus, a nematode that infects mice.

Rose Spots in Typhoid Fever. Litwack, K D et al, Arch Derm, v 105; Feb 1972

“Rose spots noted in 30-50% of cases”….”can be seen in psittacosis, leptospirosis, brucellosis, rat-bite fever, and shigellosis…” “Rose spots may be defined as asymptomatic, rose-red, 2- to 4-mm, discrete, slightly elevated macules which blanch on pressure. Their characteristic distribution is over the anterior surface of the trunk between the level of the nipples and umbilicus, extending at times to the proximal aspects of the extremities and the back. They are usually first seen between the seventh and tenth day of illness, recurring in crops for the next one to two weeks. Lesions are not numerous, usually no more than 6 to 12, and fade completely in three to four days. Occasionally rose spots may first make their appearance at the time of the relapse.”

TYPHOID FEVER, CHRISTOPHER M. PARRY, M.B.,et al. 1770 · N Engl J Med, Vol. 347, No. 22 · November 28, 2002 · www.nejm.org

A few rose spots, blanching erythematous maculopapular lesions approximately 2 to 4 mm in diameter, are reported in 5 to 30 percent of cases….. Typhoid must be distinguished from other endemic acute and subacute febrile illnesses. Malaria, deep abscesses, tuberculosis, amebic liver abscess, encephalitis, influenza, dengue, leptospirosis, infectious mononucleosis, endocarditis, brucellosis, typhus, visceral leishmaniasis, toxoplasmosis, lymphoproliferative disease, and connective-tissue diseases should be considered. For patients in countries where typhoid is not endemic, a travel history is crucial…. The third-generation cephalosporins (ceftriaxone, cefixime, cefotaxime, and cefoperazone) and azithromycin

are also effective drugs for typhoid…”

Hematological and biochemical changes in typhoid fever, Ali Hassan Abro et al, Pak J Med Sci    April – June 2009 Vol. 25 No. 2 166-171

n=75 61% anemia, 40% thrombocytopenia, 10.6% lymphocytosis


As an addition to my discussion of zoological medical metaphors in TWiP 165 and culinary metaphors in TWiP 159 I offer the following list, inspired by the term ‘rose-spots’, with its pleasing floral associations.


heliotrope rash (Heliotropium is a genus of flowering plants in the borage family, associated with dermatomyositis)

framboise (French=raspberry,   the initial primary lesion of yaws)

crops [of lesions, think herpes]

cotton-wool spots (retinal lesions in endocarditis)

ash leaf spot (seen in tuberous sclerosis)

cauliflower ear (ow!)

gin blossoms (slang, and unfair stereotyping of sufferers of acne rosacea)

miliary tuberculosis (resembling millet seeds Latin: milium=millet)

sago spleen (amyloid deposition that resembles grains of sago-granulated starch derived from palm trees)


mulberry molars (associated with congenital syphilis)

cherry angioma

strawberry nevus

peau d’orange

apple red birefringence (microscopy term for amyloid appearance after Congo-red staining)

berry aneurysm

vegetative state

phylloides tumor (rare breast tumor….phylloides=resembling a leaf)

sarcoma botryoides (botyroid= like a bunch of grapes)

amygdala (due to the increase in generalized aggression, everybody seems to be talkin’ about the amydgala lately, the word means almond in Greek)

glans (means ‘acorn’ in Latin)

bamboo spine (seen in ankylosying spondylitis)

prune belly

cardiac vegetations

word salad  (a lamentable non-specfic term that has proliferated of late)

rice-water stools

bean-shaped calcifications are considered pathognomic for lipoid proteinosis. (1975  Radiology 117 302/1)

Ben writes:

Dear hosts of this wonderful Acanthamoeba podcastellanii,

I hope this case guess makes it in time, I’ve been very busy trying to finalise my studies in Germany, so this will be brief. I believe the retired US navy physician is infected with Entamoeba  histolytica. Like Dickson hinted at, the list of potential parasites is narrowed down significantly by looking only at those that resolve with metronidazole. I feel E. histolytica was the best fit, although I would not be surprised if there was secondary infection too. 

Two weeks ago I visited the Berlin Medical Museum (Berliner Medizinhistorisches Museum), and it is an absolute must visit if you’re ever in Berlin. Part of the exhibit includes some of Virchow’s original pathology samples, slides and drawings and there is a lecture theatre that was partly ruined in the war, where he announced his cell theory findings to the scientific community (see picture attached). Another incredibly confronting part of the museum has whole organs, diseased and ‘normal’ for comparison. One thing I found hard to come to terms was that for every single organ they had there, they had either a syphilis or miliary TB infected sample. I never before appreciated how nasty these diseases really could be, and how much of a nightmare it must be for a physician’s differential diagnosis.

We’ve had our warmest day for the year in Hamburg, hitting 34oC, but tomorrow I leave for the slightly cooler climate of the Swiss Alps to attend the upcoming malaria Gordon Research Conference .

Thank you for all your wonderful work, and to all the listeners out there, remember, if you ever feel alone, Demodex folliculorum will be with you every step of the way J



Anna writes:

Dear TWiP trio,

The sailor in the Dominican Republic seems to have a case of Entamoeba histolytica. My guess is based on the rapid response to treatment with Flagyl, and the symptoms being more consistent with amoebic dysentery than with Giardia — which should be easy to recognize since it smells quite distinctive coming out “both ends”. 

