Monday, February 15, 2016

Case of the Week 385

This week's case was donated by an internal medicine resident, who passed the object shown below in his stool. He reported intermittent post-prandial abdominal pain and loose stools for several years, and a complete blood count 2 years ago showed peripheral eosinophilia. He has an extensive travel history, including trips to regions of Asia and Africa, where he ate the local food.






He unfortunately didn't save the specimen to submit to the laboratory since his wife was too grossed out and flushed it!


This resident now wants to know what to do next.

Questions:
1. What is your presumptive identification from these photographs?
2. What is your advice for further identifying the nature of this object?

10 comments:

Anonymous said...

The morphology of the object is compatible with tape worms of the Toenia species. The scolex most likely be still in the patient. The examination of a gravid proglotid after india ink injection and clearing will determine the species involved. A stool examination for ova will only identify to the genus level.

Florida Fan

Eagleville said...

Agree with Florida Fan. Taenia.
One of my prized possessions is about 3 feet of a Taenia sp.(I was a med student and the intern kept the other half as we were the designated team to unravel the worm and search the poop for the scolex which we never did find). This was a 6-foot worm in a 4-yr old girl who was living with her hippy parents in Mexico in 1970. The only symptom was that her mom found proglottids in her underpants

Eagleville said...

Agree with Florida Fan. Taenia.
One of my prized possessions is about 3 feet of a Taenia sp.(I was a med student and the intern kept the other half as we were the designated team to unravel the worm and search the poop for the scolex which we never did find). This was a 6-foot worm in a 4-yr old girl who was living with her hippy parents in Mexico in 1970. The only symptom was that her mom found proglottids in her underpants

Anonymous said...

The proglottids look more wide than long which would more likley go with D.latum. It seems to be a pretty long segment which would also favor the fish tapeworm. Trying to find the distinctive scolex or eggs would be helpful but just a microsopic exam of the proglottids should tell you for sure. Too bad the specimnen is gone. Although I would treat this with praziquantil, that often does not get rid of the scolex. The only sure way is a duodenal injection of diatrizoic acid under endoscopy.

Eric said...

Agree that the proglotids look more like D. latum than those belonging to the genus Taenia.

Anonymous said...

A review of the second and third picture does show that the proglotid is wider than long and there seems to be a median row of genitalia consistent with that of Diphyllobothrium sp.
In such case, I remain corrected.

Florida fan

Anonymous said...

Diphyllobothrium ssp. I would do further OAP to rule out retained worm(s)..looking for eggs.

Lee

William Sears said...

It's hard to tell about width vs length of proglottid because some sections have width longer and some length longer. Overall, there are some sections where width is greater than length and that combined with the impressive size of the entire worm would make me vote D. Latum.

Next Step: look for some sort of remnant, either eggs or perhaps remaining proglottid or scolex in subsequent stools. A little golytely and a strainer would help us flush out the answer...

Anonymous said...

I think if they were Taenia proglottid they would have a prominent genital pore on one side. I vote D. latum as well.

-HLCM fan

MD said...

I think on the morphology alone it would be hard to distinguish between Taenia and Diphyllobothrium, examination of the proglotids or eggs would give the clue. Not crucial, since empirical treatment with prazinquantel would take care of either. (Meanwhile, I studied and practice in Colombia, where helminthiasis is endemic, and we never ever search poop for anything! I know it´s described in books, but come on! Is that really necessary? You see an infestation, you treat it, scolex or no scolex)