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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Links for this episode

• 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.

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

Music by Ronald Jenkees