This Week in Parasitism

Maria Adelaida Gomez joins TWiP to discuss her career and the work of her laboratory on understanding the healing process during cutaneous leishmaniasis.

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

Guest: Maria Adelaida Gomez

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• CIDEIM
• Healing in cutaneous leishmaniasis (J Immunol)

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Music by Ronald Jenkees

Eyal joins TWiP to solve the case of the Female Traveler with Intermittent Fever and Ring Enhancements in the Liver.

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

Guest: Eyal Leshem

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Case Study for TWiP 229

Woman in her 40s is referred to me to be seen in the office from one of my colleagues. She reports that she has been having recurrent issues with worms exiting her anus and vagina since 2018. She reports that she lives with her husband and 4 children and they have never reported any issues. She reports that initially she took something over the counter and things resolved. She then a couple years later has this problem again and this time discussed the problem with her housekeeper from El Salvador who gave her an antiparasitic tablet from her home country. This problem has now recurred and she was referred to a GI doctor who she explains laughed at her and suggested she see a psychiatrist. She come in now very upset and tearful. She relates that she has this itching that wakes her up at night and was able to take pictures of something she found on the anus. She has photos as well as a video of a thin white 1 cm motile thing with on end coming to a point. 

She reports a normal nonrestrictive diet. She reports no travel outside the US or even outside the local area. No PMH, no PSH, family history of different cancers. She does not work outside the home. She reports no pets. She has an unremarkable exam and labs only notable for low vitamin D. 

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Music by Ronald Jenkees

TWiP discusses a tapeworm that causes extreme lifespan extension in infected ant workers, and a candidate antibody drug for prevention of malaria.

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

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• Extreme lifespan extension in tapeworm-infected ant workers (Roy Soc Open Sci)
• Candidate antibody drug for prevention of malaria
• Ceilidh goes viral (YouTube)

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Music by Ronald Jenkees

Jim Small joins TWiP to solve the case of the 41 year old Man with sudden GI distress and itchy hives, followed by a discussion of parasites and childhood stunting.

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

Guest: Jim Small

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• Parasites and childhood stunting (Trends Parasitol)
• Letters read on TWiP 227

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Music by Ronald Jenkees

TWiP reviews some parasite stories of 2023, including progress in the control of malaria and polio, and review a connection between parasites and childhood stunting.

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

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• Second malaria vaccine (Nature)
• Malaria report 2023 (WHO)
• Malaria and climate change (WHO)
• Parasites and childhood stunting (Trends Parasitol)
• Sea creature spotted off Japan identified (Science)

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Music by Ronald Jenkees

Lee Gottesdiener joins TWiP to help solve the case of the 46 Year Old Man with Ongoing Upper Extremity Swelling, and review plant‑based production of a protective vaccine antigen against the bovine parasitic nematode Ostertagia ostertagi.

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

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• Vaccine against cow parasite (Vert Farm Daily)
• Protective vaccine against bovine parasitic nematode Ostertagia ostertagi
• Hero: Dr. Katy Ewer
• Letters read on TWiP 225

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Case Study for TWiP 225

41-year-old male mechanical engineer, former Army Ranger trainee, moved from Denver, CO to Chattanooga, TN. He was in his usual state of vigorous health, hiking, doing Spartan races, working on his semi-rural property,  and commuting to his place of work daily when about three months previous to his diagnosis, he began having episodes of sudden GI distress with diarrhea, followed by itchy hives in axilla and groin. He treated these episodes with Benadryl and got relief. At 10 PM one evening, he had another such episode, again took Benadryl, but began to experience gradual onset but relentlessly increasing shortness of breath and wheezing. He was taken at high speed to the Emergency Room by his wife. He reported that relaxation with a repetitive, meditative prayer seemed to control the symptoms but said it was like his throat was closing.

Past history includes variable exercise and cold-induced asthma treated with an inhaler as a child, with only rare episodes in adulthood related to high exposure to allergens like cat dander. Family history is not contributory. Diet was omnivorous. They had one dog, a labradoodle named Raphael, which they chose because he was “hypoallergenic.”

In the Emergency Department, he was treated with bronchodilators, intramuscular epinephrine, and antihistamines, and the symptoms abated.

The experienced ED physician ordered a diagnostic test, having seen other similar cases in the region. A lifestyle intervention was successful.

Chuck Knirsch returns to TWiP to discuss the Neglected Tropical Diseases Roadmap published by WHO, which sets global targets and milestones to prevent, control, eliminate or eradicate 20 diseases and disease groups.

Chuck Knirsch returns to TWiP to discuss the Neglected Tropical Diseases Roadmap published by WHO, which sets global targets and milestones to prevent, control, eliminate or eradicate 20 diseases and disease groups.

Hosts: Vincent Racaniello, Dickson Despommier, and Chuck Knirsch

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• Neglected Tropical Diseases Roadmap (WHO)
• World malaria report 2023 (WHO)

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TWiP solves the case of the Haitian female with AIDS and voluminous diarrhea, and review the pathogenesis, epidemiology, prevention and treatment of malaria and Chagas disease.

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

Click arrow to play Download TWiP #223 (63 MB .mp3, 88 minutes)

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• Malaria (Lancet)
• Chagas disease (AJTMH)
• Hero: Joe Cook
• Letters read on TWiP 223

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Case Study for TWiP 223

46 yo man with minimal pmh, elevated cholesterol, ongoing right upper extremity swelling, 5-10 years intermittently. Goose egg swelling on hand, foot. Lasts for hours, every few months. Go to ER, right upper extremity. Lives in NYS suburbs, Is vet and epidemiologist. Has done extensive travel, Liberia, Ghana, DRC, Uganda, Rwanda, 2 week duration. Doing work, fair amount of animal contact with bats, rodents, birds. PE unremarkable except for swelling of right arm. Blood work unremarkable. 2.5 yr later notice prickling irritation under right eyelid, think they see undulation under skin. 

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Music by Ronald Jenkees

At the meeting of the American Society for Tropical Medicine and Hygeine in Chicago, Natasha joins TWiP to solve the case of the Man with a Generalized Seizure and Infectious Forms in the Brain.

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

Guest: Natasha Spottiswoode

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• Treatment of Balamuthia encephalitis with nitroxoline (Emerg Inf Dis)
• Letters read on TWiP 222

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Case Study for TWiP 222

Haitian creole speaking, cachetic female in her 50s w/ hx HIV (noncompliant on medication), migrating from Haiti brought in by her daughter for dysphagia, cough x days, associated with NBNB vomiting, oral thrush extending to soft palate, concerning for oropharyngeal candidiasis. Weeks of nonresolving diarrhea. Admitted for failure to thrive and deconditioning, found to be Parainfluenza 3 positive), undergoing TB rule out. Diarrhea is voluminous, pt is dehydrated, there has been significant weight loss and lethargy over the last few weeks.

MHx:

HIV 

Shx:

Lives in haiti

Remarried, Last sexual encounter 2 years ago.

Denies illicit drug use. Drinks alcohol 

Allergies: No Active Allergies

Labs return with CD4 count in the 50s, elevated viral load. CD4 55/3%

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Music by Ronald Jenkees

Michelle and Alexander join TWiP to solve their case of the 36 Year Old Male with shortness of breath, stinging pain in the extremities, fatigue, abdominal cramps, and bowel irregularities, and discuss host cell invasion by Trypanosoma cruzi.

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

Guests: Michelle Naegeli and Alexander Grieb

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• cAMP-dependent invasion by Trypanosoma cruzi (PLoS NTDS)
• Letters read on TWiP 220

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Case Study for TWiP 221

This is the case of a  man in his 50s, with no remarkable prior medical history, who received care at a hospital in northern California, USA, after experiencing a generalized seizure. Magnetic resonance imaging (MRI) demonstrated a solitary left temporal lobe T2 hyperintensity with gadolinium rim enhancement and surrounding edema. After receiving treatment with dexamethasone and levetiracetam, he was transferred to an academic medical center.

Examination by neurology consultants noted disorientation, inattention, moderate aphasia (difficulty communicating), and mild right hemiparesis. Cerebrospinal fluid (CSF) testing revealed increased nucleated cells up to 80/UL (60% lymphocytes, 17% neutrophils, 23% monocytes), protein concentration 38 mg/dL, and glucose concentration 100 mg/dL. 

They proceed to do a brain biopsy from the left temporal lobe lesion with cultures from the brain biopsy sample that did not grow bacteria, fungi, or mycobacteria. They performed metagenomic next-generation sequencing (mNGS) on a CSF sample and sent brain biopsy samples for universal broad-range PCR amplicon sequencing (uPCR) for bacteria, fungi, Mycobacterium tuberculosis, and nontuberculous mycobacteria. which is preliminarily reported as showing well-formed granulomata with acute inflammation. Rereview of neuropathology raised concern for certain round infectious forms that are about 50um in size with some surrounding clearing and a dark area within these forms.

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Music by Ronald Jenkees

TWiP solves the case of the Hiker from Queens who Denies Bug Bites, and reveal two different malaria experimental vaccines that target different parts of the parasite life cycle.

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

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• Malaria transmission-blocking vaccine (Lancet Inf Dis)
• mRNA vaccine against malaria (Nat Immunol)
• Letters read on TWiP 220

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Case Study for TWiP 220

Sent by Michelle and Alexander from the First Vienna Parasitology Passion Club

A 36 year old male presents to the local ED with shortness of breath. Additional symptoms included a stinging pain in different parts of his extremities, fatigue, abdominal cramps and bowel irregularities. On exam he was resting comfortably and his vitals were normal, but the patient appears very distressed by his symptoms. His left eye showed signs of irritation, including redness and swelling. A detailed history reveals travel to the Caribbean about 4 years ago and several short trips to central and east Africa, all between 5 and 10 years ago. His initial labs were grossly unremarkable and a chest x-ray showed no abnormalities. The patient himself suspected a specific parasitic etiology of his symptoms, so we performed a number of serologies and stool examinations in search of  parasitic diseases. None of the tests revealed evidence of an ongoing infection. 

He is HIV negative and not sexually active at the moment. He has no pets and no other recent travel history. He eats a normal diet and has been out of work for two years.

Thank you for the opportunity to participate in this fantastic project! All the best, 

Michelle and Alexander from the First Vienna Parasitology Passion Club

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Music by Ronald Jenkees

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?

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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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• Join MicrobeTV Discord server
• 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.

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

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

—————————-

The TWiP team solves the case of the Woman From Hawaii With Allodynia and abdominal pain, bilateral hip and leg pain, dizziness, and diffuse hyperesthesia.

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

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• Use coupon code MicrobeTV when purchasing a spike t-shirt from Vaccinated.us
• Accidental host (TWiP 207)
• Hero: Dan Colley
• Letters read on TWiP 209

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Case Study for TWiP 209

Man in his early 70s with PMH sig for HTN, DM-II, HLD, BPH is admitted to the hospital after coming from Guatemala to visit his son. He feels faint with standing and is noted to have a HR in the 40s and does not feel well when he stands. He is also noted to have diarrhea, but this has been going for an unclear period of time. On EKG he is noted to have a RBBB.

PMH  HTN, DM-II, HLD, BPH PSH neg

Allergies NKADR

Social -no toxic habits reported, reports living in Guatemala City but grew up in the rural areas. Enjoys fruit juice

FH-noncontrib

Exam: slow heart rate, orthostatic

A number of blood and stool tests are collected and he is referred to a tertiary care center for implantation of a cardiac pacemaker. At the tertiary care center the patient is seen by an Infectious Disease Specialist and a number of tests are ordered by the Infectious Disease Consultant but they are canceled by Cardiologist who writes in their note “no concern for an infectious process”. Now one of the tests collected at the first hospital returns with an interesting result that is later confirmed by a second test.

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

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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• 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).

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Music by Ronald Jenkees

Claire joins the TWiP team to discuss her training and experience as an infectious disease physician, and her transition to science communication, then we solve the case of the Honduran Male with Seizures.

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

Guest: Claire Panosian

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• Claire’s website
• Claire’s videos (Vimeo)
• Letters read on TWiP 207

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Case Study for TWiP 207

Woman in 20s, spent time in Kenya 6 months prior, vomited up a worm. 0.5 cm in length. Sent to lab. Was moving. Earlier that day she went out with friends to sushi place, ate fish. Developed horrible abdominal pain, then vomited. 

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Music by Ronald Jenkees

The TWiP team solves the case of the Ghanian Women With Leg Swelling, and relate how Anopheline mosquitoes are protected against parasite infection by tryptophan catabolism in gut microbiota.

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

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• Bacteria protect mosquitoes from parasite infection (Nat Microbiol)
• Letters read on TWiP 206

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Case Study for TWiP 206

42 yo Spanish speaking male, originally from capital city of Honduras. Admitted to hospital after seizure. Grew up in Honduras, 20 year history of seizures. Now in NYC area. Treated with carbamazepine, 2x a day. Has not filled scrip for 3 months. Fast heartrate, o2 sat fine, no fever. No surgery, no toxic habits. Unremarkable physical exam. Undergoes blood work and head imaging. CBC normal, normal diff, slight elevation in blood glucose. Imaging of head reveals non-specific coarse calcification. Eats regularly.

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Music by Ronald Jenkees

The TWiP team solves the case of the Pregnant Ghanian Living Near a River, and reveal emodepside, a drug for treatment of onchocerciasis.

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

Download TWiP #205 (56 MB .mp3, 93 minutes)

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• Emodepside for onchocerciasis (PlOS NTD)
• Hero: Dr. Mwelecele Ntuli Malecela
• Letters read on TWiP 205

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Case Study for TWiP 205

Two women, 80s and 50s. Former had 9 children, lives in Ghanian village with large lagoon, many mosquitoes. Concerned about chronic swelling of left leg, groin area for much of her life. Walks barefoot. 50 yo with 4 children, both legs started to swell, cold, mosquito bites. With time left leg becomes hard, swollen, disfigured. Has gone to hospital for ulceration. Common problem in her village, mostly women but some men. Problems getting access to medications. 

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Music by Ronald Jenkees

The TWiP team solves the case Two Ghanians Near A Fast-Flowing River, and discuss a promising new drug for treatment of African trypanosomiasis.

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

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• Oral fexinidazole for African trypanosomiasis (Lancet)
• Hero: Madeline Albright
• Letters read on TWiP 204

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Case Study for TWiP 204

Pregnant woman, 20 yo, living in eastern Ghana near Volta River delta. Often in river. In second trimester. Comes in with abdominal pain, bloody diarrhea. Ovoid forms seen in stool, 160 microns, have single lateral projections. Other ovoid forms 45×30 microns which contain polar bodies.

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Music by Ronald Jenkees

The TWiP team solves the case of the Shopkeeper with Thirst, Rash, and low Blood Oxygen, then review a study on the effect on survival to adulthood in Tanzania of mosquito net use in early childhood.

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

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• Mosquito net use in Tanzania (NEJM)
• Michiaki Takahashi (Wikipedia)
• Letters read on TWiP 203

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Case Study for TWiP 203

Two individuals, same issue. Small village in Ghana, near fast flowing river. Teenaged boy, father farmer. Boy develops severe itchy rash on right leg. Light and dark areas. They live nearby, father farms near river. After school they swim in river then travel. Father in 70s, has 2-3 cm nodule on left knee, second on in groin area, no other problems. Has some visual issues. Nodules are firm, fixed to the skin.Both have positive diagnostic skin snip.

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Music by Ronald Jenkees

Sara from the Febrile Podcast joins the TWiP team at The Incubator to solve the case of the Man With an Egg Laden Colonic Mass, and Daniel presents a new puzzle for us to solve.

