Colorado State University’s Uncultured Microbe Society writes:
Greetings from Colorado; we hope everyone on TWIP is doing well. Here in Colorado with it being the start of March, the weather is getting more pleasant. The trees are growing back their leaves. Just simply put, its awesome. Now to discuss something that is also awesome…. The episode 253 of TWIP. Regarding the case presented, our guess is schistosoma. To get an idea of what species, we would request more information on the location of the spine on the egg that was mentioned. We would also be curious if the patient had spent any time in river/lake water which could have been the route of infection from the cercariae. We felt that the location of the patient, the abdominal pain and elevated AST and ALT all fit for this parasite. We were stumped on the cause of the cough which, we now think after doing some research is from what is called Katayama syndrome which can be an acute sign of schistosomiasis. For our treatment of the patient we would prescribe praziquantel. In regards to management the two medications mentioned of Augmentin and Coartem seem to be for bacterial infections and for malaria. Both of which would not treat the schistosomiasis. We were also curious if they did a urine sample exam for any eggs. When they did the stool sample, did they use Fecal sedimentation? Anyhow, thanks for another amazing episode and look forward to the next one.
Sincerely,
Colorado State University’s Uncultured Microbe Society
Srenanthan writes:
Trypanosomiasis in acute presentation
Srenanthan
James writes:
Hola Twipolitas,
I am writing to you from a cold but clear and sunny Manchester, England.
Firstly, I was so sorry to hear of Dickson’s passing. I am sure lots of people will be writing in with tributes, so I will try to keep it brief. The Dickson-Vincent dynamic in the early episodes was the reason I got hooked on this podcast and why I subsequently developed an interest in parasitology. The patient and seemingly all-knowing but never pretentious Dr. Despommier paired perfectly with the inquisitive and sometimes mischievous Dr. Racaniello. Listeners of early episodes will remember Vincent bemoaning that he had to “be nice to Dickson or we are going to get mail”. I think we all knew the teasing came from a place of friendship and respect, but it just reflects the audience’s affection for him. It really felt like we were being taken on a journey with Dickson as the teacher and Vincent as our fellow student. As many have alluded to in their tributes, Dickson had a gift for storytelling, which is what made him such a great teacher. He’s taught me that just because I’ve finished my formal education doesn’t mean I have to stop learning. His passion for all things interesting shone through and was infectious, he will be greatly missed by us all.
I first wrote into TWiP with a case guess just a few episodes ago for the case at the end of episode 249, but my last-minute entry didn’t quite make the cut. As I mentioned in the email, I am a junior doctor in the UK, currently busy preparing to sit the second part of the Royal College of Physicians membership exams while applying for internal medicine training. I’m trying to do the case guesses without consulting the internet to test my knowledge and see what I’ve learned. But I’ll keep it short as I’ve got to get back to studying…
Dr. Griffin’s cryptic description of lack of eosinophilic clearing is a little perplexing, although I do recall a similar description in the case of a lady from the DR with disseminated strongyloidiasis. However, we currently have no reason to believe this young lady is immunocompromised, and there is no evidence of a secondary bacteraemia on the blood cultures. Hence, I take this to mean there is some significant degree of blood eosinophilia present. Nonetheless, blood eosinophilia and ova in the stool in West Africa means we are dealing with some kind of helminth. The bilateral CXR infiltrates would, therefore, likely be due to migration to the lungs, probably with associated pulmonary eosinophilia. Given that Dr. Griffin surreptitiously mentions “nice places to swim” in the local area, I would lean towards acute Schistosomiasis, also known as Katayama fever. This would fit clinically with her acute febrile illness, pulmonary infiltrates, transaminitis, and I think schistosomal ova would be seen in the stool exam. Maybe the first hospital treated her incorrectly with albendazole or mebendazole, suspecting another helminth, and then she was treated with praziquantel after the correct ID and recovered.
