Case of the Week 684

 For our last case of May, we have a fun submission from Dr. Megan Shaughnessy. She noted the following in some fresh monkfish she purchased from a small local grocery store. What is the likely identification? Also, what is the risk to humans if ingested?

Answer to Case 684

Answer to the Parasite Case of the Week 684: Anisakid L3 larvae

The following is our third and final discussion from our amazing guest author and 3rd year medical student, Hadel Go. I'm sure you will all agree that her discussions have been among the best we've ever had on this blog. Congratulations on the excellent work, Hadel!

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Worm cases are always my favorite because the comments are either “They are so beautiful!!” (@Parasite_Power on Twitter) or “…That’s a wholelottanope” (Valmik in the comments).

This is a nematode in the Anisakidae family, likely Pseudoterranova or Anisakis spp., the two most common cause of human anisakiasis, as many of you suggested. A third genus, Contracaecum, is also a possibility. Mario George Nascimento and Melinh Luong point out that its dark color implicates Pseudoterranova (vs Anasakis which is usually white/pink/red). 

However definitive identification to the genus level requires closer inspection of the intestinal cecum and its positioning as mentioned by Idzi P. in the comments and seen in Case 563 which he donated.

Diagnostic features of Pseudoterranova and Anasakis spp. include a “mucron… and 3 poorly formed anterior lips with a small boring tooth” (see Case 157 and Case 557). The table below shows some varying characteristics between the two more common culprits:

Larva	Anisakis simplex	Pseudoterranova decipiens
Appearance	White, milky	Yellow-brown
Dimensions	19-36mm long; 0.3-0.6mm wide	25-50mm, 0.3-1.2mm wide
Other features	Blunt tail, long stomach, Y-shaped lateral cords, no cecum	Anteriorly directed cecum

 

LIFE CYCLE (CDC)
1. Marine mammals defecate into the sea releasing unembryonated eggs
2. Eggs become embryonated in water
3. L2 larvae form in eggs and hatch out
4. Free swimming L2 larvae are ingested by crustaceans and mature into L3 larvae in the hemocoel
5. Fish (any marine fish is susceptible) and cephalopods eat infected crustaceans
6. Larvae migrate to mesentery and muscle tissues of the new host
7. L3 larvae are transferred from fish to fish until ingested by a marine mammal
8. L3 larvae molt twice in the mammal and develop into adults which produce eggs

Anisakiasis occurs when these parasites at the L3 larval stage are ingested in raw or undercooked saltwater seafood. While some larvae will die following ingestion, or make their way up the esophagus into the oral cavity (much to the dismay of the human host!), they may also attach to the wall of the human esophagus, stomach, or intestine causing damage or inflammation. Since humans are incidental hosts, the anisakids do not mature into adults. Symptoms include abdominal pain, nausea, vomiting, distention, diarrhea, blood/mucus in stool, and mild fever. If a patient is allergic to anisakids, rash, itching, angioedema, or anaphylaxis can occur (even when the worms are dead). Complications include intestinal obstruction, peritonitis, and intestinal perforation. Severe immune response following penetration of intestinal tissue can resemble Crohn’s disease.

These roundworms can be visualized and removed with an endoscope, confirming the diagnosis. If not removed, they will eventually die and can cause inflammation. A biopsy can reveal an eosinophilic granuloma containing the dead nematode. Endoscopic or surgical removal of the parasites is curative. Treatment with albendazole has been used successfully to kill the worms, although not FDA approved for anisakiasis. Unembedded worms are usually eliminated by the body within 3 weeks.

Avoid infection by following one of these FDA recommendations which kills the parasite:
- Cook seafood (145°F or above)
- Freeze at -4°F or below for 7 days
- Blast freeze at -31°F or below until solid and store at -31°F or below for 15 hours
- Blast freeze at -31°F or below until solid and store at -4°F for below for 24 hours

I’ve often been asked if I eat sushi and sashimi knowing the prevalence of these worms… and the answer is YES, I love Japanese cuisine and I eat them regularly. All fish intended for raw consumption in the US are required by the FDA to be frozen as stated above so they should be safe. The dead parasites may still be on the tissue, but they won’t be infectious. I would however be more hesitant to eat raw or undercooked fish when traveling to places where there are less stringent regulations. Ask for sushi/sashimi grade fish and use your best judgement!

TAXONOMY
Kingdom: Animalia
Phylum: Nematoda (roundworms)
Order: Rhabditida
Family: Anisakidae

Read more:
1. CDC - Anisakiasis
2. Anisakidosis: Perils of the Deep | Clinical Infectious Diseases | Oxford Academic (oup.com)
3. Anisakis, Something Is Moving inside the Fish - PMC (nih.gov)
4. Assessing the risk of an emerging zoonosis of worldwide concern: anisakiasis - PMC (nih.gov)

Thank you @leon_metlay on Twitter for sharing this paper:
Intestinal anisakiasis. Report of a case and recovery of larvae from market fish - PubMed (nih.gov)

This is my third and final post as a guest blogger here and I’d like to thank Dr. Bobbi Pritt for the opportunity to learn more about these creatures and share what I’ve learned with you all!