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

Guest: Sara Deng

Click arrow to play Download TWiP #201 (72 MB .mp3, 60 minutes)

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• Febrile podcast
• Hero: Eloise Blaine Cramm
• Support MicrobeTV at Parasites Without Borders
• Letters read on TWiP 202

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Case Study for TWiP 202

Man 60 yo shopkeeper in Rohingya Camp displaced Myanmar natives. 3 months getting up at night, urinating, thirsty, losing weight. Develops rash on elbows, abdomen, very itchy. Rest of family has rash as well. Starts headache, fever, cough, trouble breathing, seeks medical care. O2 sat is in 80s. Past med/surg healthy individual, heavy smoker, HIV negative. Living in dwelling with tin roofs, dirt floors, many people crowded. Elevated WBC count; elevated glucose.

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Music by Ronald Jenkees

The TWiP team solves the case of the Man with a Cat and Ring Enhancing Lesions, and discuss domestic mammals as reservoirs for Leishmania donovani on the Indian subcontinent.

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

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• Reservoirs for Leishmania (Transboundary Emerg Dis)
• Support MicrobeTV at Parasites Without Borders
• Letters read on TWiP 201

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Case Study for TWiP 201

Older male, >65, abdominal pain over last several months, getting worse, otherwise feels well. No change in weight. Past medical, surgical unremarkable. Social: grew up in rural inland China. As adult lived in large city. Always active and healthy, eating fish and leafy vegetables. Move to US 10 years before illness. No pets. No toxic habits. HIV negative. Unremarkable exam. Labs: elevated white count, platelets low, not anemic. Differential on white count: neutrophils predominant. Gets belly CT: reveals mass in colon. Colonoscopy done, mass resected. Pathology: shows adenocarcinoma, but also eggs in sample. Slightly ovoid, 80 microns.

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Music by Ronald Jenkees

The TWiP team solves the case of the Gentleman from New York with Intestinal Issues, and review a 20 year study of butterflies, their associated parasitoid wasp and Wolbachia introduced into an island community.

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

Download TWiP #200 (41 MB .mp3, 68 minutes)

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• Accidental parasitoid introduction (Mol Ecol)
• Hero: Gerald Keusch
• Support MicrobeTV at Parasites Without Borders
• Letters read on TWiP 200

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Case Study for TWiP 200

Man in 30s with HIV-AIDS, presents with lower extremity weakness, headache, fever, ends up in hospital. Lives with wife and her cat, doesn’t take his medications. CD4 less than 100. Told to take medicine every day, one 3x week, one weekly. Does not drink alcohol, only eats well cooked meat. Born and raised in San Juan. Has had multiple sexual exposures with multiple women over years. Thin coating on tongue, lungs bowel normal. Has weakness in lower extremities. Skin unremarkable. Labs: CT shows multiple ring enhancing lesions with surrounding edema, also on MRI.  

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

Music by Ronald Jenkees

The TWiP team solves the case of the Traveler to Tanzania with a Purple Lesion, and discuss Mosquirix, the first vaccine approved for Plasmodium parasites.

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

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• PWB on Facebook, Instagram, Twitter
• Historic malaria vaccine (Nature)
• Efficacy and safety of RTS,S/AS01 (Lancet)
• Letters read on TWiP 199

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Case Study for TWiP 199

Gentleman in 40s, repeated intestinal issues, diagnosed with Giardia and treated, a year later again, again not feeling well. Stool testing shows Blastocystis and Endolimax nana. Lives in NYC area, single, active socially with different partners, no other medical problems, does take PREP for AIDS. Exam and labs normal except for stools. HIV negative. Treated with metronidazole, no impact on symptoms. Coincides with successful encounters.  

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

Music by Ronald Jenkees

The TWiP quadfecta solves the case of the Traveler With Watery Diarrhea, and reveals that a heat-shock response regulated by a transcription factor protects human malaria parasites from the high temperatures of fever.

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

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• PWB on Facebook, Instagram, Twitter
• Malaria parasite resists fever due to heat shock response (Nat Micro)
• Malaria beats the heat (Nat Micro)
• Letters read on TWiP 198

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Case Study for TWiP 198

31 yo woman, previously healthy, traveled to Tanzania, went on 11 day long safari. One week later, at home, developed fever and severe headache, went into hospital. Thick blood smears negative, physical exam normal, small purple lesion near buttocks. Started on treatment for African tick bite fever. Did not get better, lesion grew in size. Biopsy of lesion, nothing remarkable on microscopy. Improved, sent home, 10 days another bout of fever that went down in 2 days. Lesion healed. PCR for plasmodium, Borrelia negative, but seroconverted for Rickettsia. Went home, a week later another 3 day bout of fever.   

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Music by Ronald Jenkees

TWiP solves the case of the Adventurous Eater with Areas of Swelling, and discusses an experimental Trypanosoma vivax vaccine comprising an invariant flagellum antigen.

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

Download TWiP #197 (39 MB .mp3, 64 minutes)

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• PWB on Facebook, Instagram, Twitter
• Experimental T. vivax vaccine (Nature)
• Letters read on TWiP 197

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Case Study for TWiP 197

Gentleman in late 20s, has for weeks had watery diarrhea that is not getting better. Recently took trip to Oaxaca, Mexico. Stayed at nice hotel, all fruits, vegetables, salads well cleaned. Always ate at hotel. Developed diarrhea there. Went with three others, stayed at same place. No prior surgeries, no family history, no medications, no toxic habits. Daniel recommends one test and that gives diagnosis and therapy and he resolves.  

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Music by Ronald Jenkees

TWiP solves the case of the Homeless Man With Skin Issues, and discusses an experimental mRNA based malaria vaccine.

Hosts: Vincent Racaniello and Daniel Griffin

Download TWiP #196 (49 MB .mp3, 81 minutes)

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• PWB on Facebook, Instagram, Twitter
• Entomophagy (TWiP 131)
• Malaria mRNA vaccine (NPJ vaccines)
• Letters read on TWiP 196

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Case Study for TWiP 196

30 yo woman having areas of swelling in different parts of body, blood work shows elevated eosinophils. History: prior had been travelling around SE Asia. Had some loose stools on return, some tingling in fingers, otherwise fine. Adventurous eater, fish, pickled fish, salads. Previously in good health, no surgeries, all in family healthy. No meds. Lives alone. Went to Indonesia and Thailand. Toxic habits: no smoking, drinks periodically, HIV negative. On exam: swollen area on arm, biopsy is done. Pathologist report: cross section has what appears to be larval nematode.  

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Music by Ronald Jenkees

Christina returns to the TWiP trifecta to solve the case of the Beachgoer with Red Lines on Her foot, and an experimental malaria vaccine based on the junctional region of the circumsporozoite protein displayed on a virus-like particle.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Christina Naula

Download TWiP #195 (46 MB .mp3, 76 minutes)

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• PWB on Facebook, Instagram, Twitter
• VLP-based malaria vaccine (Cell)
• Promise of a malaria vaccine (Ann Rev Micro)
• Hero: Maria Mota
• Letters read on TWiP 195

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Case Study for TWiP 195

Gentleman in 60s, does not have permanent home, comes in with skin issues. Pruritis all over. Wearing heavy coat, unwashed polyester shirt. 1 cm diameter patches, erythematous, areas where open from scratching. Cover much of torso. Solve case by examining his clothes.  

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

Music by Ronald Jenkees

TWiP solves the case of the Long Island Man with Unilateral Eye Pain, followed by a discussion of how enteric helminth coinfection enhances host susceptibility to West Nile virus by a tuft cell-IL-4 receptor signaling axis.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Christina Naula

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• PWB on Facebook, Instagram, Twitter
• Helminth infection enhances West Nile viruses pathogenesis (Cell)
• Hero: Franz Von Lichtenberg
• Letters read on TWiP 194

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Case Study for TWiP 194

Woman in 40s, on return from Puerto Rico where she often went. Went to local beaches, brought their dogs. Noticed problem on foot, raised red serpiginous lines, slowly moving all over the foot. Bloodwork showed elevated eosinophils. 

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

Music by Ronald Jenkees

Audun returns to help solve the case of the Ecuadorean Gentleman Treated for COVID-19, followed by a discussion of the interaction of Blastocystis with the intestinal microbiota and the immune system, and of course a new clinical case from Daniel.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Audun Lier

Download TWiP #192 (46 MB .mp3, 76 minutes)

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• PWB on Facebook, Instagram, Twitter
• Blastocystis interactions with gut microbiota and immune system (PLoS Path)
• Hero: Lucy Engel Graves Taliaferro
• Letters read on TWiP 193

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Case Study for TWiP 193

Male, 50s, seen by physician for unilateral eye pain, blurred vision, watery drainage. Soft contact lens wearer. Given eye drops, oral medication, sent for another opinion when does not resolve. Has hypertension, hyperlipidemia, no surgeries, no allergies, is on hypertension/statin med. Works in store. No toxic substance use. HIV negative. Lives on large piece of land with his own well, away from city, own septic tank. Left eye is very red. Ophthalmologist report: decreased visual acuity in left eye, injection of conjunctiva, edema, erosions, send corneal scrapings for culture. Swims in Long Island Sound. No travel history. No pets. 

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Music by Ronald Jenkees

The TWiPers solve the case of the Teenager in Malawi with Red Urine, then Audun joins to present our clinical case for this episode.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Audun Lier

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• PWB on Facebook, Instagram, Twitter
• Hero: George B. Craig
• Letters read on TWiP 192

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Case Study for TWiP 192

Older gentlemen with chills, muscle aches, headaches, shortness of breath, family members same symptoms. Hypertension, diabetes. From rural Ecuador, worked in timber industry, worked on farm. No pets. COVID positive. Treated with steroids, ab. Got worse over next two weeks. Developed bloodstream infection and pneumonia. Saw serpiginous trail on diagnostic agar plate of sputum sample. Started on treatment and recovered. No eosinophils on admission, later developed eosinophilia. 

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Music by Ronald Jenkees

The TWiPers solve the case of the Rural Man from North Carolina with Blurred Vision, and discuss the results of single-cell RNA sequencing of Schistosoma mansoni.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• PWB on Facebook, Instagram, Twitter
• RNAseq atlas of S. mansoni (Science)
• Hero: Kathleen Hussey
• Letters read on TWiP 191

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Case Study for TWiP 191

Visit in Malawi, capital, teenage son of USAID worker urine has started to turn red. New to Malawi. On weekends go 2.5 hr east to lake and place to swim, Lake Malawi. Given pills, taken morning and night, clears up. Rest of family has been swimming in Lake Malawi. All in family are healthy. 

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

Music by Ronald Jenkees

Christina from Glasgow returns to help the TWiPlets solve the case of the Ghanian Woman with Abdominal Mass, followed by discussion of the impact of COVID-19 on malaria morbidity and mortality in Africa.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Christina Naula

Download TWiP #190 (57 MB .mp3, 94 minutes)

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• PWB on Facebook, Instagram, Twitter
• COVID-19 effects on malaria in Africa (Lancet)
• Hero: Clark Read
• Letters read on TWiP 190

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Case Study for TWiP 190

Male, 50 yo, rural NC, suddenly notices blurred vision right eye. Went away 1 hr later, normal vision. Returned next night, same eye, then corrected. Went to local doctor, sent to larger med center, went to Presbyterian Hospital NYC. Had exposure to various animals, normal diet. Dickson and Dr. Brown went to see this gentleman. Examined by head of ophthalmology dept. Dickson looked through ophthalmoscope and saw cause of his blurred vision in anterior chamber of eye. Next morning when were going to remove it, had penetrated optic nerve and disappeared. Sent home and never heard from again. Made living by selling hunting dogs, ran a kennel. 

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

Music by Ronald Jenkees

Christina from Glasgow joins the TWiPlets to solve the case of the Elderly Gentlemen with Full Body Rash, and to present a new clinical case for listeners to solve.

Guest: Christina Naula

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• Support MicrobeTV through Parasites Without Borders
• Hero: Tony Fauci
• Tony Fauci on TWiV 219 and 641
• Letters read on TWiP 189

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Case Study for TWiP 189

At a clinic in Ghana, woman seen for hernia, large swelling in right upper abdomen that grew steadily in previous year. Exam found to have mass, too high for inguinal hernia. Thought to be in liver. Mother, subsistence farmer, 50s, not unwell, no jaundice, mobile, overweight. Lump was firm, did not appear to be fluid filled, did not reduce under pressure, smooth, over 20 cm. Concern was liver cancer. Due to remoteness of clinic not possible to order tests. One test was done which could deliver the diagnosis.

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

Music by Ronald Jenkees

Dickson, Daniel and Vincent solve the case of the Baby with Hydrocephalus, and present a new clinical case for listeners to solve.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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Links for this episode

• PWB on Facebook, Instagram, Twitter
• Letters read on TWiP 188

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Case Study for TWiP 188

Man in 90s, suffering for months, healthy, hypertension, diabetes, large man, over 6 ft, 200 lb, rash. Full body rash for months. Gone through allergy med, cream, prednisone, some helped but regressed. Tried ivermectin 3 pills, got better for a few weeks, then rash worsened. Primary care doc did thorough exam, found abnormal area between toes, did scraping, sent to lab. When came back, asked some questions. Wife is also suffering. Gave larger dose of ivermectin, repeated 2 weeks later, wife also treated, and then recover. Not COVID-19, no HIV-AIDS, no drinking or smoking. Started before COVID, first in wife. Had gone on trip, not far away, stayed in hotel. No pets.

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

Music by Ronald Jenkees

Dickson, Daniel and Vincent solve the case of the Middle Aged Woman with Loss of Vision in One Eye, and discuss the role of heme oxygenase in the various protozoan infections.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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Links for this episode

• Heme oxygenase-1 in protozoan infections (PLoS Path)
• Support Floating Doctors at PWB
• Letters read on TWiP 187

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Case Study for TWiP 187

Pregnant newly married, living North Shore, first pregnancy. Affluent family, measured successful lawyer who cooks. Organic eating. Boy born at 9 mo, has midwife, has delivery at home. Baby has enlarged head. OB diagnosed with hydrocephalus. Mother healthy. No meds. Works in retail store, lives with husband, not working for second half of pregnancy. Drank alcohol rarely. No significant travel. Patient reports having no pets but her brother owns small farm, and husband likes serving rare meats, all kinds, which she has eaten since she married him. Will do ultrasound, CT, blood work.

Music by Ronald Jenkees

Dickson, Daniel and Vincent solve the case of the Elder Gardener Feeling Poorly, and discuss the three-dimensional ultrastructure of Plasmodium falciparum during cytokinesis.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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Links for this episode

• Three-dimensional structure of malaria parasite (PLoS Path)
• Support Floating Doctors at PWB
• Letters read on TWiP 186

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Case Study for TWiP 186

Middle aged woman quite upset, referred to Daniel. Sheltering at home, one day looking at her children, noticed problem with vision. When covers right eye, notices area of loss of vision in left eye. No other associated symptoms. Admitted to hospital, blood tests, eye exam (lesion in back of eye had developed). Blood: WNV serology, another was done but he’s not saying. Comes back positive. No cat or dog exposure. Healthy, no prior medical problems, no surgeries, no toxic habits, HIV unknown, married. 

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

Music by Ronald Jenkees

Dickson, Daniel and Vincent solve the case of the Wife of a Guy with Cyclospora Diarrhea, and discuss the discovery of an intrinsic oscillator that drives the bloodstream stage cycle of the malaria parasite.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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Links for this episode

• Intrinsic oscillator in malaria parasite (Science)
• Malaria parasite has intrinsic clock (Science)
• Letters read on TWiP 185

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Case Study for TWiP 185

Seeing this type of case 1/week for last several weeks. 75 yo female, admitted with fever, body aches, cough, loose stool for 2 week, sodium 118. Sheltering in place in Long Island, some gardening, no travel. Blood testing detected low sodium. COVID-19 negative, no other symptoms. Blood work: wbc 2000; hematocrit 24; platelets 40; sodium 120s. Unremarkable physical exam. Lyme test negative; other tick borne diseases negative.

