The TWiP team solves the case of the Woman Who Vomited Up a Worm, and discuss how malaria transmission intensity can modify the effectiveness of the RTS, S/AS01 vaccine in Africa.

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

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Links for this episode

• Malaria intensity modifies vaccine effectiveness (J Inf Dis)
• Letters read on TWiP 208

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Case Study for TWiP 208

An adult female resident of Hawai'i presented to the emergency department (ED) with several days of fever, abdominal pain, urinary hesitancy, and generalized itchiness. white blood cell [WBC] count 14,000 cells/mL) without eosinophilia. Urinalysis suggested a urinary tract infection and she was treated for acute UTI and discharged home.

The following day she returned to the ED because of worsening abdominal pain, bilateral hip and leg pain, dizziness, diffuse hyperesthesia, and allodynia (Pain from stimuli which are not normally painful) (worse on her feet and legs.) Urine culture from her initial ED visit grew normal urogenital flora. Her leukocytosis increased and she now had eosinophilia (WBC count 15,500 cells/mL; absolute eosinophil count 574). Laboratory evaluation was otherwise unremarkable. CT scans of the brain, abdomen, and pelvis were normal.

She was hospitalized and her allodynia worsened despite treatment with analgesics. She also developed a sensation of "electric eels swimming through [her] body. Electromyography and nerve conduction studies were normal. The patient underwent a lumbar puncture and CSF examination was notable for eosinophilic meningitis with 138 WBCs and 13% eosinophils (absolute eosinophil count 18).

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

Music by Ronald Jenkees