TWiP solves the case of the man with somnolence and something extra-erythrocytic, and presents a new puzzle for you to solve.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

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• Letters read on TWiP 253

26-year-old female with no past medical history.  Patient is from Georgia in the US and is volunteering in Hérico, Guinea (town in the Lélouma Prefecture in the Labé Region of northern-central Guinea). She arrived in Guinea in December  2023.  She was taking doxycycline for malaria prophylaxis and says that she has not missed any doses

On October  2024 she presented with fever and dry cough.  Lab work was done and follow up planned for the following day.  The patient slept poorly, was febrile to 104 and had ongoing cough.  The next day she went to the hospital and was evaluated in the ER for acute febrile illness of unclear etiology.  

In the hospital, VS were 97.9F, BP 105/70, P 94 Oxy sat 98%, normal physical exam.

She was started on Augmentin and Coartem.

Pause here to think about the differential at this point and maybe some more history and what testing you might want

WBC 14, Hb 13, HCT 40, PLT 285, Neut abs 8, Eos Abso0.80; BUN/creat  normal, AST normal; ALT 44, GGT 125

Stool parasite screen + for some sort of eggs, malaria smear negative, CXR with b/l infiltrates

She was given a medication (vomited 30 min after dose received).  She then received a second dose of medication 5 hours after the first) and was discharged. The following day the patient returned to the ER, stating that she felt worse.  Her temperature had climbed to 104 overnight, and she developed watery diarrhea and nausea.  There were no additional episodes of vomiting.  She was given an additional dose of a medication, ibuprofen, and started on ceftriaxone 1 gm IV Q12 hrs.  During the day she continued to have low grade fevers and developed abdominal pain.  That night she was again febrile to 104 F.   

She remained admitted for 5 days with ongoing symptoms of diarrhea, nighttime fevers and diffuse abdominal discomfort.  Three more malaria tests were negative (rapid test and slide review)

Blood cultures collected – no growth

She continued to have mild elevation of WBC and slight elevation of AST and ALT.

The patient was transferred to a different hospital. They give her a different medication, and within 24 hours symptoms resolve. 

What is the diagnosis and what happened here with management?

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Music by Ronald Jenkees

TWiP discusses a study of the safety and immunogenicity of a late liver-stage attenuated malaria parasite delivered by mosquito bite.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

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• Live attenuated malaria vaccine (NEJM)
• Plasmodium metabolism during hepatic development (Cell)
• Heroes – Jimmy and Rosallyn Carter, and the Carter Center
• The Carter Center Guinea Worm Eradication Programme
• Guinea Worm data visualisations (Our World in Data)

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Music by Ronald Jenkees

TWiP solves the case of the woman who went to Belize and notices a lesion on her face, and presents a new clinical case for you to solve.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

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Recent case, Arusha hospital, 1800 m, 28 yo comes in, has been visiting game parks. Developing fevers, malaise, bad headaches, body aches, somnolent. Blood smears negative, no malaria. Repeat blood smear, see something extra-erythrocytic. This gives them the diagnosis. HIV neg, no toxic habits, no history. Symptom onset about a week ago. Rest of family is ok. 

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Music by Ronald Jenkees

TWiP reviews a study showing that the gut microbiota is essential for suppression of colitis by Trichinella spiralis.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

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• Gut bacteria and Trichinella suppression of colitis (PLoS NTD)

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Music by Ronald Jenkees

TWiP solves the case of the middle-aged man with eosinophilia and a history of sexual activity with paid sex workers in Okinawa, and presents a new case for you to solve.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

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• Letters read on TWiP 249

Woman in 30s or 40s goes to Belize and after returning notices a lesion on her face. She goes to see several physicians and despite a number of topical creams the ulcer on her face does not heal. She is then referred to our office where a certain parasitic infection is considered and we involve our friends at Columbia to help us with the diagnosis..

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TWiP reviews the observation that infection of Azlheimer’s disease mice with Toxoplasma gondii reduces brain amyloid density globally and regionally.

Hosts: Vincent Racaniello, Dickson Despommier, Daniel Griffin, and Christina Naula

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• Toxoplasma reduces amyloid in brain (J Inf Dis)
• Hero: Theodor Hiepe (Parasitol Res)

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TWiP solves the case of the Manhattan man with pain on urination or ejaculation, and presents a new case for you to solve.

Hosts: Vincent Racaniello, Dickson Despommier, Daniel Griffin, and Christina Naula

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• Hero: Charles Louis Alphonse Laveran
• Letters read on TWiP 247

A middle-aged male is referred to evaluation because of eosinophilia. This man is married, living here in the NY tristate area, and this was picked up on ‘routine blood work’ by his primary care doctor. This man had been in the military, serving as a marine, with time spent in Okinawa, Japan. This individual does report sexual activity with paid sex workers while in Okinawa  but has been monogamous with his current wife for many years. A number of investigations are done with a test coming back showing serological evidence of a prior parasitic infection and he was treated with an antiparasitic medicine with resolution of the eosinophilia. The eosinophilia returned and he was referred to us. Blood work is now down showing evidence of a viral infection that might explain why the eosinophilia returned after treatment. Pt is HIV negative. This was prior to the COVID-19 pandemic. He is on no medications and in general feels fine.

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TWiP taps into Dickson’s knowledge of Trichinella to discuss an outbreak in humans who consumed rare bear meat, and the impact of globalization and climate change on the epidemiology of the species.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Outbreak of human trichinellosis (CCDR)
• Impact of climate change on Trichinella (Food Waterborne Parasit)
• Letters read on TWiP 246

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Founder of Floating Doctors Ben LaBrot joins TWiP to solve the case of the 1 year old in northeastern Panama with a fatal leg infection, followed by a discussion of the history and mission of Floating Doctors.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

Guest: Ben LaBrot

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• Floating Doctors
• Letters read on TWiP 245

A man in his early 20s comes in reporting pain when he urinates or ejaculates. He reports that he is sexually active. He does confide that he has been in a relationship with a woman but he had a sexual encounter outside this relationship about 2 weeks ago when they were on a break and he did not wear protection. He feels like he needs to urinate more often and describes thin white discharge from the penis. He reports that he has no history of any sexually transmitted infections and had no medical issues prior to this.

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Music by Ronald Jenkees

Lilach Sheiner joins TWiP to talk about her career and her work on engineering Toxoplasma gondii secretion systems for intracellular delivery of multiple large therapeutic proteins to neurons.

Hosts: Vincent Racaniello, Dickson Despommier, and Christina Naula

Guest: Lilach Sheiner

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• Engineering T. gondii for protein secretion (Nat Micro)

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Music by Ronald Jenkees