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

Music by Ronald Jenkees

Dickson, Daniel and Vincent solve the case of the Safari Goer With Watery Diarrhea, and explain how a microsporidian endosymbiont of Anopheles mosquitoes might impair the transmission of malaria.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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Links for this episode

• Contribute to Parasites Without Borders
• Microsporidian impairs Plasmodium transmission (Nat Comm)
• Hero: Eugene T. Lyons (obituary)
• Image credit: Josh
• Letters read on TWiP 184

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Case Study for TWiP 184

69 yo female with several months of abdominal symptoms started in S. Africa, water shortage as described for her husband in the previous TWiP. Husband had C. cayetanensis. Her symptoms improved; her stool was positive for B. hominis and E. nana. Given many different treatments. Then comes to see Daniel. Some abdominal discomfort, mucosy stools. All past med/surg unremarkable, nothing in family, sent for repeat labs, stool O&P all normal including GI PCR

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Music by Ronald Jenkees

Dickson, Daniel and Vincent solve the case of the Female with Itchy Anus, and reveal the structure of a roundworm membrane protein involved in digestion of nutrients.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Structure of roundworm digestive complex (PLoS Path)
• Hero: Dr. Anthony Fauci
• Fauci Pharmacy (TWiV 219)
• Letters read on TWiP 183

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70 yo male. Returns with wife from safari in S. Africa. Reports suffering from 2 weeks watery diarrhea. Severe water shortage in S. Africa, limited washing water, hand sanitizers to clean hands so problem with hand hygiene.  5 days after arrival he and wife have water diarrhea, 12 per day, nauseated, abdominal cramping. Ab no effect. Stool culture, ONP, negative. Healthy, no past med/surg, no allergies, nothing runs in family. Stool sent off for ONP acid fast stain, also GI PCR panel. Prompts treatment for 7 days trimethoprim sulfamethoxazole, resolves.

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Music by Ronald Jenkees

Dickson, Daniel and Vincent solve the case of the Ugandan Volunteer With Morning Bites and discuss integration of HIV-1 into the Schistosome genome, with a sprinkling of COVID-19 throughout.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• PWB social media: Facebook, Instagram, Twitter
• Daniel on TWiV
• HIV-1 integration into Schistosome genome (PLoS Path)
• Image from John Southall's Treatise of Buggs, 1730.
• Letters read on TWiP 182

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60 yo female comes in with husband, grew up in Lima Peru. Having issue had when child, would get itchiness around anus, mother would have her eat pumpkin seeds. Every 2-3 weeks wakes up with severe itching. Put in q-tip and extracted something, has video of it. ONP stool cultures negative. Referred to Daniel. Negative medical history, no allergies, no surgeries, no medications. Does travel, mainly to Uganda. HIV negative, no toxic habits. Husband reports no symptoms. Has children/grandchildren.

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Music by Ronald Jenkees

Dickson, Daniel and Vincent solve the case of the Two Volunteers With Watery Diarrhea, discuss diagnosis of SARS-CoV-2 in the New York area, and reveal an approach to preventing honeybee colony collapse by imbuing their gut bacteria with the ability to produce antiviral and antiparasite double-stranded RNAs.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• PWB social media: Facebook, Instagram, Twitter
• Daniel on TWiV Special
• Engineered symbionts limit honeybee pathogens (Science)
• Letters read on TWiP 181

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Risks of being helpful. Volunteer from previous case. Diarrhea is gone, now has second issue. Since coming to Uganda noticing on waking in AM often has series of 1 cm red raised lesions in a line, 3-4, on torso. Swollen and itchy. New ones in the AM. Manager says welcome to Uganda. They move out of room, leave bedding behind. Lesions stop. What is going on and when can they move back into room?

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Music by Ronald Jenkees

The TWiP professors solve the case of the Ugandan Child with Splenomegaly, and reveal that mutations in the P. falciparum genome that confer artemisinin resistance interfere with endocytic uptake of hemoglobin.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Endocytosis pathway mediates artemisinin resistance in malaria parasites (Science)
• Letters read on TWiP 180

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Uganda with a twist. Meets two people with watery diarrhea, 12 episodes/day, loss of appetite. No fever, no blood in stool. Living for months at staff guest house. One week prior to onset went on weekend trip to area with waterfalls. Were served outdoor meal: meat, salad, fruit. Recommends empiric treatment trimethoprim/sulfamethoxzole for 7 days. Prompt resolution of diarrhea. A few days later, upon drinking coffee with milk gets severe cramps. 20s, long term female volunteers. 

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Music by Ronald Jenkees

The TWiP DVD solve the case of the Child Who Passed Worms, and discuss a non-human primate model for severe malarial anemia.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Primate model of severe malarial anemia (Sci Rep)
• Ascaris skirt (and more!)
• Hero: Harold W. Brown
• Letters read on TWiP 179

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From Uganda, eastern up in mountains, rainy season. 6 yo girl brought in by mother on Monday, reporting several days of feeling poorly, headache, fever, muscle aches. Negative malaria smear on Monday. Wednesday returns, feeling worse, fever higher, headache worse. Lungs clear, belly (pain on left side) has large spleen. Living in good conditions, well dressed, dirt floor house, concrete walls. Toilet is hole in back. Same dietary habits, high in carbs. No mosquito netting. Water from stream. No siblings. HIV negative.

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Music by Ronald Jenkees

The Knights of the TWiP solve the case of the Man Who Lost Weight, and discuss a Plasmodium protein kinase that is a malarial drug target.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Protein kinase as malaria drug target (Science)
• Hero: Myron Schultz
• Letters read on TWiP 178

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Eastern border of Uganda with Kenya, in mountains. Drinking water from nearby stream. Two young boys come to clinic, without parents. Sent in by grandmother because 1 yo brother has been passing worms. Long, white, flat. Shown photos in PD7, pinkish worm, 8 inches long, round. He points to those, what he has been seeing in brother’s stool. 1 year old seems small, protuberant abdomen; brother small for stated age, bit of protuberant belly. Diet: high carbohydrate, flour deep fried; yams; cabbage; some rice; soybeans; pumpkin; bananas.

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Music by Ronald Jenkees

The TWiPsters solve the case of the Rashy Schoolteacher, and reveal a drug from rotifers that live on the snail intermediate host which paralyzes schistosome cercariae and prevents infection of mice.

Hosts: Vincent Racaniello, Dand Daniel Griffin

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• Progress towards global eradication of dracunculiasis (MMWR)
• Rotifer compound that paralyzes schistosome cercariae (PLoS Biol)
• Image credit
• Letters read on TWiP 177

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49 yo man sent to Daniel for ID consultation. Reports in August visited Hawaii with family, then flies to CA. Family event there. Take him to Pakistani restaurant. One day later has gastrointestinal issues, nausea, diarrhea. Goes to urgent care, send stool for O&P. Look at stool, shows chilomastix mesnili. No medicines, will be ok. Over this period of 1 week he loses 15 pounds. Gains 5 back. End of October feels fine, no bloating or diarrhea. No symptoms but goes to gastroenterologist. Stool test returns with D. fragilis; and chilomastix mesnili. Now sees Daniel. Not on any meds. No allergies, no toxic habits, athletic. No illness in family. Normal exam. He ate salads in Hawaii.

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Music by Ronald Jenkees

The TWiPpers of the bite fantastic solve the case of the Indian Man Who Hiked, and discuss the effects of schistosome soluble egg antigen on infection of lymphocytes with HIV-1.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Effect of schistosome soluble egg antigen on HIV-1 infection (PLoS P)
• Hero: Lawson Soulsby
• Letters read on TWiP 176

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Recent case, woman in late 20s, schoolteacher. Outer boroughs of NYC. Wakes up on Saturday, completely rash-y, head to toe. Goes to urgent care center, say is allergic, give anti histamines and steroids. Persists after a few days, goes to allergist. Only allergen positive, dust mites. Few days later goes to GP, still itchy and rash-y. He does more thorough exam, notices she has small red lesions on fingers and between fingers. Several children in classes she is teaching has similar malady. Given therapeutic, rash goes away. Otherwise healthy, HIV negative. Partner not around at the time this develops.

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Music by Ronald Jenkees

The TWiP'ers solve the case of the Sudanese Boy With Fever, and reveal antibodies against that slow invasion of red blood cells potentiate other malaria-blocking antibodies.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Antibodies that slow malaria invasion (Cell)
• Hero: Sir Leonard Rogers (pdf)
• Letters read on TWiP 175

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70 yo man born in India, came to US 1985. Has not gone back for 2-3 years. Admitted with acute onset of fever, cough, not eating well. Was fine until a week ago, had lost consciousness, fever 102F. Negative cultures for urine and blood. Some kidney stones, type II diabetes, elevated cholesterol, no surgeries. No family medical issues. Started on vancomycin on zosyn. Works in post office, lives with house in private home. No toxic habits. Has history of hiking trip 1-2 months prior, in Rhode Island, in June. No pets, animals. Exam unimpressive. Labs: crit 25, hemoglobin 9. Platelets 39. Bilirubin 5.3. Liver enzymes slightly elevated. Chest CT clear, blood smear: anisocytosis, microcytosis, polychromasia, 4.3% reticulocytes. Daniel orders one test, 90 minutes later starts treatment. HIV negative.  

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Music by Ronald Jenkees

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPloid organisms solve the case of the Doctor with Chronic Epigastric Pain, and reveal how levels of linoleic acid in the intestine enable the sexual cycle of Toxoplasma gondii in cats.

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• Determinant of T. gondii sexual cycle(bioRxiv)
• A Year's Worth of TWiP by Kevin Carney
• Hero: William Trager
• Letters read on TWiP 174

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12 yo male living in refugee camp after fleeing Sudan. Presents to doctor with history of fever for many months, every other day; chronic abdominal pain. Tried antimalarials, no effect. Broad spectrum antibiotics, no effect. Exam: fast heart, clear lung, enlarged liver, enlarged palpable spleen. Camp has limited resources, no more diagnostic tests. Tried intravenous amphotericin. Child improves.  

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Music by Ronald Jenkees

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The podcastellani hosts solve the case of the Sailor With Dysentery, and reveal the first virus discovered in Plasmodium species.

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• Matryoshka RNA virus of Plasmodium (bioRxiv)
• Hero: Rose Gana Fomban Leke
• Letters read on TWiP 173

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Successful individual in NY area with 9 months of epigastric pain. Did upper endoscopy, saw in stomach several small mobile white serpiginous moving objects. 2.8 mm. Seem to be trying to burrow into gastric mucosa. One grabbed and sent to lab. History: curious habit of curing his own protein sources. 

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Music by Ronald Jenkees

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The metacyclic TWiPomastigotes solve the case of the Child With a Painless Leg Lesion, and reveal how to kill mosquitoes with a genetically modified fungus.

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• Transgenic Metarhizium kills mosquitoes (Science)
• Hero: Veena Tandon
• Letters read on TWiP 172

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Retired US Navy physician, lives aboard his sailboat, just finished doing remote medical volunteer work in C. America. In DR when has sudden onset of dull prog worsening epigastric lower abdominal pain. Over next 12 hr intensifies, near tears, went to local medical center. Admitted, given IV, probiotics. Febrile, elevated WBC 20,000, platelets low, white counts left shift. Initially some constipation, then diarrhea with some blood. Discharged without diagnosis; still fever and chills; rash rose colored spots on torso. Daniel gets involved; 3 day course of azithromycin, symptoms continue; then metronidazole, feels better, fever, pain, symptoms resolve. Wife is ok. Three men working on his boat, one had bloody diarrhea before the patient did. Keeps a bowl of nuts around.

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Music by Ronald Jenkees

The Leishmaniacs solve the case of the Child With Band Keratopathy, and reveal a eukaryotic parasite with functional mitochondria but without mitochondrial genomes.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Elmer Pfefferkorn, 87
• Eukaryotic parasite without mitochondrial genomes (Sci Adv)
• Hero: Charles Wardell Stiles
• Letters read on TWiP 171

By boat to remote village, young boy (

The TWiPlicates solve the case of the Child With Retinal Granuloma, and discuss an association of the complement protein collectin-11 with the pathophysiology of Chagas disease.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Chagas disease pathophysiology and collectin-11 (PLoS NTD)
• Hero: Theobald Smith
• Image credit: Toxocara canis by Ben Liffner
• Letters read on TWiP 170

3 yo girl, same context: mobile clinic in Bocas del Toro archipelago. Small village on remote island. Initially had red eye, rubbing a lot, mother noticed she seemed to have vision loss. On exam ophthalmologist did fundoscopic exam, sees band keratopathy, calcium on the cornea, and outer retinal punctate lesions.

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Music by Ronald Jenkees

The TriTWiPomonads solve the case of the Child Who Passed a Worm, and reveal recombination between bovine and human schistosome species.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• S. bovis and S. haematobiumhybrids (PLoS Path)
• Hero: Ann Bishop
• Letters read on TWiP 169

9 yo boy brought into mobile clinic set up in small village Bocas del Toro archipelago. Initially had red painful eye a few months ago, lasted 1-2 weeks. Eye no longer red but has issues with vision in the eye. On eye exam, some peripheral vision, but no sharp clear vision. Notes retinal retraction, seems quiet granuloma over macula of affected eye.

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Music by Ronald Jenkees

The Giardians of the Galaxy solve the case of the Woman With a Colonic Stowaway from Hispaniola, and discuss activation of intestinal tuft cells by Trichinella spiralis.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• T. spiralisand intestinal tuft cells (PNAS)
• Hero: Carl Theodore Ernst Van Siebold
• Letters read on TWiP 168

18 month old child, on medical mission for previous year with older sibling and 2 parents. Back in US for 2-3 months, just as leaving remote location were given dose of allbendazole. Call comes to Mom, child is at child care and has passed something. It is serpiginous, 5-6 inches in length, moving a bit. Not flat, but round. Child otherwise fine.

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Music by Ronald Jenkees

The Tremendous Trio solve the case of the Woman With Foul Steatorrhea, and reveal breakdown of the glycocalyx associated with severe and fatal malaria.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Glycocalyx and severe malaria (Clin Inf Dis)
• Hero: Bridget Ogilvie
• Letters read on TWiP 167

Woman 30 yo, traveled to DR, went to tourist part. On return for yearly physical, asked about her chronic constipation. She said does not have it any more, has normal bowel habits. A few weeks after her return this occurred. Primary care doc was intrigued, sent off some tests. Found Entamoeba hartmanni. What might the doc have done? What were the consequences of infection?

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Music by Ronald Jenkees

The Podfessors solve the case of the Teenager With Swollen Scrotum, and continue the story arc of Daniel's favorite cells, B-1 cells, and their association with protective immune responses in human Chagas disease.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• B1 cells and Chagas disease (Front Immunol)
• Daniel discovers B1 cells (J Exp Med)
• Hero: Bridget Ogilvie
• Image credit
• Letters read on TWiP 166

Recent consult from gastroenterologist. 61 yo woman on trip to Thailand, Cambodia for a few weeks. Developed diarrhea, took azithromycin, 3 days. Diarrhea continued, back in states now ongoing a few weeks. Left lower abdominal pain, bloated, gassy, loose stools, stick and foul smelling. Not sexually active, but is relevant. Not restrictive in what she ate. Drank bottled water. Did not eat raw items.

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Music by Ronald Jenkees

The TWiP team solves the case of the Four Year Old with Fever, Headache, and Cough, and discuss the release of extracellular vesicles from Leishmania amazonensis that manipulate the host immune response.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Crackles (Wikipedia)
• Extracellular vesicles released by L. amazonensis (Front Microbiol)
• Hero: Marietta Voge
• Image credit
• Letters read on TWiP 165

Still in Uganda. Young boy came from a distance to see Daniel, teenager with large swelling in scrotum, left side, 4-6 cm diameter, superior to testicle. Not only young man in area with similar problem. Daniel asked, are there people with large swollen legs? He said yes, my brothers wife, left leg is large, swollen, irregularity. Nontender. Can be transilluminated, and it glows.