Looking forward to hearing the answer,
James
Håkon writes:
Greetings TWIP Team,
Returning book winner here, thought this case sounded interesting and wanted to try and weigh in. Before we get into it however, I just wanted to briefly offer some insight into some of the trypanosomes discussed in the last episode.
The horse STI trypanosoma of horses you were discussing is T. equiperdum (Dourine disease), not T. evansi (Surra disease). While T. evansi is an incredibly interesting pathogen for multiple reasons, perhaps the most fascinating interaction it has is its ability to not only parasitize vampire bats but to then use them as vectors to transmit back into other animals. Kind of neat! Whereas T. equiperdum is exclusive to horses and has no vector.
This week’s case seems like a case of schistosomiasis in our unfortunate traveler who was assumed to have malaria. Proper medication of praziquantel likely helped and given the bitter taste likely caused the vomiting.
Thanks again,
Håkon
Kimona writes:
Dear TWiP team,
Pardon the length, but you hinted at including a differential…..hopefully I’m not too verbose.
Malaria despite diligent chemoprophylaxis, is always in the differential for a febrile illness in tropics – but less likely after repeatedly negative blood smears and treatment with Coartem.
Cryptosporidium hominis is found worldwide and can clinically vary from asymptomatic to profuse diarrhea with abdominal cramps. It’s oocysts are found in stool but it is often self-limiting in healthy people.
Giardia lamblia is also seen worldwide and cysts or trophozoites can be found in stool but this presents mainly with diarrhea and steatorrhea and perhaps less fevers and acute illness. It is also often self-limiting or can be treated with a nitroimidazole drug.
Entamoeba histolytica is a protozoan whos cysts and trophozoites are seen in stool and has an intestinal phase producing diarrhea, colicky abdominal pain and fever. If it spreads hematogenously it can reach other tissues, most commonly forming abscesses in the liver and, by extension, pulmonary involvement. Perhaps this was the diagnosis at first hospital and her vomiting in the ER was triggered by a nitroimidazole. She would thereafter have been given an intraluminal agent, like paromamycin, to prevent continued spread. An ultrasound at that time may have shown liver abscesses. But E. histolytica is difficult to distinguish from E. dispar (non-pathogenic) on microscopy and could have served as a ‘red herring’ in her original diagnosis.
TPE (tropical pulmonary eosinophilia) can develop from many filarial infections, and may cause marked eosinophilia and pulmonary findings on chest XR, but usually includes nocturnal wheezing/cough. And less likely to have abdominal and diarrheal symptoms unless a very high worm burden.
My ultimate diagnosis settles on acute Schistosomiasis, aka Katayama fever.
Schistosoma mansoni, a trematode found in SSA, is easily acquired while swimming in local lakes. A snail is the intermediate host, releasing infectious cercariae that can penetrate host skin and eventually end up as adult mated pairs living in the mesenteric plexus (for S. mansoni). Katayama fever is an acute illness seen mostly in people with high exposure levels or no previous immunity. It’s a hypersensitivity reaction to migrating schistosomulae or egg production and presents with fever, cough, eosinophilia, diffuse patchy infiltrates on chest Xray and even abdominal symptoms. Gold standard for diagnosis is by microscopy for ova in stool, but antibodies are often positive prior to this. PCR can also be used with the added benefit of schistosome speciation.
Interestingly, adult schistosomes can harbour enteric bacteria, like Salmonella, and introduce these directly into the bloodstream. I entertained this as a possible co-infection (all-be-it not parasitic), but would have expected growth on her blood cultures and successful treatment by the ceftriaxone given during her first hospitalization.
Praziquantel is the drug of choice for schistosomiasis, with Oxamniquine as an alternative. In an acute illness, a short course of corticosteroids may be given initially, to prevent exacerbation of symptoms.
Looking forward to the reveal!
Warm regards from Vermont,
Kimona
Paul writes:
Returning book winner:
Diagnosis: Acute schistosomiasis due to schistosoma mansoni. Also known as Katayama fever, it occurs most often in new immigrants to an endemic region.
