TWiP 209: A worm in paradise

September 27, 2022

The TWiP team solves the case of the Woman From Hawaii With Allodynia and abdominal pain, bilateral hip and leg pain, dizziness, and diffuse hyperesthesia.

Hosts: Vincent Racaniello, Dickson DespommierDaniel Griffin, and Christina Naula

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Download TWiP #209 (41 MB .mp3, 69 minutes)

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Case Study for TWiP 209

Man in his early 70s with PMH sig for HTN, DM-II, HLD, BPH is admitted to the hospital after coming from Guatemala to visit his son. He feels faint with standing and is noted to have a HR in the 40s and does not feel well when he stands. He is also noted to have diarrhea, but this has been going for an unclear period of time. On EKG he is noted to have a RBBB.


Allergies NKADR

Social -no toxic habits reported, reports living in Guatemala City but grew up in the rural areas. Enjoys fruit juice


Exam: slow heart rate, orthostatic

A number of blood and stool tests are collected and he is referred to a tertiary care center for implantation of a cardiac pacemaker. At the tertiary care center the patient is seen by an Infectious Disease Specialist and a number of tests are ordered by the Infectious Disease Consultant but they are canceled by Cardiologist who writes in their note “no concern for an infectious process”. Now one of the tests collected at the first hospital returns with an interesting result that is later confirmed by a second test.

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Music by Ronald Jenkees

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2 comments on “TWiP 209: A worm in paradise

  1. Heather Kotok Sep 30, 2022

    My question is in an acute vs chronic condition with neuroangiostrongyliasis or other differentials would the eosinophils still be high in a chronic condition? My understanding is Rat Lungworm will die in the body, not complete it’s lifecycle in a human host. In this case the neurological challenges would still exist and not be treatable after the acute stage. Would a diagnosis with the two types of tests still be positive years later, when the eosinophils are not present.

  2. Ayanna Nov 2, 2022

    Case Study for TWiP 209
    Hello from rainy Trinidad and Tobago
    I have quite enjoyed episodes of TWiP
    after being introduced to it by a colleague this summer .

    I am not sure if I am too late or not but I would like to submit my thoughts on this case of a Man in his early 70s with PMH significant for HTN, DM-II, HLD, BPH admitted to the hospital after coming from Guatemala to visit his son.

    Given his age and history of being from rural Guatemala I would want to screen this patient for Chagas’ disease .
    Though it possible that he could be Bradycardic from ischemic disease, his history offers other clues that he more than likely has complications of untreated Chagas’ disease which he would have acquired earlier.

    Diagnosis using thick and thin smear would give evidence of acute Chagas .
    In Chronic infection an antibody test becomes more useful.

    Definitive Treatment in this case would be to pace the patient . One could also look for evidence of mega colon which could account for his gi issues .

    Other treatment is normally nifurtimox or benznidazole. These will help with active infection but will not reverse the complications of disease . I wonder about screening his wife and his son if they lived in the similar environment .

    Looking forward to the discussion of this case .