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Music by Ronald Jenkees

The TWiP legends solve the case of Surfer Sans Septum, and discuss how two symbiotic bacteria in the tsetse fly allow colonization with Trypanosoma brucei.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• A Tale of Three Species (mBio)
• V.B. Wigglesworth (Wikipedia)
• VB Nimble, VB Quick
• Hero: James Paget
• Letters read on TWiP 164

Welcome to Uganda. Mother brings in 4 yo female child, end of rainy season, concerned that has one day of fever, headache, cough. On exam looks ill, unremarkable except rapid heart rate, localized crackles in right lower lung. Several children in family. Spends day swimming in local stream. Take care of animals. Help gather drinking water in morning. Live in dirt floor home, thatch roof, with animals around. Saw many others with same problem. What tests do you want to do?

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Music by Ronald Jenkees

The doctors of awesome solve the case of the Woman Who Visited Lebanon, and reveal that immunoglobulins protect the olfactory organ of trout against infection with the Ich parasite.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Mucosal Ig protect trout from Ich (PLoS Path)
• Hero: Sir Patrick Manson
• Letters read on TWiP 163

From here in US before leaving for Uganda: male has lesion affecting nose. Has been having problem with nose for 2 yr, in 40s, surfer, hit nose with board. Southern eastern Costa Rica. After that had blood and scabs from nose. Inside of nares, scab formed. Did not improve with time. Saw ENT doc on LI, said he hit nose and needs reconstructive surgery. Entire septum destroyed. 20+ years ago had non healing ulcer on left hand, saw physician in CR, was treated for 20 days.

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Music by Ronald Jenkees

The TWiP professors solve the case of the Baby With Pericardial Effusion, and discuss whether the flagellate without a flagella, Dientamoeba fragilis, causes human illness.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Patients with Dientamoeba fragilis infection (Am J Trop Med Hyg)
• Hero: Dr. Eloise B. Cram
• Image credit
• Letters read on TWiP 162

A fresh case. Woman in late 30s born in Palestine, moved to NY. Presented for care with sore throat, swollen lymph nodes. Married Lebanese man, he’s still there, travel back in forth. Had been in Lebanon for 3 weeks before illness. Ate special raw meat dish while in Lebanon. No other animal exposure. Small children at home, works in office. No medical/surgical history, no meds. On exam, has posterior cervical lymphadenopathy. Otherwise normal exam. HIV negative. Low grade fever.

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Music by Ronald Jenkees

The TWiPsters solve the case of the Brazilian Immigrant With Heart Problems, and describe how genome organization controls trypanosome antigenic variation.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Trypanosome genome organization and antigenic variation (Nature)
• Hero: Arthur Looss
• Letters read on TWiP 161

Daniel was asked to see 30 yo female from Bolivia, had to travel back during 3rd trimester. Was there for most of 3rd trimester. Child born in US, pericardial effusion, ascites, moderate PDA. Heart function is ok. Woman was healthy, no issues during pregnancy. Baby’s  white count elevated, diagnostic evaluation. It is a parasite.

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Music by Ronald Jenkees

The TWiPlets solve the case of the Electrician from Tamil Nadu with a Liver Mass, and reveal that dogs and humans share a common Chadian Guinea worm.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Chadian Guinea worms in humans and dogs  (PLoS NTD)
• Hero: Karl George Friedrich Rudolf Leuckart
• Image credit
• Letters read on TWiP 160

Referred to Daniel for consult, 40 yo immigrant from Brazil, a farmer had worked there, family in US. While here 1 y ago sees physician for increased heart rate, arrythmia, premature ventricular contractions, A-fib and flutter, treated by cardiologist then gets implantable defibrillator. Diagnostics: EKG, right bundle branch block; Echo shows heart is dilated with apical aneurysm; thrombosis.

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Music by Ronald Jenkees

The TWiP triptych solve the case of the 9/11 Survivor infested with parasites, and discuss the effect of community ivermectin treatment for onchocerciasis on Loa loa infections.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Ivermectin for onchocerciasis and loiasis (PLoS NTD)
• Hero: William Boog Leishman
• Thanks to Caitlin for the image
• Letters read on TWiP 159

Going back to India, gentleman in 20s seen during rainy season in south. Week of feely achy, fever, severe pain in right upper part of belly. Vomiting, no diarrhea. Married, no children, works indoors in trades - electrician. Drinks large amount of palm date liquor. Previously healthy, no allergies, no medical issues. No travel. On exam: right lung base decreased breath sounds; upper right area of belly can feel liver coming down. Area of intercostal tenderness. Elevated white count; left shift, eosinopenic, alk phos up. Chest xray: shows effusion in right base. Ultrasound of liver: fluid filled single lesion. Lesion aspirated.

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Music by Ronald Jenkees

The TWiP hosts solve the case of the Thai Woman With Red Bumps, and reveal that a master manipulator contacts ant brain tissue to control its behavior.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Imaging parasites in ant brain (Nat Rep)
• Brain worm turns ants into zombies (Nat Hist Museum)
• Hero: Giovanni Battista Grassi
• Image credit
• Letters read on TWiP 158

Male in 50s comes to see Daniel, concerned that is infested with parasites. Retired firefighter, 9/11 survivor. Several years of skin issues not resolved. 2009 dating Haitian girl, goes to Haiti to assist with disaster relief efforts, there notices itchy rash, worse at night, elevated eosinophils.  Prior biopsy showed arthropods with compound eyes. Treated with oral ivermectin, topical permethrin. Ulcers form, preceded by small white objects that pop off skin and these can swim in water. Repeat cystoscopies triggered by hematuria. Multiple biopsies and skin scrapings, all unrevealing. Had episode with forked headed worms came out while on toilet. Became temporarily blind. Another physician suggested were drug related. Brings Daniel video of swimming, skin scrapings. Spent time in Egypt where he swam in fresh water. Has issues with substance abuse. Family history unremarkable. One exam, has ulcerated areas widely. CBC eosinophil 700. Calcification at bladder periphery. Many negative tests returned. Review of many biopsies, stool ONP, all unremarkable.

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Music by Ronald Jenkees

The TWiP professors solve the case of the Woman With Intracellular Ring Forms, and explore the role of Coxiella and Rickettsia endosymbionts in acquisition of Babesia by ticks.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Endosymbionts and Babesia in ticks (Front Microbiol)
• Q fever with Robert Heintzen (TWiM Special)
• Hero: Percy Garnham
• Image credit
• Letters read on TWiP 157

Back to Thailand. Housewife, complaint has multiple red bumps on body, intense itching, worse at night. On head, legs, upper chest. Also does not feel well, feverish, muscle aches, difficulty breathing. Moved into abandoned residence, symptoms began a few days later. Many coconut husks around. Thatched roof. Husband and children developed similar symptoms. No med/surg history, no allergies. No meds. Unused mattresses, rat nests around. No toxic habits, no travel. No pets. On exam: not febrile, not toxic, increased heart, breathing comfortably. Has multiple red papules, central punctum. Labs unremarkable. Diff: unremarkable 6% eosinophils. Skin scraping from lesion on chest done.

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Music by Ronald Jenkees

The TWiP crew solves the case of the Ecuadorian with Immunodeficiency and Chronic Diarrhea, and discuss oral transmission of Chagas disease in mice.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Imaging Chagas after oral transmission (Sci Rep)
• NJ invasive species strike team and app
• Red Mother
• Hero: Angelo Dubini
• Image credit
• Letters read on TWiP 156

While on ID consultant service on LI during July, asked to see woman in late 70s admitted for fever, confusion, diarrhea. 2-3 days of abdominal pain, nausea, vomiting. Week prior was a family party, drank two large glasses Scotch. Had watery, nonbloody diarrhea 4-5 times per day; vomiting 2-3 times/day. Developed 103F fever, headache, lost appetite, 4-5 days did not eat. Hospitalized. No one else in party became ill. 2005 had episode of turning yellow after visiting Nepal. No surgeries, no allergies, no diseases running in family. ITP on prednisone, other drugs listen to podcast as well as PMH. Social history: worked in retail shop in Kathmandu, retired. Born west Bengal India, moved to Kathmandu as teenager, lived until 50s in nice part of town. Moved to LI 25 years ago, returns periodically to Nepal, last in 2017 for 2 months. Earlier this month had done 3 day camping trip with family on LI in tents. Brought water to drink, no contact with animals. Belly: small liver on percussion, no enlarged spleen, fluid wave, belly distended, white count elevated 38,000, no eosinophils. CAT scan of belly: cirrhotic liver, some acidic fluid. Notice intracellular ring forms less than 4% on smear.

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Music by Ronald Jenkees

Justin joins the TWiP team to solve the case of the Gentleman with B cell Lymphoma, and consider the finding of Dracunculus species in river otters from Arkansas.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Justin Aaron

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• Dracunculus in river otters (J Parasitol)
• Image credit
• Letters read on TWiP 155

Another challenging one. 60 yo man with poorly defined immunodeficiency: low Ig, low T cells, on chronic Ig therapy. Admitted with 1 yr chronic diarrhea. Had upper endoscopy, inflammation of duodenum, crypt hyperplasia, diffuse ulceration. Lower colonoscopy: granular appearance to cecal mucosa. Loss of haustral folds. Biopsies done and sent for culture. PMH: poorly understood interstitial lung disease. Unable to work, no toxic habits. Born Ecuador, moved to US in early 40s, living in Staten Island. No fever, bp low, hr >100, resp high teens. Remarkable: looks frail but not terribly ill. Labs: normal WBC, shifted to left with increase in neutrophils and eosinophils. Albumin low; respiratory pathogen positive for rhinovirus. Serum CMV: >4000 (virus measurement). Started on ivermectin, WBC rises, broad spectrum Ab.

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Music by Ronald Jenkees

Vincent and Daniel solve the case of the Man in the City with Groin Rash, catch up on the long backlog of email, and present a new case, possibly the most complex one yet on the show.

Hosts: Vincent Racaniello and Daniel Griffin

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• Bloodless malaria diagnostic (BBC)
• Image credit
• Letters read on TWiP 154

Daniel's colleague will solve this case, in two weeks. 79 year old man history of chronic lymphocytic leukemia that became B cell lymphoma, had chemotherapy a few weeks before coming. Was discharged with scrip for prednisone, but pharmacy made error gave him enough to take every day for over two weeks. Patient has fevers up to 100 degrees at home, headache, develops dry nonproductive cough. Brought to ER by family, there reports has lost weight. No nausea, no vomiting, no abdominal pain or diarrhea. Admitted to hospital. Has fever, chest x-ray suggests pneumonia, started on ab. Fever and symptoms continue, stop steroids. Chest CT shows multifocal ground glass opacifications and nodules. Increase ab to broader spectrum, ID is consulted. Positive test for latent TB. History hypertension, coronary artery disease, enlarged prostate. Gets bactrim, antifungal, antiviral. Born in DR, living in US since 70s. Visits occasionally had been a few months before. Lives with wife, no pets, no smoking, no toxic habits. Heart rate in 90s, looking fatigued, coughing, scattered crackles in lung, old systolic murmur, no rashes, confused, but family says he is always like that. TB test is negative. Negative for strongyloides. WBC count has increased, 30% eosinophils (over 7000). Stool ONP ordered but becomes constipated. CAT scan of belly shows thickening of colon.

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

Music by Ronald Jenkees

Vincent and Daniel solve the case of the Panamanian Farmer with Three Weeks of Diarrhea, and discuss how microbes egested during bites of sand flies exacerbate the severity of leishmaniasis.

Hosts: Vincent Racanielloand Daniel Griffin

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• Sand fly microbesand leishmaniasis severity (Cell Host Micr)
• Letters read on TWiP 153

Man in clinic, in city recently, developed rash in groin area, concerned about this. Lives in open relationship with male partner, had sexual encounter with another male. Few weeks. Rash is in the pubic hair, is very itchy. Mostly around umbilicus, can see blue spots in this area. These are skin changes. Buys magnifying glass to look and describes seeing things which we see as well. No notable medical history.

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Music by Ronald Jenkees

The TWiP peeps solve the case of the Panamanian Mother with Steatorrhea, and reveal new monoclonal antibodies that effectively block malarial infection.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Plasmodiumimmunity from injected sporozoites(Nature)
• New monoclonal prevents malaria infection(Nat Med)
• Parasite Hero: Carlos Chagas
• Image credit
• Letters read on TWiP 152

40 yo man in same Panamanian village, diarrhea for several weeks, notices blood mixed in with stool. Works in fields. No weight change, no fever, but tired. Drinking water from rooftop, lives in home with wooden slat floor, no electricity, many animals around, no one else sick in family. Lower belly tenderness, normal rectal exam. Farmer with 3 weeks of bloody diarrhea.

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Music by Ronald Jenkees

The Podfessors solve the case of the Itchy Child from Panama, and discuss competition for blood in human malaria-helminth co-infections.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Competingfor Blood (Ecol Letters)
• Parasite Hero: William C. Campbell
• Image credit
• Letters read on TWiP 151

Woman in 30s, mother of last two boys we saw, same locale. Concerned about abdominal pain for 3 years. Fullness, bloating of lower abdomen. No blood in stool, but occasionally loose stools, difficult to clean, stick/pasty/greasy stool. Had visited hospital, underwent test, told it is an ovarian cyst and needs surgery. Took omeprazole, allbendazole, azithromycin, none helped. On exam, diffuse abdominal tenderness. Portable ultrasound: small ovarian cyst 1.5 cm, not tender.

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Music by Ronald Jenkees

The TWiPers solve the case of the Panamanian Man With Leg Ulcer, and describe how a crab predator preferentially feeds on parasite infected prey - even though the parasite makes them faster!

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Parasite enhances susceptibilityto predators (Oecologia)
• Parasite Hero: Miriam Rothschild
• Image credit
• Letters read on TWiP 150

Up to Costa Rican border, travel by boat 2.5 hr, up stream through mangroves. Mobile med clinic in village in small island in archipelago. Mother concerned about two children, have a very itchy rash on trunk and arms. Worse at night, needs medicine. Boy is 6 yo, has rash on buttocks, arms, genital area. Nothing out of ordinary in medical history. Living in same village as previous case, few hundred people, home has slat wood floors, toilet is over water. Dogs, pigs, chickens; no electricity; water comes off roof. On exam see rash, on dermoscopy see 1 cm long brown lines, clotted blood deltas at end. In this area many kids have this rash.

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Music by Ronald Jenkees

Shivang joins the TWiP triumvirate to solve the case of the New Yorker With Rash and Pins and Needles, and reveal how agrochemicals increase risk of human schistosomiasis by causing high snail density.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Shivang Shah

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• Even dinosaurs had parasites (Cosmos Mag)
• Why some people are wormier than others (RSTMH)
• Angiostrongylus species in badger lungs (thanks, Rachel!)
• Spread of rat lungworm (Hawaii News Now)
• Aussie teenager swallowed slug (news.com.au)
• Agrochemicals increase snail numbers (Nat Comm)
• Parasite Hero: Émile Brumpt
• Image credit
• Letters read on TWiP 149

31 yo man ulcer on let, 4 cm diameter. Raised borders, reddish and hard. Feels well, concerned not resolving. Started as bump, slowly enlarged, ulcerated, 1 month now. Healthy, no prior med, diabetes in mom. Works in field with machete, lives with family, social drinking, smoking. Lives in isolated villages on Northern Panama archepelago, many animals and insects. Homes are raised, slats on floor. No fever, normal bp hr, breathing low teens. Healthy athletic young man, otherwise good health except for ulcer on left leg. Non tender, no pain, base of ulcer red; no purulent material, borders raised but not undermined. Feels hard around edge, no scab. Did dermoscopic exam: erythema, small yellowish teardrops, small white starbursts.