Comment:
Pause to consider the differential and more history:
The differential diagnosis of someone presenting with fever and cough is quite long, and would include common bacterial infections, viral infections, TB, some parasites and allergic/hypersensitivity reactions.
More history would include asking about exposures to ill people, exposure to water activities, animals.
The mildly elevated eosinophil count with slightly abnormal liver tests and eggs in the stool specimen considerably raises the likelihood of parasitic disease. The providers appear to have anchored on bacterial disease as the cause and continued antibacterial treatment without widening the differential to include parasitic disease in spite of having some lab findings supporting a parasitic cause.
The effective treatment was praziquantel.
Additional comment: Having a negative malaria smear would seem to contradict treating immediately with Coartem, although this drug has a role in prophylaxis and co-treatment with praziquantel for schistomiasis.
Paul
Rafid writes:
Dear fellow TWIP team,
Please accept my condolences for the death of your dear friend and colleague Dickson Despommier. He may be gone physically but he lives on in my heart and mind. I can hear his voice right now in my minds eye. Even though I did not know him personally and never met him I will miss him. I am very saddened that he is gone.
May I suggest that everyone listening to this episode take a moment from their day and listen to lacrimosa from Mozart’s requiem to his memory.
Back to the case. Although many parasites can be in the differential and cause digestive , hepatic and pulmonary abnormalities, I think the most likely answer is Shistosoma Mansoni.
Cheers Returning champion
Rafid
John writes:
Seeking to win the book, and I found this case challenging however I want to improve my brevity, hopefully without sacrificing the details on my thought process.
To narrow down the field I looked at what may be endemic to the region, what O&P test can detect, and the symptom list like the absence of anemia and dry, not productive cough.
According to Cleveland Clinic, Ascaris lumbricoides can infect lungs and intestines with cough, fever, abdominal pain, nausea, vomiting, diarrhea, and trouble sleeping. There were many other parasites that had many of these symptoms and the lack of improvement after initial treatments may be due to overlap and more than 1 infection. I did rule out Giardia, Cryptosporidium, Strongyloides, Schistosomiasis and Amebiasis but was shaky on Strogyloides with only anemia not lining up there.
Treatments for Ascariasis often improve fast with Albendzole or Ivermectin and would not have been taken care of by the previous medications attempted so this matches the outcome described.
P.S. not for reading on the show but I wanted to clarify when the episodes are recorded vs the submission date, I’m easily confused so I could be looking at the dates wrong, but I feel like what is reported as the cutoff date is after the date of TWIP recording on recent episodes. I hope this submission is in time and if you can help me clarify I would appreciate it. Thanks as always, love the show, cheers.
Michelle and Alexander from the First Vienna Parasitology Passion Club write:
Dear TWiP-Professors,
We are deeply saddened by the passing of your friend and colleague Dickson, whose work as an educator, raconteur and scientist has had a profound impact on the trajectory of our medical interests.
We believe that the patient in Guinea has contracted Katayama fever, caused by Schistosoma mansoni. The disease is very common in Guinea, infecting almost 1 in 4 people, and commonly causes fever and pulmonary symptoms. The severe case in a non-native person, the characteristic ova on stool examination and the lack of efficacy of praziquantel during the initial phase of the disease are also typical.
Thank you for this great case! All the best,
Michelle and Alexander from the First Vienna Parasitology Passion Club
Ramón writes:
Acute Schistosomiasis (Katayama fever), probably S.mansoni
Ramón – Ibiza (Spain)
Jay writes:
Dear TWiPanosomes,
We get to toss our hats in the ring for two parasitic infections here: the initial but incorrect diagnosis made at the first hospital, and the second and correct diagnosis made later.
For the first diagnosis, it must be something that can present with fever, dry cough, bilateral infiltrates on chest x-ray, and eggs in stool. It’s also something treated with medication that can lead to nausea and vomiting.
