This Week in Parasitism

TWiP solves the case of the 19 month old Female Having Issues, and discusses the finding that selection for insecticide resistance can promote Plasmodium falciparum infection in Anopheles mosquitoes.

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

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• Insecticide resistance in mosquitoes promotes Plasmodium infection (PLoS Path)
• Letters read on TWiP 219

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Case Study for TWiP 220

73 y/o M w/ no significant PMhs who is referred to ED for fever, lethargy and progressive weakness as for the past 2 weeks. Thursday of the prior week he went to his PCP and blood work was performed. CBC demonstrated RBC inclusions. Labs also demonstrated anemia, thrombocytopenia, mildly elevated total bili and ALT. He was started on PO azithromycin and atovaquone on Saturday, however, he has not noted much improvement. He was seen in our office Monday and reports intermittent fever to 102, continued chills . Additional symptoms include dark urine, chills, occasional diaphoresis. Normally patient rides his bike 15 miles a day and runs 3 miles per day but states now he barely has the energy to walk a few feet and is now in a wheelchair. He report that he regular goes for Runs in parks in Queens.

He denies any bug bites, tick bites, rashes, blood transfusions in the past year.

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Music by Ronald Jenkees

TWiP solves two cases this week, the Man with Issues after COVID-19, and the Man with Left Arm Weakness, then describe how the malaria parasite evades mosquito immunity by glutaminyl cyclase–mediated posttranslational protein modification.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

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• Malaria parasite evades mosquito immunity (Proc Natl Acad Sci USA)
• Letters read on TWiP 218

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Case Study for TWiP 218

A fun twist for today. Did I mention recently I was spending time with Paul Calle at the Central Park and instead of Jeff Bezos showing up for Dinner Chevy Chase was there.

Here we have the case of a 19 month old female who seems to be having some issues. Lots of increased respiratory effort even with minimal exertion. Some issue with loose stools and then followed by the onset of facial swelling. No sig PMH or PSH, fairly confident there is not smoking or drinking of alcohol and certainly not HIV+. On exam the increased respiratory effort that is audible.

Directed testing reveals canine coccidia and giardia in the stool.

So what is going on? Should I be worried about my daughter who has had lots of exposure?

Send your case diagnosis, questions and comments to [email protected]

Music by Ronald Jenkees

TWiP solves the case of the Man With Dog Exposure, and discuss rapid and spontaneous post-partum clearance of Plasmodium falciparum related to expulsion of the placenta.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

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• Post-partum clearance of P. falciparum (J Inf Dis)
• Letters read on TWiP 217

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Case Study for TWiP 217

We have two cases today!

A man in his 60s who provides IT support for a bank and all done via zoom and remote work is referred to me. He reports having issues after COVID diagnosis Sept 5th, 2022. He had 4 vaccine doses and with diagnosis was treated with Paxlovid. Feel better than about week 3 wakes up with URI symptoms for about one week and by the 28th was improving. He had cold agglutinins detected. Referred to ophtho by his primary with some eye discomfort and noted to have elevated intra-ocular pressure elevation. Sleep and fatigue were a problem but slowly improving. Cognitive issues noted but improving.

He reports an issue a few years prior to this current problem where he developed fever, a sore throat, tender lymph nodes in the neck both in front and in the back. This resolved after about a week but was then followed by months of fatigue, sleep disturbances and not feeling well. He reports no specific dietary preferences and reports no cat exposures. He saw several physicians and one did a number of blood tests.

A man in his late 30s presented to an ER at an outside hospital prior to ultimately being transferred to an academic center in NYC.. He reports onset of left arm weakness that prompted him to come to the ER. He reports on pointed questioning that he had COVID about one month prior and felt he had fully recovered. He did have a headache that preceded the onset of weakness. The OSH triggers their stroke protocol and perform a head CT which reveals a hypodense lesion on the right side of the brain not consistent with a stroke.

A bit more history is obtained, some further testing is done,and based on this the patient is transferred on some sort of therapy.

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Music by Ronald Jenkees

Eyal joins TWiP to solve the case of the case of the Feverish Patient from Israel, and reveals his training and experience with travel medicine in Israel.

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

Guest: Eyal Leshem

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• Letters read on TWiP 216

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Case Study for TWiP 216

This is a case from one of my colleagues in North West China. Many years ago when I was asked to teach at Kunming University I had a plan to climb in the beautiful Tianshan mountains and again a second time when I ended up distracted at the southern edge of the Gobi desert and instead spent time in a Tibetian monastery. Stories for another day. For today we have:

A man right around age 30 who presented with right lower extremity weakness, numbness and issues with bowel and bladder function. When he was just a few years old he had reported dog exposure and had a lesion removed from his liver. No reported dog exposure since he was young. He is found to have a mass in the right upper buttock. His wbc is normal but ESR and CRP are elevated. He has a CT which reveals cystic lesions and significant destruction of L5 through the sacrum and coccyx.

What could this be and what is recommended as next steps.