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Music by Ronald Jenkees

The TWiP-tologists solve the case of the South American Child With Belly Pain, and reveal how B1 cell IgE blocks parasite clearance by inhibiting mast cell activation by B2 cell IgE.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Do not eat raw earthworms! (Pediatrics)
• Would you let worms in your veins? (Science)
• Guinea Pig Doctors by Jon Franklin and John Sutherland
• Parasite Hero: David Bruce
• Letters read on TWiP 148

Will have a guest on next show to unveil! Female teenager living in NYC, previously in good health, rash for 2 week, abnormal feeling in legs. Initially had URT infection, no cough or fever. Rash is itchy, worse at night. But feeling of pins and needles, sharp stabbing in feet and legs. In ER told is zoster, started on gabapentin. Few days later fevers, pain getting worse. Seen by neurologist and ID doc, admitted. No past med/surg. Type 1 diabetes in aunt, father migraines, no autoimmune diseases. Had received chickenpox vaccine! Social: lives with parents and younger brother, much travel, Holland, Hawaii, most recent, pet lizard. In Hawaii, salad that she ate but no one else. Physical: febrile, heart rate >110, bp ok. Does not want to move because of pain. Neurological: extremity movement is slow. Rash irregular on chest, neck, back, abdomen. Labs: white normal, not much shift. Sed: 24, slightly increased. Lumbar puncture: increased white cells 280, 32% eosinophils.

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Music by Ronald Jenkees

The three amigos of parasitology solve the case of the New York Lawyer With A Foot Ulcer, and discuss a survey of rodents for the raccoon roundworm in California.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Monthly case studies (CDC)
• The Parasite on the Playground (NYTimes)
• Introduced rats and raccoon roundworm (J Parasitol)
• Parasite Hero: Theodor Bilharz
• Letters read on TWiP 147

Three year old boy, in tropical S. America, brought in by mother, says has been sick about a month. Previously healthy, 4 healty siblings, vaccines up to date, now has abdominal pain. Belly pain increases throughout day, poor appetite, constipated, has goat stools, pellets. Has had fever, seems swollen, face pale, urine dark, belly distended. Occasionally coughs. Living conditions: home has dirt floor where he spends most of day. On exam is febrile, doesn’t look well, no teeth, sleepy, not responsive, distended belly, pale, weight 13 kg. Diffuse scaly skin inflammation around perianal area, breakdown of skin around mouth. HIV, HTLV1 negative. Dogs, chickens, goats around, they come in house. Stool O&P sent out, contained something that gave diagnosis.

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Music by Ronald Jenkees

The TWIPniks solve the case of the Man With Diarrhea and 100 Micron Objects In Stool, and discuss the reticulocyte receptor for Plasmodium vivax.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Reticulocyte receptor for Plasmodium vivax (Science)
• Image credit: Parasitic Diseases, 6th Ed.
• Parasite Heroine: Marietta Voge
• Letters read on TWiP 146

27 yo male lawyer comes NY area to be seen, has 4 cm ulcer on right foot. Painless, has raised borders, minimal surrounding erythema. Going on for quite a while. Initially was papule, enlarged, ulcerated, this enlarged and has been more than 4 weeks. No past med probs, allergic to penicillin but just upset his stomach. No meds. Social habits: drinking. Own apt in NYC. Travel: 1 month before papule was whitewater rafting in Costa Rica, noticed when he got back. Wore sandals, got lots of insect bites. Afebrile, normal BP, fit athletic young man. Non tender lesion, base is red, white fibrous coating. Border raised but not undermined. No surrounding swelling, no eschar over wound, open non healing.

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Music by Ronald Jenkees

The Estimados Profesores of TWIP solve the case of the Man With Motile Objects, and reveal the secreted and excreted proteins of Giardia parasites.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Excretory and secretory products of Giardia intestinalis (PLoS NTD)
• Image credit
• Letters read on TWiP 145

Male 40s, visiting NYC on business. Lives in Thailand, seeks medical attention for diarrhea and abdominal pain. Diarrhea is continuous, even at night. Feels swollen. Stool cultures come back negative. CBC reveals eosinophilia. Clinician orders stool O&P. See something in stool: large elliptical objects, over 100 microns.

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Music by Ronald Jenkees

The TWiPtomaniacs solve the case of the Boy With Visual Disturbances and Itching, and discuss identifying secreted and excreted proteins of Trichinella parasites.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Malaria plasmepsins involved in invasion and egress (Science)
• Image credit
• Letters read on TWiP 144

Individual in 30s, male, presented to physician with stomach upset, uncomfortable feeling in legs. Has motile objects in stools. From Vancouver BC, was eating salmon, reports was either dried/smoked or marinated. Not sure if this is relevant. Brought motile objects to physician.

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Music by Ronald Jenkees

The TWiPians solve the case of the Woman With Anemia, Eosinophila, and a Worm in Her Intestine, and discuss a study on the function and druggability of two malarial aspartate proteases.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Malaria plasmepsins involved in invasion and egress (Science)
• Letters read on TWiP 143

From 1990s seen by a colleague, boy late teens, initially presented to ER in US chief complaint, visual disturbances and itching preventing sleep. Immigrated from Oaxaca, searching for work. Lived in modest dwelling with dirt floors, no running water, got from local river. Reports dogs, farm animals, many insects. On exam: tender nodules on head, skin irritated from scratching, small punctate lesions on right cornea. Is referred to specialists. Ophthalmologist called in, referred for further diagnostics.

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Music by Ronald Jenkees

The TWiPsids solve the case of the Guatemalan Positive for Rhinovirus, and reveal how to kill all African trypanosomes with a primate apolipoprotein.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• APOLs kill all African trypanosomes (Nat Micro)
• Trypanocidal properties of APOL1 on TWiP 85: Channeling tryps
• Letters read on TWiP 142

Woman in 50s, immigrant from rural area with limited resources. Admitted to hospital with iron deficient anemia and eosinophilia. In US. Sent for colonoscopy. Note long slender serpiginous motile object, recovered, 4.5 cm long, one end slender, other large and curled but not blunt. Send worm to parasitology lab for identification. What might fit description? Is this usually associated with eosinophilia? What about anemia, is severe or mild? Would this person have come from outside the US to acquire this, or could they have acquired the infection in the US.

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Music by Ronald Jenkees

The TWiP Wataalamu solve the case of the One Year Old From Kenya With Moving Skin Lesions, and describe how to make mosquitoes refractory to Plasmodium with engineered symbiotic bacteria.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Engineered Serratia make mosquitoes refractory to Plasmodium (Science)
• Operation Sea Spray (Wikipedia)
• Photo credit
• Letters read on TWiP 141

A 59 yo Spanish speaking female on Long Island originally from Guatemala. Goes to ER after returning from 10 day trip to visit friends and relatives in Guatemala and El Salvador with fever, cough, diffuse muscle aches, fatigue, chills. Respiratory pathogen panel done, positive for rhinovirus. Told that it's just a virus, go home. 5 days later returns with fever and chills, pain in upper belly, feels constipated. Admitted. No past med/surg, no allergies, no significant family history, no meds. Works cleaning houses. Travel: spends most time in and around big cities, lots of exposure to animals, ate all local fare; conch ceviche, fresh eggs, flattened chicken dish. Elevated white count left shifted, neutrophils increased, eosinophils cleared; cultured Salmonella from blood. IV antibiotics given, gets better, about to go out the hospital door, when results of stool O&P comes back from initial admission. Observed: Entamoeba coli; Endolimax nana; Blastocystis hominis. Released to home, 2 weeks later feels fine.

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Music by Ronald Jenkees

The triple TWiP solve the case of the Peace Corp Veteran with Eosinophilia, and discuss the genome sequence of the hyper-prevalent parasitic eukaryote Blastocystis.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Genome diversity of Blastocystis (PLoS Biol)
• Photo credit
• Letters read on TWiP 140

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. Get $30 off your first delivery and FREE SHIPPING by going to blueapron.com/twip.

From Dr. Arthur Mumelo, northern Kenya. One-year-old girl. Brought by mother with skin lesions that developed a week prior. The lesions are five in total – on the forehead, neck, back, chest and right arm. The lesions look like boils/furuncles but keep changing size and appearance – like something is moving under the skin. They are painful and itchy. Child is breastfeeding well. No other complaints. Child was born at Nyahururu County Referral Hospital. Gets vaccinations at Melwa Health Centre (Rural), vaccinations are up to date. They live in a wooden house with a dirt floor, roofed with corrugated iron sheets. The house has two rooms. They sleep on raised beds. There is a big community dam in the neighborhood, with stagnant water throughout the year. They don’t use mosquito nets. They have reliable clean water supply from the government. They have one dog but the neighbors’ dogs also visit their compound and living area. They hang their clothes on the clothesline after washing; never dry their clothes on the grass. Clothes not hot-ironed. On Examination; Child is breastfeeding well, afebrile, no pallor, no jaundice, not in distress. Occipital lymphadenopathy; tender, mobile. Furuncles on the forehead, chest neck, back and right arm. They are 1-3cm in diameter and 0.5 cm high, tender, have a central punctum from which serosanguineous fluid is discharging.  This is a rural health centre – the only labs done are a peripheral blood film – which showed increased eosinophils and neutrophils. HIV test – negative.

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Music by Ronald Jenkees

The TWiPwalas solve the case of the Woman with a Worm in Her Eye, and discuss the role of nitric oxide in the resistance of rats to Schistosoma japonicum.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Nitric oxide blocks schistosome development (PNAS)
• Photo credit: Dave the Sheep Shearer
• Letters read on TWiP 139

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get 3 meals free with your first purchase – WITH FREE SHIPPING – by going to blueapron.com/twip.

Seen at Columbia Medical Center, a crossover. Woman in 30s returns to US after 2 years in Peace Corp, Cameroon and Gabon. On medical exam 2 years earlier: eosiniphilia noted, no diagnosis reached. Now comes to NYC 2 years later to attend grad school, again eosinophilia noted. Asymptomatic.

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Music by Ronald Jenkees

The TWiPsters solve the case of the Child from DR with Poppy Seed Sized Things On His Head Hair Shafts, and reveal how the skin parasite landscape determines the infectiousness of Leishmania.

Hosts: Vincent Racaniello and Daniel Griffin

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• Tr (Cell Host Microbe)
• Letters read on TWiP 138

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get 3 meals free with your first purchase – WITH FREE SHIPPING – by going to blueapron.com/twip.

New Yorker, female teenager from an outer boroughs, visual loss in right eye noted during routine eye exam. Not sure when started. Left is 20-20, otherwise feels fine. No surgeries, no noted medical history, no medications, in school, living with family, no toxic habits. Travel: had been upstate NY in past year. No pets. Defect in right eye pupillary reflex, pallor to optic nerve. Serologies: toxocara, HCV, syphilis, all negative. Dilated fundal exam: sees 1850 microns motile worm in the eye. Not on surface, not Loa Loa.

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Music by Ronald Jenkees

The TWiPtoids solve the case of the Man from India with a Neck Lump, and explore the role of a transmissible dysbiotic skin microbiome in inflammation during cutaneous leishmaniasis.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Transmissible dysbiotic skin microbiome in cutaneous leishmaniasis (Cell Host Microbe)
• Letters read on TWiP 137

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get 3 meals free with your first purchase – WITH FREE SHIPPING – by going to blueapron.com/twip.

Little town in DR, fall of 2016, have already mentioned this patient; little boy 2-3 years old, not behaving well, warned if doesn’t behave, los gusanos will eat you! Mother asks Daniel to help son: lately is more irritable, troublesome, not well behaved; notices things in his hair. Has small poppy seed sized things on side of hair shafts. She picks them off in fingers and smashes them. What are they, what do I do? Simple dwelling, dirt floor, walls and tin roof, animals everywhere. No money for medicines, what can she do?

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Music by Ronald Jenkees

The TWiP Titans solve the case of the Man from Queens with a Blister Burster, and explain the role of inflammatory monocytes during Leishmania infection of the skin.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Inflammatory monocytes and skin Leishmania (PLoS Path)
• Dracunculiasis (TWiP 37)
• Photo: Daniel using a LifeStraw
• Letters read on TWiP 136

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free with your first purchase – WITH FREE SHIPPING – by going to blueapron.com/twip.

Patient seen by Daniel in India, 18 yo Islamic college student, left home, living in dorms in south, Hindu couple prepare meals, called dorm parents. He is being seen because developed lump in left side of neck, 1-2 cm mass. Previously completely healthy, no med/surg, no allergies. Prays multiple times a day, observes dietary restrictions. Afebrile, normal, but has 2 cm firm nontender lump inside interior portion of sternocleido mastoid muscle. Not tender. End of November, rainy season. No screens on dorm windows. No animal contact. Ultrasound done, and was helpful. Noticed in his neck over several weeks.

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Music by Ronald Jenkees

Dickson returns to the TWiP hosts to solve the case of the Woman from Colorado With Loose Stools, and explain how single-sex infection with female Schistosoma mansoni reduces hepatic fibrosis.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• ASM Grant Writing Online Course
• Single-sex Schistosoma infection (PLoS NTD)
• Asterix the Gaul
• Letters read on TWiP 135

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free with your first purchase – WITH FREE SHIPPING – by going to blueapron.com/twip.

Patient seen in clinic by Daniel's colleague, living in Queens, needs home care. Man with wound on foot, needed daily care. Living 9 months, recently developed painful blister, he put his foot in water, got great relief, blister opened up. Open lesion did not look normal, there was something in blister. Went to see parasitologist, saw something there, wrapped it around piece of wood. Not previously seen a physician, no surgeries, knew little family history. New to our country, where could he have possibly come from? Rural part of some country. Resource limited region. How many days of treatment will he need?

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Music by Ronald Jenkees

Daniel and Vincent solve the case of the Haitian Girl Who Failed To Thrive, and visit two studies that address the question of whether infection with Toxoplasma gondii alters human behavior.

Hosts: Vincent Racaniello and Daniel Griffin

• ASM Grant Writing Online Course
• Is Toxoplasma infection related to brain and behavior impairments? (PLoS One)
• Toxoplasma infection and sexual attraction (Evol Psychol)
• TWiP 21 - The giant intestinal worm, Ascaris lumbricoides
• Candiru (Wikipedia)
• Image credit
• Letters read on TWiP 134

Woman in 30s, coming in Colorado to be seen, reports foul smelling loose stools multiple times each day, cramping and nausea. Started a few weeks ago. No fever, summer, no unusual travel, skiing up in mountains, hiking, backpacking. Originally from NE, moved to Colorado one year before. Often drinks from streams. Treats water with iodine. On overnight trips pack food and cook on stoves. Sticky stools, trouble wiping clean. Yes, my stools do float. Color, not as dark. Well formed. No medical problems, no surgeries, no allergies. Takes no medications. Lives alone in private home. Drinks beer, no other toxic habits. None of her friends report similar problems. Sexually active, does not always use protection. Physical exam: unremarkable.

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Music by Ronald Jenkees

Daniel and Vincent solve the case of the Woman With Anal Area Discomfort, and discuss the multiple functions of a clathrin adapter protein in formation of rhoptry and microneme secretory organelles of Toxoplasma gondii.

Hosts: Vincent Racaniello and Daniel Griffin

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• Journal of Microbiology and Biology Education SciComm Issue (link)
• TWiP 19: Enterobius vermicularis, the pinworm
• Multiple roles of Toxoplasma gondii clathrin adaptor AP1 protein (PLoS Path)
• Image credit
• Letters read on TWiP 133

Seen while working in remote mountain makeshift mobile clinic in Dominican Republic, on Haitian border. Traveled 3 h by pickup truck, remote mountain town, womens centers. Set up makeshift mobile clinic in this center. Mother concerned about 6 yo girl, failure to thrive compared with sister, protuberant belly, frequent abdominal discomfort, going on over 1 year. No surgeries, no meds, first time ever seeing medical person. Mother and sister are family. Three children in family. Father does timber work. Very impoverished region, living in dirt floor home, drinking untreated water from local stream, go to bathroom outside, could be contamination. Diet: carbohydrate, plantains, rice, beans. On exam: lungs clear, heart fine, belly protuberant, liver and spleen not enlarged, some edema. Mother said noticed long motile worm in girls feces. Firm belly, not painful to her.