Case of the Week 683

 This week's case is from a 4 year old boy with sudden onset of 'explosive' watery diarrhea, accompanied by low grade fever, nausea, vomiting, and loss of appetite. A stool specimen was obtained after 1 week of symptoms, and the following objects were noted on a modified acid fast stain. They measure approximately 5 micrometers in diameter. 

Here are some questions to consider:

1. What parasite is shown?

2. Name 3 common ways that infection is acquired.

3. What is the typical recommended treatment?

4. What are the risk factors for severe infection.

As with last week, Hadel Go is serving as a guest author, and will help us answer these questions later this week. Stay tuned!

Case of the Week 683

Answer to Case 683: Cryptosporidium sp. oocysts

The following OUTSTANDING discussion is from our guest author, Hadel Go, a third year medical student with a strong interest in clinical parasitology.

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We received some excellent feedback! Thank you all for leaving comments on the blog, on Twitter, and on LinkedIn.

Yes, these are Cryptosporidium oocysts. These protozoans can be identified by their size and consistent red color on modified acid-fast staining of stool samples. They can also be diagnosed from H&E stained tissue biopsies (see images here: Cryptosporidium, parasitewonders.com), but nucleic acid amplification tests (NAATs) and immunofluorescence microscopy have the greatest sensitivity and specificity. The two main species that cause infection in humans are C. parvum and C. hominis, although several others are also capable. Species identification requires molecular methods like NAAT and/or sequencing.

Transmission is fecal-oral through food and water contaminated by stool from an infected person or animal. Some examples include swallowing pool water, eating unwashed fruits/vegetables from unsafe farms where produce is contaminated with feces containing oocysts (@StephenTristam on Twitter noted a strong association with farming communities), handling infected farm animals especially calves (@KevKeel brought up infections among vet students!), caring for an infected person, engaging in anal sexual contact (as mentioned by @RA_MLS), and touching your mouth with contaminated hands.

Cryptosporidiosis will present with explosive watery diarrhea, stomach pain, nausea, vomiting and fever 2-10 days after acquiring the parasite as seen in our 4-year-old case patient. These are self-limiting in most immunocompetent individuals. Replenishing fluids and electrolytes to prevent dehydration is usually sufficient. The infection is mainly concentrated in the small intestine, but complications can lead to malnutrition and wasting due to malabsorption or severe dehydration especially in babies.

Immunocompromised patients such as people with HIV/AIDS, inherited immune diseases, or on immunosuppressive drugs can progress to severe chronic infection which may become fatal. The respiratory tract can also be affected (respiratory cryptosporidiosis) resulting in a persistent cough.

Nitazoxanide is the FDA approved treatment for diarrhea caused by Cryptosporidium in immunocompetent patients ≥ 1 year of age. However, as Idzi P. mentioned in the comments, “efficacy in immunocompromised patients is not yet clear… for patients with HIV, anti-retroviral therapy (to improve immune status) could resolve the symptoms.”

Prevention is essential: practice good hygiene, wash hands often, do not swallow water when swimming, only drink filtered or treated water/ice especially when traveling or camping, practice safe sex, do not consume undercooked meat or unpasteurized milk/apple cider, wash your fruits and veggies. To avoid recurrent outbreaks, please do not go swimming if you have diarrhea or within two weeks of resolution of symptoms.

The differential diagnosis is a protozoa in the same family - Cyclospora cayetanensis (discussed in Case 457). It causes cyclosporiasis which presents similarly and can be differentiated from Cryptosporidium species by measuring the oocysts. Their location within enterocytes also varies; see photos from Case 343. The table below compares the two:

	Cryptosporidium parvum	Cyclospora cayetanensis
Oocyst size	4-6 μm	7.5-10 μm
Acid-fast staining	Red staining (can be variable)	Often variable staining
Autofluorescence under UV	No (as pointed out by Idzi P.)	Yes
Location in enterocyte	Replicates outside the cytoplasm just below the cell membrane	Replicates within the cytoplasm
Transmission	Oocysts are immediately infectious leading to massive outbreaks	Person-person transmission unlikely because sporulation can take weeks and occurs in the soil.

DID YOU KNOW?
- Each sporulated oocysts contains 4 sporozoites.
- Cryptosporidium is resistant to chlorine treatments alone due to their protective outer shell.
- Ultraviolet light and boiling are effective ways to inactivate this protozoan.
- Cryptosporidium parvum oocysts are commonly found in young calves 1-4 weeks old.
- Cryptosporidium zoonotic infection can occur from sheep, cows, pigs, rodents and other animals.