I suspect the clinicians at the first hospital mistakenly thought this was Loeffler syndrome due to Ascaris lumbricoides. Treatments for Ascariasis include albendazole or mebendazole. Both of these medications can lead to nausea and vomiting. I suspect the eggs found on stool exam were asymptomatic infection, very common in Guinea, rather than the cause of her current disease. Loeffler syndrome occurs in infection, before eggs appear in the GI tract, so the diagnosis doesn’t really fit her clinical presentation.
At the second hospital, they took a different approach. I suspect their diagnosis was Katayama fever due to Schistosoma mansonii. The swimming hole was a good clue. She may have been treated with corticosteroids and praziquantel. She got better within 24 hours or so.
I’ve first discovered TWiP about two years ago, and I wrote in my first guess a little over a year ago. I had the honor of hearing Dickson read one of my letters last year. I will miss him on this podcast.
My heart goes out to you for this loss,
Jay
Jay Gladstein, M.D. | Chief Medical Officer
APLA Health & Wellness
Olympic Medical Clinic | Los Angeles
Justin writes:
Hello dear hosts,
This case was a challenge, and I’m still not sure exactly what the patient was suffering from.
My main thoughts were strongyloidiasis and schistosomiasis. Both would have respiratory difficulty and abdominal pain during initial infection.
Daniel mentioned she may have gone swimming in local water, which makes me think Schistosoma mansoni would be more likely, but Strongyloides fuelleborni may have been transmitted while walking barefoot on the beach or in a local garden. Both are endemic to Guinea and can cause gastrointestinal disturbance.
My final guess will be Schistosoma mansoni.
I look forward to hearing how to tell these two apart.
Thanks for a great show as always!
Justin
James writes:
Inhaled fungal infection, aspergillosis maybe.
James
Ridgefield, WA
Frithjof writes:
Dear Professors,
Greetings from Osnabrück, the City of Peace in northern Germany.
I was saddened to hear about the passing of Dickson Despommier, who co-founded your podcast and played a pivotal role in captivating a broader audience (including me) with the fascinating world of parasitic diseases. Please accept my heartfelt condolences.
Regarding the case of the 26-year-old volunteer returning from West Africa, my initial differentials would include malaria and pneumonia, both of which can be effectively treated with Augmentin and Coartem. I would recommend a diagnostic blood smear and thick blood film to help confirm or rule out malaria.
The positive stool parasite screen suggests treatment with either praziquantel (for schistosomiasis) or albendazole (for most other parasitic infections), both of which can sometimes cause gastrointestinal side effects such as vomiting. Ceftriaxone was likely administered to cover the possibility of typhoid fever.
Ultimately, the final hospital correctly diagnosed the patient with a Strongyloides stercoralis infection, which responds well to ivermectin. The parasite’s fascinating lifecycle, involving both pulmonary and gastrointestinal phases, perfectly explains the patient’s respiratory and digestive symptoms. Given that Strongyloides primarily excretes larvae rather than eggs, it can be easily missed during routine stool microscopy.
Thank you for sharing such an interesting case!
Yours
Frithjof, proud owner of a signed copy of “Parasitic Diseases”
Ben writes:
Hello all,
Again, my condolences about Dr Despommier. In his memory, I must mildly chastise you for using Fahrenheit in the show notes.
My guess for the parasite is ascariasis. The presence in the lungs is the strongest hint.
As for what happened with the two drugs and the vomiting. I guess Albendazole or mebendazole caused vomiting. The second drug was ivermectin.
The other possibility is that Pyrantel was used due to possible pregnancy. It is a paralytic and may be slow to work. Though in this case the vomiting would have been from the ascariasis, not the drug.
Thank you,
Ben in Liverpool (returning champion)
Conterno et al 2020.
https://doi.org/10.1002/14651858.CD010599.pub2
Mayo Clinic ascariasis page.
Jason writes:
In TWiP 253’s Case of The Ailing Georgian in Guinea, the patient sounds as if they were initially misdiagnosed with infection with Ascaris lumbricoides, and later correctly diagnosed with infection with Schistosoma mansoni.