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Music by Ronald Jenkees

The TWiP-tastic peeps solve the case of the Thai Man Coughing Up Blood, and reveal potential therapies for trypanosomiasis that are inhibitors of protein import into glycosomes.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

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• Inhibitors of protein import into trypanosome glycosomes (Science)
• Hookworm (TWiP #22)
• Photo by Nita
• Letters read on TWiP 132

Young NYC woman with son (10), chief complaint of discomfort and itchiness in anal area. Has tried to look but nothing abnormal. Married, no complaints from husband or child. Two older kids have no complaints. But son has also been scratching in anal area. Everything fine 3 months ago, sister came to visit with 3 young pre-school children, may have caught something from them. No past med or surg history, no allergies. No meds, work out of home, no toxic habits, no recent travel. Have dog. Do lots of volunteering with children. History of sushi consumption. She does not like raw fish but son does. Worse itching at night. Going on for a number of weeks. Reports being under a lot of stress recently due to family.

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

Music by Ronald Jenkees

Jonathan from the podcast Arthro-Pod joins the TWiPerati to solve the case of the Peruvian Woman With Inguinal Insect Bite, and discuss warm autoimmune hemolytic anemic that develops after babesiosis.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest:  Jonathan Larson

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• Jonathan Larson (Twitter, Google Plus)
• Arthro-Pod podcast
• Warm hemolytic anemia after babesiosis (NEJM)
• Tickborne diseases of the US (CDC)
• Image credit
• Letters read on TWiP 131

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free with your first purchase - WITH FREE SHIPPING - by going to blueapron.com/twip.

Thailand. 39 yo man reports 7 months of coughing up bright red blood, several times with mucus. Otherwise feels well. Big fan of salted crab som tum. Fisherman, lives with family. Healthy, no past med/surg problems. No meds. On seeing him: afebrile, chest xray abnormal: area of increased opacification. Not a smoker. No toxic habits.

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

Music by Ronald Jenkees

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPniks solve the case of the Man With AIDS, and explore how secretion of extracellular vesicles influences the social motility of Trypanosoma brucei.

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• T. brucei exosomes and social motility (PLoS Path)
• Image credit
• Parasites Without Borders
• Letters read on TWiP 130

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free with your first purchase - WITH FREE SHIPPING - by going to blueapron.com/twip.

Back in Peru. 24 yo female seen in ER, lives in rural area outside of big city, adobe house in highlands, thatched roof, dirt floor, 3000 meters. Quite ill with skin lesion for 48 h. 2 days before was pulling on pjs, felt sharp sudden pain in right upper leg. Next day found small living creature in pajamas, inguinal region. Developed red lesion, enlarged, developed black central dot. Then begins vomiting, comes to hospital. No fever, breathing fast 20, hr 70, bp 160/10, on exam see in right inguinal region an enlarging, necrotic area 1-2 cm, starting to look sick. Whites at 26000, left shift, 200 platelets, eosinophils 4%, bilirubin 3.5, creatinine 4.9 (going into renal failure, not making much urine). Hematocrit 14, BUN 59.7, CPK 227, RBCs and leukocytes in urine. No health problems, no surgeries, first interaction with health system. No toxic habit. Brings in the small creature!

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

Music by Ronald Jenkees

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiP Masters solve the case of the Australian Wildlife Carer, and review evidence that nodding syndrome may be caused by an autoimmune reaction to the parasitic worm that causes river blindness.

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• Nodding syndrome an autoimmune disease? (Sci Transl Med)
• Nodding syndrome: Preventable and treatable (Sci Transl Med)
• River Blindness lyrics (Google Play)
• Image credit
• Letters read on TWiP 129

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free with your first purchase - WITH FREE SHIPPING - by going to blueapron.com/twip.

Young male in 30s, presents to ER with male partner, NY area, chief complaint over 1 month significant diarrhea, watery, non bloody. Abdominal cramping. Feels poorly, low energy, fever. Some vomiting, lost noticeable amount of weight, can’t stay hydrated. Past: AIDS positive, not on meds, last CD4

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPerati solve the case of the Man Who Sat in Feces, and discuss a study on how Dickson's favorite parasite induces the formation of a collagen capsule.

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• Induction of collagen synthesis by Trichinella (Vet Parasitol)
• Letters read on TWiP 128

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free with your first purchase - WITH FREE SHIPPING - by going to blueapron.com/twip.

Daniel doesn’t expect anyone to get this. From Australia, 80 yo retired teacher from Atherton, northheast Australia, presents to clinic with generalized weakness, concern of chronic lyme or Q fever. Seen by neurologist, concern about motor neuron disease. 18 months of illness, insidious onset of limb (arms and legs) weakness. No issues with speaking, swallowing or breathing; no weight loss; no fever, sweat, chill. History of osteoarthritis, joint replacements; myocarditis; vertigo; allergic to pen and dox. Father, rhematoid arthritis, brother colon cancer. On a number of medications. Does extensive travel, when not traveling, is a volunteer carer in Australia (abandoned wildlife), over the past three years. Lives with husband. Marsupials, hand feeds puggles and juvenile spiny anteaters, has pet cockatoo. No history of polio, HIV negative. Neuro exam: diffuse non tender muscle with no rash. Normal upper and lower limb tone, strength is symmetrically reduced proximally. Reflexes good at knees, normal sensation to all modalities. Normal cranial nerve exam. Test results: has eosinophilia, elevated muscle enzymes, EMG shows myopathic changes, nerve conduction normal. Stop statin therapy, no change. This is a rare parasite.

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

Music by Ronald Jenkees

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPsters solve the case of the Peace Corps Volunteer with a Liver Lesion, and discuss the dependence of Leishmania survival on the gut microbiome of the sandfly.

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• Leishmania depends on sandfly gut microbiome (mBio)
• Kava (Wikipedia)
• Letters read on TWiP 127

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free with your first purchase - WITH FREE SHIPPING - by going to blueapron.com/twip.

The last of our trio for the Peace Corp, an eosinophilia case. 29 yo pc volunteer in Rwanda, male, 3 weeks of feeling poorly. Starts with rash on lower back and upper legs, maculopapular rash. Fatigue later, cough, then diarrhea, 51% eosinophils (9000). No significant exposure to fresh water. Stool sent for oandp. Said sat down and got something on behind, realized later was feces, this was where rash developed. OandP seeing larva in stool. HIV neg, no med issue, no surgeries, no Kava. 

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiP Trinity solve the case of the Peace Corps volunteer with diarrhea, and reveal how immunizing against a virus ameliorates exacerbated leishmaniasis.

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• Viral vaccine prevents exacerbated leishmaniasis (PLoS NTD)
• For whom the trich tolls (TWiP 47)
• A virus in a parasite in a human (virology blog)
• Virologists in the mist (TWiV 128)
• Letters read on TWiP 126

This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free - WITH FREE SHIPPING - by going to blueapron.com/twip.

Another Peace Corps volunteer in Fiji. 24 yo male, several days of fever, headache, dry cough, rash. Feels poorly, starts diarrhea. No blood or mucus, no vomiting but abdominal discomfort. Heart rate over 100. At private nearby hospital for evaluation: no prior med probs or surgeries. Social history: MSM, not always protected, drinks every weekend. Home blown away by cyclone. Alcohol: drinks beer, a lot. White rice, split peas, bread diet. Fan of cava, also drank unfiltered water. He is admitted, continues to feel poorly. Continued fevers, localized abdominal pain RUQ. On exam he has tender palpable liver, elevated WBC 17.8, eosinopenia, 0 cells. AST/ALT slightly above normal. Dengue, chick, lepto, blood all negative. Ultrasound of liver: shows 8x8 cm mixed echogenic lesion in right lobe. HIV negative. 

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPonderers solve the case of the Timber Worker with Severe Shaking Chills, and describe an experimental malaria vaccine comprising attenuated sporozoites produced by genetic engineering.

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• Genetically engineered P. falciparum sporozoite vaccine (Sci Transl Med)
• Parasitology Superhero: Francesco Redi
• Image credit: Betsy Weissbrod
• Letters read on TWiP 125

This episode of TWiP is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free - WITH FREE SHIPPING - by going to blueapron.com/twip.

Thanks to the Peace Corps - 24 yo female serving in Cameroon, teaching English and science at local school. Been in country 5 months, first 3 lived with host family, now in own home in community with electricity, 12 hr from Yaounde, capital. Reports intermittent diarrhea, loose stools, abdominal discomfort. No prior problems, no problems in family. No meds. No drinking or smoking. Lots of animals present, roam into class. Eating all local fare, cooks some, or buy locally. Eats fish, vegetables, no fish. Sleeps in house with mosquito nets. Not sexually active, AIDS negative. Young kids at school 6-12 yo, 20 in room. Does not eat at school. Not clear if water is treated. Not on antimalarials. Going on for a few a few weeks. No fever, no rash.

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The prolific podcast-shedding Hosts solve the case of the Global Health Intern with a snakelike lesion on her foot, and reveal the role of a single-stranded DNA binding protein in differentiation of trypanosomes.

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• RPA protein and differentiation of T. cruzi (PLoS NTD)
• Image credit
• Letters read on TWiP 124

28 yo male from referral hospital near thai-burma border. Fever and chills 2 days, feels poorly, small amount of dark urine. Severe shaking chills, 1x per day, no rash. No diarrhea, difficulty breathing. Seen by local health care volunteer, went to hospital then tertiary hospital in Bangkok. Exposure history to pigs, dogs, insects, etc. Involved in timber industry and farming, sleeping out at night with no cover, clothes and sandals. No meds. Not married, family lives with him. Family is fine. Sleep in dwelling but no screens. No toxic habits, HIV negative, sexually active but not brothels. High fever, low bp, rapid heart rate, breathing rapidly, scleral icterus, dry mucus membranes, neck supple, lungs clear. 2/6 systolic murmur. Abdomen soft but tender, enlarged liver and spleen. Many cuts, bruises, bug bites. Labs: low platelets, low hematocrit, low glucose. Blood smear: abnormal, 5-10% infected RBCs with multiple band forms. 

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPanorama solve the case of the Dutch Woman with Wormy Objects in Her Stool, dissect a study on cytoadhesion of malaria infected red blood cells, and introduce Parasitology Superheroes.

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• Myiasis (Wikipedia)
• Cytoadhesion of Plasmodium in severe malaria (PLoS Path)
• Image credit
• Letters read on TWiP 123

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

Nurse in early 20s, recent grad, decides to spend year in global health internship in western DR/Haitian border. On her foot has skin issue: told is fungal infection, using antifungal cream, is getting worse. Several days, only on one foot. Healthy, no past med/surg/allergies, no meds, no HIV, lives with local family. Daughter, wife, husband, cat. No toxic habits. Originally from US, swims, walks barefoot to and from, shoes off in house. Easts local food, exposure to dogs, cats, sister. Very itchy, but not open; rash area is raised. Blistery in certain areas, involves different areas in different days, snakelike. 

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPniks docs solve the case of the Female from Peru with Epistaxis, and discuss the effect of community deworming on immunosuppression.

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• Community deworming and immune hyporesponsiveness (PNAS)
• Paul C. Beaver (one, two)
• Photo by Oscar Adam Oscarson
• Letters read on TWiP 122

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

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Case Study for TWiP 122 First of a series of cases with a theme, a 23 yo female international aid worker, chief complaint of diarrhea. Dutch descent, born in US, been in rural area of western DR, close to Haitian border. It’s been raining, houses have tin roofs, other flat concrete, rainwater pours off. Child comes by with mangoes, she buys one, washes it in rain water from the roof. Bites open mango, peels it, eats mango. The same night she is not feeling well, loose stools, abdominal discomfort. Next day, goes with group to border town; then has full fledged diarrhea. Looks into toilet, sees white objects 1 cm in length on stool, and they are moving. Uniform width, thinner than long, wormy looking. Has been participating in other activities in this area, swims in local river, walks barefoot, eating lot of local foods. Lunch: rice, beans, cooked meat, avocado. Dinner, yucca, fried salami, etc. Healthy before, no family history, not on meds, living with one of local families, no toxic habits. Dogs, cats, pigs, chickens around. One month earlier, cat in family home had kittens, she played with them. Very excited about that. Local physician contacted, he treats her. 

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPanosome docs solve the case of the Mali Man with Profuse Diarrhea, and review the presence of Trypanosoma cruzi in vectors, canids, and humans along the Texas-Mexico border.

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• T. cruzi in vectors, canids, humans at Mexican border (PLoS NTD)
• Tetracapsuloides bryosalmonae (Wikipedia)
• T. cruzi in US (Clin Micro Rev)
• Image credit
• Letters read on TWiP 121

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

Back to Peru. 55 yo female from highland central valley area near Cuzco. Works in farming, no prior skin lesions but has multiple hypopigmented scars on exposed extremities (trauma during working), now reports many years of bloody nasal discharge. Seen in Lima by Daniel in outpatient clinic. No other medical problems, no surgeries, no allergies, everyone in family fine, husband and kids. Still working. No travel except to see doctor. Exam in right nare: ulcerated lesion inside nose, muco-cutaneous lesion. Simple test will decide. No anemia, no fever. Not eosinophilic, labs normal, HIV negative.

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiP triumvirate solve the case of the Thai Woman with Facial Swelling, and explain how Th17 T cells protect against the intracellular parasite Trypanosoma cruzi.

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• Th17 cells protect against Trypanosoma cruzi (PLoS Path)
• Plasticity of helper CD4+ cells (Science)
• Image credit
• Letters read on TWiP 120

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

A 48 yo man from Mali comes to hospital ER in Washington Heights in NY with profuse watery diarrhea. Born in Mali, came to US at 18, working in US as long haul truck driver for 30 y, frequently visits Mali, recently to attend his father’s funeral. Got symptoms one week after return (was there for 3 weeks). 3 liters diarrhea/day. No past med/surg history, not seen doctor in long time. No allergies. Unknown what father died of, Mother in Mali is ok. No medications. Some alcohol, marijuana use. Does report that has exposure to professional female sex workers, no condoms. Temp of 39 C, bp down 80/40, heart over 110, rapid breathing high 20s, cachectic. Wasted. Fungating lesion perianally. Undergoes HIV testing, clade B. T cells

Hosts: Vincent Racaniello and Daniel Griffin

Vincent and Daniel solve the case of the Family with Eosinophilia, and discuss HIV-1 infection and genome integration in the blood fluke Schistosoma mansoni.

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• Family cluster of eosinophilia (Clin Inf Dis)
• Dientamoeba fragilis (Wikipedia)
• Parasites without borders
• HIV integrates into Schistosoma genome (PLoS Path)
• Image credit
• Letters read on TWiP 119

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

This episode is also sponsored by Drobo, a family of safe, expandable, yet simple to use storage arrays. Drobos are designed to protect your important data forever. Visit www.drobo.com to learn more.

This one will be kinder and gentler case. Back in Thailand but could be in several places. 25 yo Thai woman from Bangkok, to hospital, chief complaint facial swelling. Eats typical Thai diet (see previous episodes!) Som tum, etc fish that is not cooked. Migratory - moves around face. Not tender, but mild itchiness. For about a week, no pain. Healthy, no past med/surg history, family all fine. HIV negative, no drugs, no travel. On examination, has swelling on right side, 3-4 cm raised, little redness, firm, does not feel like fluid filled. No fever, no GI problems, no bloods. WBC up, eosinophils up. 