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Music by Ronald Jenkees

TWiP solves the case of the case of the boy in Uganda with a mobile piece of spaghetti in the gallbladder, and reviews papers on female genital schistosomiasis in rural Madagascar, and a volatile sex attractant of tsetse flies.

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

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•Female genital schistosomiasis in rural Madagascar (PLoS NTD) •A volatile sex attractant of tsetse flies (Science) •Letters read on TWiP 215

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Case Study for TWiP 215

This case was shared with my by a former student of the Diploma in Tropical Medicine and Hygiene course I coordinate, Prof Eyal Leshem, who is the Director of the Institute for Travel and Tropical Medicine at the Sheba Medical Center in Tel Aviv and Clinical Associate Professor at the School of Medicine at Tel Aviv University, Israel. This case is of a 24 year old male who presented to the emergency room at the end of February with a 4 day history of fever, starting three weeks after he returned from a long trip.

He reports traveling in India during October of the past year. From November to early January, he stayed in Papua New Guinea, from where he traveled to Thailand, returning to Israel in early February. On admission he reports a daily fever up to 40 degrees C, which I think is 104 Fahrenheit. He also mentions an itchy rash and dry cough.

We learn a bit more about this patient. In Thailand, he received a five-day course of doxycycline due to a febrile illness, which resolved after treatment. During his stay in Papua New Guinea he hiked in the jungle, was bitten by multiple insects and also report finding leeches attached to his lower legs. One insect bite on his hip took a while to heal. He also reports swimming in multiple rivers. While travelling, he did not have unprotected sexual encounters but he admits to eating street food and home made food regularly. He received pre-travel vaccines and when he was in Papua New Guinea took Atovaquone Proguanil prophylaxis daily, discontinuing therapy a week after he flew to Thailand. On physical exam he is alert and oriented, vitals normal, the examination is unremarkable except for three cropped vesicles on his penis, which the patients says are itchy. A healed insect bite on his lower hip is also noted. His white blood count and differential are normal without eosinophilia. His haemoglobin is 13 g/dl, which is borderline normal and his platelet count is lower than normal with a count of 100,000 per microlitre of blood.

What is your diagnosis? What test or tests would you like to order to confirm your suspicion. We would like you to be as accurate as you can when identifying the parasite causing this man's symptoms. What are special considerations you need to think about for treatment?

Send your case diagnosis, questions and comments to [email protected]

Music by Ronald Jenkees

Kay Schaefer joins TWiP to solve the case of the German Male with Hematuria, and discusses Tropical Medicine Excursions, which provides patient-oriented training courses for healthcare professionals who wish to improve their clinical skills in tropical medicine and travelers' health in the endemic regions of Uganda, Tanzania and Ghana.

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

Guest: Kay Schaefer

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• TROPMEDEX
• Letters read on TWiP 214

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Case Study for TWiP 214

Still in Uganda but now in a clinic in Entebbe. A boy, less than age 10, who grows up in very limited conditions, dirt floor home with other siblings presents with recurrent right upper abdominal pain, fevers, and first undergoes blood work that shows eosinophilia. He has an abdominal ultrasound performed which shows what looks like a mobile piece of spaghetti in the gallbladder with dilated ducts. He also has a stool examination performed.

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Music by Ronald Jenkees

Jessie Stone joins TWiP to solve the case of the Boy With a Swollen Belly, and discusses Soft Power Health, a clinic that she founded in Uganda to provide healthcare for people in need.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Jessie Stone

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•Soft Power Health •Letters read on TWiP 213

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Case Study for TWiP 213

A 49 y.o. German male is seen with significant gross hematuria. He reports no travel outside Europe but does report that he visited France twice, 7 years before and 1 year before. He reports swimming in the Solenzara River in the southeastern part of the island, near a busy campsite. He might have gone into the Gravona River in western Corsica near Ajaccio, at a turtle park and near a campsite, and at the Tavignano River. The patient also reported swimming in the Restonica River. He reports never swimming in the Cavu River and using GPS data from his smartphone and camera, he reconstructed his bathing sites precisely and this history was confirmed.

Exam was unremarkable. Complete blood count was unremarkable and did not show eosinophilia.

This complaint triggered cystoscopy and biopsies that were sent for histological analysis. These findings triggered referral to the Tropical Medicine department at LMU Hospital Munich.

Now in the next episode we will have a guest to discuss this case as well as tell us a bit about themselves. I am hoping people will tell us what they think this might be but then perhaps do a bit of research and go into a little more detail.

Send your case diagnosis, questions and comments to [email protected]

Music by Ronald Jenkees

Shauna Gunaratne joins TWiP to solve the case of the Man from Mali with Painless Skin Lesions, and discuss her plans for a tropical medicine institute in New York City.

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

Guest: Shauna Gunaratne

Click arrow to play Download TWiP #212 (51 MB .mp3, 84 minutes)

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• Letters read on TWiP 212

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Case Study for TWiP 212

14 year old boy with a history of slow progressive development of abdominal ascites over years. Appears wasted and malnourished. Afebrile, no history of weight loss or night sweats, no history of TB exposure, HIV negative. Had an older brother who died the year before of apparently the same disease. Had lived early life by the shores of lake Victoria. Currently has really impressive abdomen.

