This week's case was generously donated by Dr. Piryanka Uprety and the excellent Clinical Microbiology and Hematology Laboratories at the University of Pennsylvania. The following structures were initially observed by a hematology fellow in a wet mount (40X) from a BAL specimen. Photographs and videos are courtesy of Joyce Richardson, Vivian Whitener, and Darrin Jengehino from the Hematology Laboratory.
Wet preparation of the BAL fluid with iodine showed the following:
Answer: Adult Toxocara cati; the presence of this adult worm represents either environmental contamination (e.g. from an infected cat) or spurious passage by the child.
This case generated an excellent, entertaining, and somewhat disturbing (!) discussion. As many of you correctly noted, this is an adult Toxocara species. It has a similar appearance to Ascaris lumbricoides, but can be differentiated by the presence of the pronounced short, wide cervical alae:
The shape of the alae allow it to be differentiated from other Toxocara species. Note that the alae narrow towards that anterior end, giving the appearance of an arrow (image by my excellent parasitology technologist, Emily Fernholz).
Humans are not a definitive host, but can acquire infection with the larval form of the worm when accidentally ingesting eggs in contaminated soil or infected paratenic hosts. The larvae cannot mature in humans, but can migrate throughout the body causing a potentially serious condition called visceral larva migrans.
So how did this adult worm end up in a human host? Well, we can't really say for sure that it actually was IN this patient since it was noted outside of the body during bathing. Therefore it could have been expelled by family cat and simply ended up in the bathtub.
Alternatively, it could be that the child had ingested an adult or immature worm from the environment (the term kitty spaghetti will stick with me forever! See the comments for more information) and it had passed through her intestinal tract and was expelled intact. Authors from the US CDC published a interesting series of cases like this in 1998. You can read the article HERE.
Regardless of the scenario, it is clear that there is an infected household cat that needs to be treated. As I mentioned above, eggs that are shed from infected cats can mature in the environment and pose an infectious risk to humans (i.e. visceral larva migrans).
Happy New Year! This week's case is by Idzi Potters and the Institute of Tropical Medicine Antwerp. The following were seen in an unfixed stool specimen at 400X original magnification. (Hint: maximize the size of the video for best viewing). Identification?
Congratulations to Martin, Ali, Florida Fan, Mark, Atiya, Sara, and Alexandra who got this correct!
The videos show the beautiful 'spiraling' motility of this organism, similar but distinct from the 'falling leaf' motility of Giardia and the 'jerky' motility of Pentatrichomonas hominis. In the lab, of course, we would also have the final fixed morphology to aid in our diagnosis and confirm our impression from the direct preparation.
Answer: Charcot-Leyden crystals, white blood cells and red blood cells
As Florida Fan mentioned, the C-L crystals are a guise for snow crystals, and the red cells may perhaps represent red delicious apples before man-made ornaments were innovated. I also envision the C-L crystals representing pine needles, perhaps?
I was very pleased to stumble upon this 'tree' when looking for some crystals to photograph. Other than the star, nothing else has been digitally added to this image.
Answer: Blastocystis sp. AND pollen.
Wow, you all impressed me by noting the less obvious Blastocystis in image 1, in addition to the pollen in all 3 images. Also, no one mistakenly thought that the pollen was a helminth egg (e.g. Taenia sp.) - a common pitfall. Excellent job!
While the Blastocystis cyst-like forms are the only parasites presents (image 1), I do agree that the pollen is the most striking finding. And very festive as Florida Fan and Idzi mentioned! I will defer the identification of the pollen to the others as this is outside of my area of expertise, but appreciate the time that some readers took to identifying the specific variety shown here.
Every week I will post a new Case, along with the answer to the previous case. Please feel free to write in with your answers, comments, and questions. Also check out my image archive website at http://parasitewonders.com. Enjoy!
The Fine Print: Please note that all opinions expressed here are mine and not my employer. Information provided here is for educational purposes only. It is not intended as and does not substitute for medical advice. I do not accept medical consults from patients.