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPinella solve the case of the Woman from Guinea, and describe the use of CRISPR/Cas9 to identify essential apicomplexan genes.

• Malarias in Guinea (CDC)
• Genome-wide CRISPR screen in Toxoplasma (Cell)
• Plasmodium parasitemia associated with increased Ebola survival (Clin Inf Dis)
• Image credit
• Letters read on TWiP 118

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

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Little bit of a twist - a human family with eosinophilia. Conveyed by good friend/colleague ID physician. Australia, NSW, 45 yo Dad, having problem with mild abdominal distention. Seen by doc in Sydney, CBC shows eosinophil count of 10,500. Wife of same age reports feeling fine, but gets CBC and also shows eosinophils of 5,200. Two daughters, 17 and 19, no symptoms, bloods: 900 and normal eosinophils. One week prior to dads symptoms, sister in law came (also in NSW) and stayed, developed severe diarrhea, discomfort, bloating, weight loss, eosinohils 4,700. Eat raw fish (not known if fresh or salt) purchased at local markets. No overseas travel or out of urban environment. No pets, no home grown foods. Went back to previous labs and found normal eosinophil levels. Full workup for strongyloides, all negative. No HIV. No toxic habits, no remarkable medical history.

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The parasite prophets solve the case of the Thai Man with Abdominal Distention, and discuss the finding that metastatic leishmaniasis dependent on a virus can be prevented by blocking IL-17A.

• TWiP 27: Trematodes
• Leishmaniavirus and IL-17A dependent leishmaniasis (PLoS Path)
• Image credit
• Letters read on TWiP 117

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

This episode is also sponsored by Drobo, a family of safe, expandable, yet simple to use storage arrays. Drobos are designed to protect your important data forever. Visit www.drobo.com to learn more.

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Woman 66 yo born in Guinea, grew up the moved to US past 10 years, just retired. Lives in Washington Heights. Mother having issues in Guinea, so went back for 3 months in 2016. Just came back a week ago, reporting headache, fever, feeling poorly. Staying in big city, with Mom (80s). Has own private toilet in nice home. No screens or bednets. Married for 40 years, recently divorces. Has had 10 children. Not sexually active. Starts with high fever, breaks, then 2 days later another for several hours, goes to ER. Given Ebola screening questions, negative, do some blood work, send her back out. 2-3 days later high fever, double vision, headache, comes to Columbia ER. No diarrhea, no urination discomfort. Has backache, feels that mouth is dry. Was admitted. Past med history: high bp, cholesterol, diabetes; not overweight; appendix out; has unknown reaction to novocaine. No smoking, drinking. Physical: 39.4 temp, 14-16 breath rate, heart rate over 100, rapid heartbeat, 2/6 systolic murmur with radiation to left carotid (flow murmur). No jugular venous distention. Abdomen right upper quadrant: slight enlargement of liver, not tender, can palpate spleen tip in left upper quadrant, slightly enlarged spleen. Normal bowel sounds, no rash. Blood: elevated white count, bands 9%. 0.1 eosinophils, platelets 79, hemoglobin 11. Bilirubin 1.5, bicarb 20, chest xray clear. Red cells: small, 79.4 mcv. Animals: don’t like animals! In middle of rainy season. Likes to walk outside in rain during day. No cats to keep out rodents. Food: all food is prepared in home. Eats all favorite foods: rice. No sick contacts, no exposure to health care setting, no bug bites. 

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPtoids solve the case of the Thai Fisherman with Chronic Diarrhea, and reveal a potential new drug for treatment of leishmaniasis, Chagas diseases, and sleeping sickness.

• Capillaria philippensis (Wikipedia)
• Proteasome inhibitor for three parasitic diseases (Nature)
• Image credit
• Letters read on TWiP 116

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

This episode is also sponsored by Drobo, a family of safe, expandable, yet simple to use storage arrays. Drobos are designed to protect your important data forever. Visit www.drobo.com to learn more.

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This week's case involves no math. 36 year old Thai man from the northeast part of the country. Comes in with abdominal distention. Eats a normal Thai diet - Som Tam, Koi Pla, lots of rice. Feels well, came in because he is getting yellowing of skin and whites of eyes - jaundiced. Previously healthy, no prior med prob or surgery. No diseases running in family. Fisherman in the northeast (freshwater). Wife and many children, monogamous, HIV negative. Lives in jungle area, near river, many dogs, chickens, monkeys, goats, cows, pigs. Bathroom is outside. No fever, thin. Distention going on for months. Getting bigger. Exam: jaundiced, has large palpable non-tender mass below liver on his right side. No enlarged liver or spleen. No travel. 

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPlets solve the sad case of the Boy Who Went Swimming, and explain why the tomato is resistant to the plant parasite Cuscuta.

• Detection of plant parasite by a tomato receptor (Science)
• Dodder (Wikipedia)
• Mixed messages (TWiP 77)
• Image credit
• Letters read on TWiP 115

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

This episode is also sponsored by Drobo, a family of safe, expandable, yet simple to use storage arrays. Drobos are designed to protect your important data forever. Visit www.drobo.com to learn more.

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This week's case is more challenging, but with a better outcome than last time. Thailand: 32 year old Thai man from southern coastal part of country, comes to ID hospital in Bangkok with two months of watery diarrhea. Rapid onset. Looks emaciated, protuberant belly. Ten times per day, has trouble flushing feces in toilet, floats. Eats normal fare, boat noodles, fish, rice, vegetables. Som tam - fish sauce from raw fish. Also with salted crab, not well cooked. No unusual past med history, healthy fisherman, no medication. Married with kids, everyone healthy. No bad habits. Monogamous. HIV negative. Liver, spleen not enlarged. Abdominal xray with contrast: loss of villi. Good appetite. No abdominal pain. Too weak to work. No vomiting.

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiP troika solve the case of the Female from the Bronx, and reveal how feeding on different plants affects mosquito capacity to transmit malaria.

• Plant mediated effects on malaria transmission (PLoS Path)
• Image credit
• Letters read on TWiP 114

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/microbe and use the promo code MICROBE.

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12 year old boy brought to hospital ER by parents with severe headache, stiff neck, fever, decreased alertness. No rashes. Has been healthy with no prior medical problems. No one else in family is ill. In summer, boy has been engaged in usual summertime activities: soccer, swimming in warm freshwater, playing outside. Undergoes lumbar puncture for CSF: start on meningitis treatment. No surgeries, no allergies. Not on any meds. Lives with Mom, Dad, few brothers. No substance abuse. Not a geographically limited illness. Has had bug bites - lots of mosquito bites. Dogs around as well. Symptoms began a day or two before hospital visit. Eats whatever family eats, food is cooked. Exam: 39.4C, bp low, heart rate up, resp up, decreased responsiveness, stiff neck, looks ill. WBC elevated, neutrophil predominant, eosinopenia. CSF glucose low, cells increased, no bacteria, fungi, acid fast bacilli on stain. CT scan, diffuse swelling of brain. Doing poorly, not a good outcome.

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Jason Zucker

The TWiP ternion solve the case of the Man from Mexico, and discuss a transgenic toxoplasma vaccine for chickens using Eimeria tenella.

• Transgenic Eimeria as a toxoplasma vaccine (Sci Rep)
• Image shows cysticercus of T. solium in brain (Parasitic Diseases, 5th Ed)
• Letters read on TWiP 113

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22 yo female comes to clinic in Bronx, reports one week of vaginal discharge and itching. Looks bad, yellowish. Sexually active with boyfriend. He has no symptoms. Some discomfort on urination. Healthy, no prior surgeries, no allergies. Mother with diabetes, father has high bp. Takes oral contraceptive pills. Not employed, lives with mother and sisters. Substance abuse: some on occasion, marijuana and alcohol, no i.v. No pets. Diet: lot of fast food. Physical exam: slightly heavy, normal but vaginal exam: discharge, thick, slight yellow light green color, no strong odor, some redness to vaginal walls, no changes to cervix. 2 weeks from last menstrual period. 

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiP trio solve the case of the Woman from Washington Heights, and reveal how helminth infection protects mice deficient in the Crohn's disease gene NOD2 from intestinal disease by inhibiting colonization with an inflammatory bacterial species.

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• Helminth infection promotes colonization resistance (Science)
• NOD2 (Wikipedia)
• Image credit
• Letters read on TWiP 112

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A case here at CUMC, 59 yo male, past medical history of childhood polio, presents with worsening lower extremity weakness, bowel and urinary incontinence. 2 year before worsening back pain, weakness, could not work. Cannot walk up one flight of stairs since 1 month; 1 week prior to admission had fever, no headaches, diarrhea, cough, or any other symptoms. Splits time between Washington Heights and Mexico. Construction worker. Rural town in southern Mexico, 10 months of the year. Worked in the corn growing area. Has been exposed to bugs. Stopped working in cornfields 20 years ago. Has son and daughter, visits them. Lives with wife, stays in Mexico, she is fine. HIV negative. Eats home prepared foods, no dietary restrictions. Physical exam: not febrile, vital signs all good, neurological: upper strength good, weakness in hip flexors, ⅗; quadriceps, but ⅕ in lower extremities ⅖ in right. Sensory has decreased as well. Possibly spinal lesion. Labs: elevated glucose, ESR 33, CRP 2.2, whites 8, 30.6 hematocrit, guaiac negative. Imaging: MRI of spine shows normal vertebrae, T9/10 inflammation of spinal cord, mass lesion, compromise of canal. Brain MRI: hydrocephalus. Problem with recirculation of CSF. 

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiP trio solve the case of the bug bites all in a row, and talk about a secreted Toxoplasma protein that is central to the parasite's manipulation of host cells.

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• Pigeon mites feed on humans at night (EPA)
• Secreted Toxoplasma protein (mBio)
• Image credit
• Letters read on TWiP 111

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82 yo woman living in Washington Heights NYC 10 days of watery diarrhea, not smelly, does not float. Wakes her up at night. No fever, sweats at night. Losing some weight, appetite. No recent travel. Born in DR early 1930s, moved to US age 30. Sometimes goes back but not for several years. Springtime. Lives with extended family, only one sick. Eats whole assortment of cooked foods, rice, beans, fresh fruits. Drinks tap water. Not working. No pets. Stays mostly inside. History of reflux, high blood pressure, cognitive decline, diagnosed with temporal giant cell arteritis. Put on prednisone, doing better. Has had gall bladder removed. HIV negative. Extended family works in city, no taxi drivers. Belly uncomfortable for >week. Temp 38.1, BP 116/78, HR 105, breathing 12/min. Exam: looks ill, has diffusely tender abdomen, decreased bowel sounds. Liver, spleen not enlarged. Oriented. Has rash on abdomen: odd patchy distribution, looks like multiple thumbprints, front of belly, extending from umbilicus. White count 8, 78 polys, 14 lymphs, 4 mono, 1 eosinophil. Sodium 129, BUN 15, Creat 0.6. Urine histoplasma negative, TB test negative.

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Paul Calle

The TWiP trio visit the Bronx Zoo where Paul solves the case of the Four Year Old with Pulmonary Edema, and talks about his career as the Chief Veterinarian and Director of the Zoological Health program for the Wildlife Conservation Society.

• Bronx Zoo
• Avian malaria (Wikipedia)
• Letters read on TWiP 110
• Video of this episode at YouTube

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This week's case involves humans. Young woman, 40s, concerned about bug bites. Several weeks ago her 13 year old daughter woke up in morning, reported bug bites. Several small, red, raised itchy areas, 3-4 in a line, just above belt line. They go on vacation in Europe, no problems. Upon return, several weeks later the Mother woke up with a similar pattern. Then second daughter has the same problem. Family lives in NY metropolitan area, which is an epicenter for this problem. Always on trunk, not on arms or legs. No travel before the first daughter's bug bites. Husband does not report any problems. Family spends a lot of time outdoors, live in suburban wooden area.

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Hosts: Vincent Racaniello and Daniel Griffin

Guest: Paul

Daniel and Vincent solve the case of the Truck Driver from India, discuss why parasites resistant to an antimalarial drug are not transmitted by mosquitoes, and introduce Paul who presents a new case study.

• Atovaquone resistant parasites not transmitted by mosquitoes (Science)
• Image credit
• Letters read on TWiP 109

This episode is sponsored by CuriosityStream, a subscription streaming service that offers over 1,400 documentaries and non­fiction series from the world's best filmmakers. Get unlimited access starting at just $2.99 a month, and for our audience, the first two months are completely free if you sign up at curiositystream.com/m​icrobe ​and use the promo code MICROBE​.

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

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The case of the Man from Assam is solved, and phagocytosis of Leishmania by B-1 cells is brought to you by the Three Twipeteers on this episode of TWiP.

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• Kalazar detect (pdf)
• Phagocytosis of Leishmania promastigotes by B-1 cells (Parasite Immunol)
• Image credit
• Letters read on TWiP 108

This episode is sponsored by ASM Agar Art Contest and ASM Microbe 2016

Todays case is a 26 yo male longhaul truck driver from northern tiger country of India. Comes into hospital at end of rainy season with 6 days of fever, chills, muscle aches, small loose stools, vomiting, trouble breathing, cough, decreased urine output. Lives in mud hut with coconut leaf roof. No one else in family  is sick (wife, two children). Significant animal and insect exposure (dogs, cows, monkeys). Got sick after coming home from a trip up north. No significant medical probs, no surgery. Really sick. Pain everywhere. Occasionally drinks palm wine. Some yellowing of eyes. Has lost a little weight. Ketonic breath. Exam: 39 fever, bp 100/71, 126 heart rate, 24 resp rate. Looks distressed, not fully sharp. Nothing focal on lung exam. Belly tender, esp upper right, spleen enlarged. Liver is tender but not enlarged. Some labs: bun elevated 102, creatinine elevated, Hg decreased 11, platelets 9000 (down), white count 10.3 no eosinophils. LDH 8000 AST/ALT normal, bilirubin 21. Never been this sick.

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPtastic trio solves the case of the Surfer from Switzerland, and reveal how taste-chemosensory tuft cells in the gut regulate immune responses to parasites.

Links for this episode:

• Taste-chemosensory cells and parasite gut immunity (Science)
• Image credit
• Letters read on TWiP 107

This episode is sponsored by ASM Agar Art Contest and ASM Microbe 2016

Todays case is a fun case about a 45 year old gentleman from Assam India, with sixteen years of fever, abdominal pain, darkening of skin, yellowing of eyes. Farmer, does not have much energy. Works barefoot in fields. Fever occurs every other day. Prior medical problems, nothing out of the ordinary. No surgeries, no meds, has never seen physician. Married, kids, no extramarital affairs, HIV negative, eats mostly cooked vegetables. Lives in concrete house, no screens, mosquito netting. Other people in area have similar problems. Water comes from pump, fill plastic jugs. Been in Assam sick his whole life, finally came to regional med center for evaluation. Underweight. No pets. Dogs around, avoids dogs. Cows, monkeys are around. Fair appetite. Exam: febrile, in face can see darkening which is increasing, also extremities. Whites of eyes are yellow (jaundiced). Striking is has a very large liver, spleen. Elevated bilirubin. Some increased liver enzymes. No physical scarring or lesions.

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiP triumvirate solves the case of the Missionary in Kenya, and review the finding of a soldier caste in flatworms that parasitize snails.

• Social organization in parasitic flatworms (J Parasitol)
• Image credit
• Letters read on TWiP 106

This episode is sponsored by ASM Agar Art Contest

This week's case comes from an ophthalmologist colleague Florian in Switzerland. Swiss female, early 20s, returns after surfing vacation in northern Africa. Accommodations were rustic, lots of animal and insect exposure, right on the beach. No screens. Had loose stools there, now left eye is bothering her, eyelid swollen, eye red. This happened after return. Thinks she has seen things moving around in her eye. Opthalmologist gave eyedrops, now looking for second opinion. Healthy, no med/surg/allergies, no meds, student lives alone, occasional alcohol. No AIDS. Surfing in Morocco. Lots of insect bites. Little tiny things moving around in eye, on surface when she looks in mirror. All blood work was negative. Florian inspects her eye, surprised to see several tiny mobile objects, headed towards lacrymal ducts. Is able to grab one, about 1 mm long, plucks three off.