A colleague of mine contracted E. histolytica traveling in a low-resource setting and it was quite debilitating. Sadly, it took her a while to get diagnosed after she was back home in the United States. It just goes to show how important it is to make infectious disease education accessible to all — as you are doing with your fabulous postcasts. 

By the way, I’m a long-time listener but am about to move to New York City! So if you do decide to have a live Episode 200 in honor of Dickson’s birthday, I would make a point of being there. It would be great to thank you in person for your outstanding work.



Jimmy writes:

Good evening Three Stooges of Podcasts,

I finished the Twip marathon and working my way through Twiv.  I wanted to discuss many topics from various episodes, but I will start with a recent one, Twip 168. 

We discussed during Twip 168 that bitter flavor receptors are found throughout GI. In many Indian cultures, natural plants have been used to resolve many parasitic diseases. Growing up in India, I had these plants in various forms, and I can vouch for their efficacy. I have provided a few articles which explore these plants’ extract as possible treatments for parasitic diseases. 




Also, found a paper while preparing for my presentation.



Bob writes:

Dear Twip 

There are now reports of a brain surgery where a tapeworm colony was removed


The Initial reports were that the surgeons were removing a tumor from the brain when the discovery took place. 

Ben writes:

Dear hosts of podcasts and parasites,

I would love if you could share this on the TWiP.

There is a Parasitology course run by the Australian Society for Parasitology, called Concepts in Parasitology, running in November this year.

I took the course two years ago and it was absolutely fantastic, covering everything from tongue snatching parasites of fish to electron microscopy of toxoplasma. It is also where I took the toxocara canis image I sent in a few weeks ago.

Down under is a long way to travel for those outside of Australia, but I promise it’s worth it! You’ll stay on the beautiful east coast of Australia and be greeted every morning by more kangaroos than you could possibly dream of.

Check it out at http://www.parasite.org.au/education/concepts-in-parasitology/

Keep up the great work



Octavio writes:

Dear Professors,

The 10 year-old boy is (in my opinion) affected with cutaneous Leishmaniasis (Aleppo boil, Dehli boil, espundia, etc).

The presentation of an indolent ulcer, non-pruritic, not painful, and the geographic area where the patient was consulted is consistent with this disease caused, probably, by Leishmania panamensis, L. guyanensis or L. venezuelensis (other are possible).

Given the (probable) lack of resources to conduct the usual battery of tests that are used to obtain a definitive diagnosis, the use of a Dermatoscope would be of value, due to its inexpensiveness and being a non-invasive method.

Citing Maria Bustamante et. al. (2017)  The polymorphous clinical spectrum of cutaneous leishmaniasis often makes its clinical diagnosis difficult. In this sense, dermoscopy plays an important role as a complementary non-invasive method. The most common dermoscopic findings (almost 100%), described by Lambrich A et al. (2011),5 include generalized diffuse erythema and vascular structures, which correspond to dilated vessels. Other signs are hyperkeratosis, central erosion or ulceration, “yellow tears”, and “white starburst-like patterns”. 

Being a Veterinarian, it’s not correct for me to suggest a treatment, but if this was found on a dog, Meglumine Antimoniate (Glucantime), allopurinol and miltefosin would be the drugs of choice, given in different protocols depending on the International Renal Interest Society (IRIS) staging of the animal’s kidney disease (the most common systemic consequence of the disease, and that is the main driver to the fatal outcome of this disease in untreated dogs).

I would like to include in this email a human case (happened in Portugal) of Panuveítis caused by (you may want to not disclose this if you would like to use it for one of the great “case reports” of Doctor Daniel Griffin) Toxocara and fly larva. It’s a case I use very frequently to increase awarness to dog deworming. Sometimes I have to use some very drastic tools to open people’s eyes (no pun intended)…

Thank you very much for your wonderful work.



Citation is from:  Dermatoscopic signs in cutaneous leishmaniasis*

Annals of Brazilian Dermatology (An Bras Dermatol.) 2017;92(6):844-6. 

And it may be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786403/pdf/abd-92-06-0844.pdf

Octávio Carraça Pereira

Veterinarian from Portugal

Jenny writes:

Hello there.

First off I love your podcast and I am also watching the you tube videos.

I have a kobo now I tried to look for your book on the kobo store but could not locate it.  What other places can I download it from?

Thank you


Anthony writes:

Climate change and vectors

Your colleague Jeff Shaman is a meteorologist.  I don’t know if he focuses on vectors.

A glance here:


shows longitudinal expansion.  Looking at altitude / latitude going up with the thermometer is a great place to start.  There’ll still be forces in place unrelated to climate change affecting population dynamics.  And even with climate change, there’ll quickly be a who’s on first, what’s on second of changes in hosts (e.g. bird migration patterns), humidity, vegetation, pathogens/predators/parasites of the vectors, etc.  These will be the ingredients of a stew of a complex model. 


Anne writes:

Hello TWiP professors and doctor,

Another article extolling the virtue of ivermectin, which I’ve heard mentioned often on your podcast.