The patient’s clinical symptomology, eosinophilia, lung infiltrates, and environmental exposure fits with acute-stage schistosomiasis, also known as Katayama fever. The eggs discovered in the ova and parasite stool test may have been incorrectly identified as those shed by A. lumbricoides nematodes. On microscopy, unfertilized or infertile eggs of A. lumbricoides bear a resemblance to the eggs of S. mansoni, minus the pathognomonic lateral spine. Another confounding variable in this case includes the symptomatic resemblance of Katayama fever to the early migratory phase of ascariasis – also known as Loeffler’s syndrome.
Patients treated with albendazole for ascariasis are occasionally prone to vomiting, as this patient experienced. If schistosomiasis was indeed the final diagnosis, then a brief regimen of praziquantel should have sufficed to clear out any adult-stage trematodes lurking within the intestinal mesenteric vessels.
Worm regards,
Jason
-returning champion, still awaiting autographed text!
Eyal writes:
Dear Vincent and the sages of the microscopic eukaryotes,
Greetings from Sydney, Australia, where the weather is just the opposite of the northern hemisphere.
I’m saddened to hear about Dixon’s passing. He was a great human being and, from what I could tell, a great friend—my sincere condolences for your loss.
As for the case of the 26-year-old female volunteer with no past medical history, this has me completely stumped. Please excuse my guess, as it is probably so far off the mark as to be ridiculous.
I didn’t know how to approach this:
- I’ve looked at different parasitic diseases in Guinea but couldn’t narrow it down to a diagnosis; there were just too many.
- I’ve tried looking at the treatments for each one but couldn’t find a pattern.
I’ve looked at infections with respiratory and intestinal symptoms and then found some interesting correlations. So here is my guess:
Based on the respiratory symptoms, bilateral chest infiltrates, and some eggs in the stool, the first hospital diagnosed lung fluke (Paragonimus spp.) and treated her with Triclabendazole (two doses of 10 mg/kg orally, 12 hours apart).
Unfortunately, the lab missed a small spike in the egg, and the lady was infected with Schistosoma mansoni.
At the second hospital, they decided to try Praziquantel, which to my understanding is the recommended treatment. Luckily, a single dose is sufficient treatment for Schistosoma mansoni.
I wouldn’t venture to comment on what went wrong with the management of the case, but on a funny side: if you paste the case notes into ChatGPT, it comes back with a diagnosis of lung fluke. So maybe the doctors in ‘hospital one’ should place less trust in it 😉 Please take this as tongue-in-cheek.
As always, my gratitude for the knowledge you all share.
Regards, Eyal
Sydney, Australia
Anna writes:
Hello!
As always, your podcasts are equal parts entertaining and educational, with a smidgeon of ick tossed in, of course. I love infection prevention with my whole heart, but there are certain facts I chose to… dis-remember, especially when it comes to how many parasites we have living in and on our corporeal forms.
I have recently pivoted from 10 years as an ICU RN, so I am just starting out my Infection Control/Prevention career. But when I read the case study, Ascariasis immediately came to mind. (Also, because I had just review it for my CBIC exam. Sitting for it on 3/1 – wish me luck!!)
My guess would be infestation by Ascaris lumbricoides, both by symptomology, available diagnostics, and patient location in Guinea. Lumbricoides being the most common roundworm to infest humans, and Guinea suffering under poverty and poor infrastructure for sanitation systems.
Treatment with antibiotics and antimalarials were not effective, but my guess is a single dose of an ascaricide like albendazole or ivermectin at the second hospital cleared up her infestation.
A correct, evidence-based use for ivermectin, I may note. Though I do have a Pavlovian surge of fury when I even read the word ‘ivermectin’ these days…
Anyway, thank you for this interesting consult. I look forward to our next interdisciplinary collaboration.
Anna Schroeder, RN, BSN, (soon-to-be!) CIC