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPanosomes solve the case of the Young Man from Anchorage, and discuss how cestode parasites increase the resistance of brine shrimp to arsenic toxicity.

• Trichinella life cycle (pdf)
• When parasites are good for health (PLoS Path)
• The Origin of AIDS by Jacques Pepin
• Letters read on TWiP 105

This week's case involves a 32 yo male with several concerns. Spent 6 weeks doing religious missionary work in Kenya, performed baptisms in Lake Victoria.Waist deep in water, no shoes. Took malaria drugs, ate lots of interesting foods: cichlids, ugali, corn based food, flavored with greens; stew with some sort of meat, beef and goat. Five weeks after return developed rash with fever, shortness of breath. Three of four friends who were with him in Kenya reported similar symptoms. The fourth who did not get sick did not go in water, nor did he eat very much. No medical/surgical history, no drugs. Had some sexual activity while there. Elevated white count, 70% eosinophils. Chest CT shows nodules in lungs. Doc told him, allergy, you will be fine. The water he went into is near a village, there are rodents nearby, and a runoff.

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Michael Libman

Michael returns to help the TWiP trio solve the case of the Delusional African Expatriate, and discuss the association of natural and induced antibodies in mice with differential susceptibility to secondary cystic echinococcosis.

• T. brucei life cycle (pdf)
• Natural and induced antibodies in echinococcosis (Immunobiol)
• The collaborative cross
• Letters read on TWiP 104

This week's case involves a young man in his thirties, admitted in hospital in Anchorage AK in early June. Chief complaint, severe muscle pain and tenderness. Usually healthy guy, 1 week ago had bad case of diarrhea with belly pain and vomiting, lasted a full week. Now has fever. Concerned because wife now is having diarrhea. Unremarkable history, unknown family history. HIV negative. All childhood vaccinations. Does not eat raw meat. No meds, does seasonal work, social drinker. Came back from successful hunt, got a black bear. Dressed in field, cooked at home really well. Wife also ate bear meat. Bear meat is in freezer. No vegetables. Also eats salmon which he caught the previous season, then frozen. Drinks water from the stream when he hunts. Physical exam: hot, 38.5, bp 115/75, pulse 105, breathing comfortably. Anxious, swelling around both eyes. Sclera not noted. Labs: WBC elevated 14,000, 30% eosinophils; chemistries fine; muscle enzymes LDH, CK elevated.

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

Guest: Michael Libman

The TWiP-scholars solve the case of the Housewife from Kolkata, discuss mutations in the IL17 gene associated with cerebral malaria, and hear a case presentation from guest Michael Libman.

• IL-17 mutations and risk of cerebral malaria (Inf and Imm)
• Echinococcosis (CDC)
• Echinococcus life cycle (pdf)
• Letters read on TWiP 103

This week's case concerns a 42 yo male, refugee in Canada, from DRC, former Zaire, where there is unending civil war. Upper middle class, professor of French at university. Had been imprisoned, tortured, lived in jungle for a few years, reached refugee camp in Tanzania, moved to Canada. Came to health care system 15 months after arrived. Was sent to psych, unstable emotionally, delusions, hallucinations, depression, post traumatic issues. Was under psych care for ~1 yr, did not improve, became worse. Sent to hospital. History: talked about having minor injury, hurt lower back, pain there bothering him. Some anemia (normochromic), basic hem/chem/urine/liver nothing remarkable. Physical exam, nothing remarkable. HIV negative. Some evidence for chronic inflammatory condition: sed rate 60 (elevated), had diffuse increase in IgG, IgM. Developed some low level autoantibodies; anti-nuclear, p-anka, anti-neutrophil cytoplasmic antibodies. Slightly elevated fever for a few days, then few days or week with no fever. No eosinophilia. Radiology: on CT did have some mediastinal, aortic, axillae, lymphadenopathy. Prob screened in Africa for malaria and treated; prob also got ivermectin. Also got head MRI: not completely normal, classic nonspecific midbrain abnormality. Diffuse mild edema. Weight loss remarkable. No visual problems.

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiPyzoites solve the case of the Uncommon Parasite, and discuss the role of eosinophils in promoting the growth of Trichinella in skeletal muscle.

• Eosinophils and IL-4 support nematode growth (PLoS Path)
• Balantidiasis (CDC)
• Letters read on TWiP 102

This week's case involves a 24 yo housewife, from a village outside of Calcutta. Comes into a tertiary care hosp, 6 months coughing up blood, fever, no weight loss. Drinks rainwater, milks her cow. Dogs everywhere, no livestock except cows. Eats meat, well cooked. No extramarital encounters. Husband well. 4 children. Cistern for drinking water is covered.  No health issues. Reports salty, clear mucus. No blood in stool, no changes in stool. Exam: looks healthy, lungs clear. Lab tests: White count of 9000, 12% eosinophils (elevated). So she has eosinophilia. Chest X-ray and CT: lesion on left side in xray. CT: shows 4 cm cavity, with air pocket on left side, mid-lung. HIV negative. Dusty soil, birds.

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Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The doctors TWiP solve the case of the Woman with White Worms, and explain the role of a secreted growth factor from a carcinogenic parasite in wound healing and angiogenesis.

• Wound healing growth factor from carcinogenic parasite (PLoS Path)
• Opisthorchis (CDC)
• Opisthorchis life cycle (CDC)
• Image credit
• Letters read on TWiP 101

Ramon - Ancient Rome was infested with parasites

This week's case involves an uncommon parasite. Young girl,

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

The TWiP trifecta solves the case of the Woman from Bolivia with Belly Pain, and discuss a method for population modification of malaria mosquitoes using a Cas9-mediated driver gene.

• Cas9-mediated drive for population modification of malaria mosquito (PNAS)
• FAQ: Gene drives (pdf)
• Image credit
• Letters read on TWiP 100

This week's case is a 27 yo female, native NY, referred to outpatient at CU after seeing OBGYN, told had seen worms in stool and underwear. Inch or two in length, pale white, round, moving, 2-3 weeks of constant abdominal bloating. Sexually active. No particular diet. Travel: works for NGO, refugee camp in Ethiopian-Sudan border, southern Sudan. Last visit month ago. Noticed worms when she got back from last trip. Eats what local people eat. Raw food popular there: kitfo, raw steak tartare, with melted butter. Made from local beef. Did not take malaria prophylaxis, did not avoid local water, does wear sandals. College graduate. Nothing remarkable in family. CBC, liver, metabolic: all normal. Stool not normal: loose, no mucus or blood.

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The TWiP trifecta solves the case of the Professor Who Went to Brazil, and discuss an amazing case of a tapeworm that turned into a tumor in an AIDS patient.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• Do young doctors need more sleep? (Slate)
• H. nana tumor in AIDS patient (NEJM)
• Hymenolepiasis (CDC)
• H. nana lifecycle (CDC/Wikipedia)
• Image credit
• Letters read on TWiP 99

Case study for TWiP 99

This week's case is a 53 yo woman visiting family in US, comes in with intense belly pain, right upper part of belly. Has become strict vegetarian after having breast cancer, on raw vegetable diet (carrots, collect plants in local markets). From Bolivia. Lives in agricultural area, avoids sheep, fearful of dogs. Housekeeper. Married, lives with husband. Noticed pain when came to US. Breast cancer: localized, removed lesion, no therapy, months ago. No allergies, family healthy. No insect bites, lives in concrete house. Physical exam: not febrile, right upper quadrant is very tender, some liver enlargement. CBC: 10,000 white count, mostly eosinophils, liver function: AST, ALT, AlkPhos all normal. Neuro exam: normal. Five months before this diet, she did have normal diet. Some meat, drank milk.

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TWiP is a MicrobeTV production

The TWiP-lets reveal Balamuthia infection in the Children from Peru, and discuss resistance to pyrethroids revealed by RNA sequencing of Anopheles mosquitoes.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• Balamuthia (CDC)
• Pyrethroid resistance in Anopheles (Parasit Vectors)
• Voltage-gated sodium channels
• Pyrethroid (Wikipedia)
• Image credit
• Letters read on TWiP 98

Case study for TWiP 98

This week's case is a Professor clinician, teacher, researcher.  In his 50s, he presents with lesion on big toe, anterior portion, tip, nodular. No surrounding redness, area is itchy. Has a small central black area the size of pencil tip, concerned because feels is getting larger over last week. Spooky. Travels, last in Brasil, had been for a few weeks, noticed toe issue a week after returned. Spent time on beach, but wore flip flops. Different types of beaches, crowded and not crowded. Went with wife. Healthy man, no prior medical problems.

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The paratenic hosts reveal a case of scabies in the Traveling Salesman, and discuss a role for natural antibody in protection from infection with Plasmodium.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• Parasite Nobel Prizes 2015
• Ivermectin story (Nat Rev Micro)
• Ivermectin target (Brain Res)
• Gut microbiota and Plasmodium protection (Cell)
• Natural antibody (virology blog)
• Image credit
• Letters read on TWiP 97

Case study for TWiP 97

Daniel has two cases this week. Two people with similar presentations. A 12 yo girl in Peru presented for care with painless dark brown area on right knee. Has brothers and sisters, often play together. No trauma, but area is expanding. Months later develops cognitive changes. Second case is a 5 yo boy from the coastal region of Peru brought in by Mother, has red swollen area on face. Mom says while playing scratched nose, swelling right cheek, eye, nasal obstruction, no response to antibiotics. MRI of both show infiltrating process. Girl, left side of brain, middle cerebral artery territory. Boy in frontal region, midline area. Thus both skin lesions associated with infiltrating process in brain. Came into clinic months after lesions started, and lesions still present.

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The TWiPanosomes solve the case about the Young Woman who Went to Belize, and relate how sandfly saliva skews the immune response and increases risk of cutaneous leishmaniasis.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• Sandfly exposure and risk of cutaneous leishmaniasis (J Inf Dis)
• TWiP 14: Leishmania
• Image is L. longipalpis (credit)
• Letters read on TWiP 96

Case study for TWiP 96

Daniel's patient for this week is male patient referred for consultation by OB-GYN: his wife is pregnant, has been admitted and is about the give birth. It is her first pregnancy. There are concerns about the husband's skin problem and whether it is a threat to his pregnant wife. No lesions on woman, husband recently developed itchy skin problem on his hands. Bilateral. Small papules on webs of fingers, brown lines, blood clots at ends, has clearly scratched the lesions. Skin between fingers is involved. Travels, often stays in cheap hotels. Beds not clean. Last trip 1 month before symptoms.  Midwest travel. Family history of heart disease. Sales occupation. No animal exposure. Travels to medium to large cities. 

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Vincent, Dickson, and Daniel solve the case about the 33 year old Chinese male with watery diarrhea, and discuss whether arsenic in drinking water might lead to treatment failures for Leishmania infections.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• TWiP 17: Entamoeba histolytica
• Arsenic exposure and Leishmania treatment outcomes (PLoS NTD)
• TWiP 14: Leishmania
• Letters read on TWiP 95

This episode is sponsored by ASMGAP.

Daniel's patient for this week is a 28 yo single female, returns from beach vacation with new boyfriend. Two weeks in Central America (Belize). Often found secluded beaches. Good health, noticed upon her return had small nodules/papules on front of thighs. Thought were insect bites, became very itchy. Noticed serpiginous red lines forming, radiating out from bumps. Felt things moving in her skin. Benadryl did not help. Daniel say something similar occurs in Lima. Healthy, no allergies, surgeries, no relevant family history, using barrier contraception, sexually active. Only drinks alcohol socially. Boyfriend did not report symptoms. She did lie on sand, used thin fabric. Stayed in hotel. There were wild dogs on beach. During her stay she ate ceviche. No intestinal symptoms.

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Vincent, Dickson, and Daniel solve the case about the man from El Salvador, discuss the use of tyrosine kinase inhibitors to treat onchocerciasis and filariasis.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• Targeting filarial tyrosine kinases (J Inf Dis)
• Onchocerciasis on TWiP 24
• Filariasis on TWiP TWiP 25
• Image shows c-abl kinase bound to imatinib (red)
• Image credit
• What good are ticks?
• Letters read on TWiP 94

Daniel's patient was seen in the clinic. He is a 33 yo chinese male, from Chinatown NYC, for several months on and off has had watery diarrhea, headaches. Tried reflexology, chiropractic therapy, with no results. Has traveled quite a bit, been in Chile (was there a few months before). Came to US when young. Grew up in the US. In Chile, has had many sexual partners, >50, of both sexes, also has done many drugs. Two years ago was diagnosed with chronic HIV, CD4 count 685, on ARVs triple therapy, virus loads are well controlled. Has had syphilis, nose job, no medication allergies. Lives with family. On exam, afebrile, looks well. Symptom onset a few months after last Chile visit. Is an addventurous eater.

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Vincent, Dickson, and Daniel solve their fishy tale, and present a new case study for your consumption.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• Freezing and the quality of sushi (Clin Inf Dis)
• Anisakis biology (CDC)
• Image credit
• Letters read on TWiP 93

April 2015 a 177 lb 5ft10in 39 yo man seen as outpatient in ID clinic, reports 2 y ago had issues with constipation on and off; throat hurts; feels closing when lies down. For several years has had skin irritation on upper chest and arms. Tried to donate blood, was rejected, told to see doctor.

Emigrated to US from El Salvador 2002, married, reports no extramarital sex, smokes 2-3 cigs/day, now quit; had drinking issue in past, no more; was agricultural worker in rural part of El Salvador; has history of asthma, on a number of medicines, including steriod nasal spray, inhaler, no visual problems, healthy appearing, not allergic to medicines. Family history: mother heart attack and diabetes; father peptic ulcer disease.

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Vincent, Dickson, and Daniel discuss how fluctuation in the price of guinea pig food could help transmission of the agent of Chagas disease, and present a new case study for your consumption.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• Ascaris on TWiP 21
• Ascaris lumbricoides life cycle (jpg)
• Child with distended abdomen due to Ascaris (jpg)
• Bottlenecks and Chagas disease (Proc Biol Soc)
• Letters read on TWiP 92

A 20 yo Japanese female student went to the emergency room with severe abdominal pain. nausea, had vomited. Had just enjoyed homemade sushi an hour or two previuosly. She prepared the sushi: rice, salmon, tuna rolls. Salmon was local, caught by boyfriend. Tuna from store, sushi grade. No past medical history, mother with anemia. Takes oral contraceptives. No toxic habits. No travel. Monogamous. Temp 100.2, bp 140/90, hr high 90s, breathing upper teens. Physical exam normal except appears distressed in pain, belly extended, tender in left upper quadrant. Friends ate sushi but no one else got sick. All guests ate both types of fish.

Send your diagnosis to [email protected]

Send your questions and comments (email or mp3 file) to [email protected]

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Vincent, Dickson, and Daniel review how Viagra might be used to block transmission of Plasmodium falciparum, and introduce a new case study.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• Malaria life cycle (jpg)
• cAMP regulates gametocyte infected erythrocyte deformability (PLoS Path)
• P. falciparum in bone marrow (Blood)
• Image credit
• Letters read on TWiP 91

Send your questions and comments (email or mp3 file) to [email protected]

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Vincent, Dickson, and Daniel discuss identification of an erythrocyte protein essential for invasion of Plasmodium falciparum, and introduce a new case study.

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin

• Dermatobia hominis (Wikipedia)
• Plasmodium falciparum erythrocyte invasion (Science)
• Plasmodium life cycle (TWiP #10)
• Letters read on TWiP 90

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