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Music by Ronald Jenkees

TWiP solves the case of the Man from Hong Kong with Multiple Comorbidities, and discuss safety and efficacy of a monoclonal antibody against malaria in Mali.

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

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• Monoclonal antibody against malaria trial (NEJM)
• Hero: Stephen Hoffman
• Letters read on TWiP 211

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Case Study for TWiP 211

Man in his 20s originally from Mali who comes in with a dermatological complaint about 1 mo after he returned from spending time in Bamako, Mali with friends and family. Reports this has been going on for months and he is getting very frustrated as he is not getting any answers. He relates that this started with itching over a "blackhead" resembling a pimple that was itchy and very small. Over the subsequent months it started to get larger with ongoing itchiness but no pain. No erythema or warmth in the area. Other lesions developed in addition to the first one. There was no drainage from the skin lesions. He started putting triple antibiotic ointment on his lesions that he bought from a pharmacy.

He then went to his primary doctor who prescribed a topical medication and PO antibiotics but this did not help.

He reports that when in Mali he stayed in his house with his parents, siblings, grandmother and other extended relatives – more than 40-50 people under one roof. food made by his family, reports consumption of only cooked meat, no uncooked meat. Ate salads and uncooked vegetables. No contact with any animals, no pets in the home. Denies any contact with any pets or farm animals such as pigs, cows, horses, cattle. Denies swimming in any lakes or ponds. No hiking or outdoor activities. No riding horses.

Was sexually active in Mali with women and is HIV negative.

On examination he has a 10 cm lesion over anterior L thigh, with verrucous and vegetative appearance with yellow crusting over central area and heaped up lesion, not undermined. No erythema, warmth or drainage. Has a similar smaller lesion measuring about 3 cm on R flank. Has a 3rd smaller lesion with some mild crusting and about 2cm over R posterior thigh.

He ends up getting a biopsy that reveals:

HISTOLOGIC FEATURES That ARE NOT DIAGNOSTIC. THERE IS NO EVIDENCE OF any specific organisms. THE EXOGENOUS MATERIAL WHICH COULD REPRESENT SOME TYPE OF FOREIGN BODY IS NOT IDENTIFIABLE AS PART OF A FLY OR ARTHROPOD, NOR IS IT TYPICAL OF A SPLINTER AND ITS PRESENCE IN THE SPECIMEN MAKES IT PROBLEMATIC AS TO ITS SIGNIFICANCE. MICROSCOPIC DESCRIPTION: WITHIN THE DERMIS THERE IS A DENSE DIFFUSE MIXED CELL INFLAMMATORY INFILTRATE INCLUDING MANY PLASMA CELLS AND NEUTROPHILS. THERE IS EXOGENOUS MATERIAL. PAS, GMS, FITE AND GRAM STAINS ARE NEGATIVE FOR INFECTIOUS ORGANISMS.

Additional testing is ordered that leads to the diagnosis.

He is planning on returning to Mali and perhaps sooner than originally planned if he does not get a diagnosis since he thinks the doctors in Mali would know what he has.

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Music by Ronald Jenkees

From ASTMH2022 in Seattle, Aisha joins the TWiP team to talk about her training and her career, including delivering a baby on an airplane, and they solve the Case of the Heartsick Guatemalan Septuagenarian.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

Guest: Aisha Khatib

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• Aisha delivers baby on airplane (The Varsity)
• Helminth infections during pregnancy (J Travel Med)
• SARS-CoV-2 transmission during air travel (Curr Op Inf Dis)
• Letters read on TWiP 210

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Case Study for TWiP 210

We are consulted about a rash. A male in his mid 60s originally from Hong Kong with PMH of T2DM, Hypertension, BPH, Hepatitis B infection, COPD (not on home o2), current smoker, ESRD with right chest cath on dialysis (MWF) presented to the ED c/o progressive SOB and DOE for 1 week. 2 weeks prior the patient missed 1 session of hemodialysis. Progressively worsening SOB, DOE, orthopnea began to develop starting one week ago with an associated productive cough with white sputum. Last dialysis was session was 3 days PTA. Pt also began developing nausea and vomiting for 3 days x12 times last week. Pt also started developing diarrhea. Pt has states to have a notable generalized pruritic rash for 3 months that has been worsening. He reports he has been seen by dermatology and was told that the rash is due to certain allergies from food and has been using an unknown cream for 1 month that does not relieve his symptoms. Pt recently admitted for management of bleeding permacath and acute hypoxic respiratory failure likely 2/2 COPD requiring intubation and vent support. Denies recent travel, recent antibiotic use, or sick contacts…but his nephrologist reaches out and is concerned about a certain diagnosis as he says three other patients that come for dialysis have recently been diagnosed with a certain diagnosis.

On exam ee has a diffuse symmetrical rash and is scratching the while time. On careful examination there are small linear scabbed areas between his fingers.

9.3

8.97 )———–( 210

28.4

Absolute eosinophil count is >1000

134 | 97 | 51

—————————-

3.8 | 25 | 5.10

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Music by Ronald Jenkees