LIFE CYCLE (3 developmental stages in bold)

1.      Oocysts (thick-walled spore, infective form) are shed in stool and ingested by host

2.      Excystation releases sporozoites which parasitize epithelial cells of the GI tract

3.      Meronts undergo asexual multiplication within the brush border

4.      Gamonts are produced from sexual multiplication

a.      Microgamonts = male; these rupture releasing microgametes

b.      Macrogamonts = female

5.      Microgametes fertilize macrogamonts forming a zygote

6.      Zygotes give rise to two types of oocysts

a.      Thin-walled oocysts cause autoinfection

b.      Thick-walled oocysts are excreted into the environment

TAXONOMY
Domain: Eukaryota
Clade: SAR
Infrakingdom: Alveolata
Phylum: Apicomplexa
Order: Eucoccidiorida
Family: Cryptosporidiidae

More information:
1. Parasites - Cryptosporidium (also known as "Crypto") | Cryptosporidium | Parasites | CDC
2. CDC - DPDx - Cryptosporidiosis Life Cycle

Thanks to Idzi P. for sharing the following articles about the 1993 outbreak in Milwaukee, WI (the largest known outbreak affecting ~400,000 people):
1. A Massive Outbreak in Milwaukee of Cryptosporidium Infection Transmitted through the Public Water Supply | NEJM
2. Costs of Illness in the 1993 Waterborne Cryptosporidium Outbreak, Milwaukee, Wisconsin

 

Case of the Week 682

This week we have a special guest author, Hadel Go, a medical student (Class of 2024) who is greatly interested in parasitology. I'm very excited that Hadel will be our first ever guest author! The following is our case that she will be teaching us about later this week.

The patient is a young man from Madagascar who presented with a 1-week history of chest pain, night sweats, and fever. Chest X-ray showed a right upper lobe peripheral cavitary lesion. Work up for tuberculosis including AFB stained smears of sputum and sputum PCR using the Xpert MTB/RIF assay were negative. Therefore, a wedge resection of the abscess was performed and revealed the following (H&E stain, 400x original magnification):

What is your diagnosis?

Answer to Case 682

 Answer to the Parasite Case of the Week 682: Schistosoma mansoni egg.

The following post is from our first ever guest author, Hadel Go. I think you will all agree that Hadel did an outstanding job writing up the answer to the case of the week, and that this is truly one of the best case answers we have had on this blog.

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Hadel Go, Medical Student, Guest Author

This is a Schistosoma mansoni egg in lung tissue as many of you correctly identified in the comments. The large lateral spine is a dead giveaway and creates the “quote bubble” morphology mentioned by Jacob @eternalstudying on Twitter. See more images here: Schistosoma mansoni, eggs, tissue (parasitewonders.com).

Here is an image of a S. mansoni egg in an unstained stool wet preparation.

The burning question in this case is: what is a Schistosoma mansoni egg doing in the lung? Typically, S. mansoni eggs are found in the stool, intestinal tract, and liver of infected humans. Paired adults (male and female) anchor themselves in a venule of the intestinal wall (often in the inferior mesenteric veins) and release eggs. Some of these eventually make their way through the intestinal wall into the lumen and out of the body with the stool, thus allowing the parasite's life cycle to continue. However, many of the eggs remain in the venule and travel via the portal circulation to the liver, where they become lodged and cause granulomatous inflammation.

Chronic infections and high parasite burden can induce portal hypertension due to obstruction by granulomas. This results in shunting and embolization of the eggs in ectopic sites outside the liver and intestines. 

Eggs can also occasionally be seen in the lungs during the acute stage of infection, during which larval migration, maturation and initial egg production occurs. Symptoms of acute pulmonary schistosomiasis occur within 2-8 weeks after exposure and patients present with a dry cough, dyspnea, wheeze, night sweats, or chest pain (as seen in this patient). Chest x-ray and CT imaging of the lungs will usually show small bilateral ground glass nodules measuring 2-15mm. Complications can include pulmonary arteritis and cor pulmonale. 

DID YOU KNOW?

Schistosomiasis is also known as bilharzia, named after the German physician and parasitologist Theodor Bilharz. It is a systemic hypersensitivity reaction to the parasite eggs that occur weeks after the initial infection. Acute symptoms include fever (Katayama fever), cough, abdominal pain, diarrhea, hepatosplenomegaly and eosinophilia. Madagascar has the fifth highest rate of schistosomiasis in the world.

LIFE CYCLE

1. Eggs in stool from infected humans are shed in water and hatch miracidia

2. Miracidia enter Biomphalaria snail tissue and develop sporocysts

3. Free swimming cercariae from snails are released in water

4. Cercariae penetrate human skin, lose their tails, and become schistosomulae

5. Schistosomulae spend a few days in the skin before entering the lymphatics and venules

6. On day 5-7, they migrate to the lungs and into the left side of the heart

7. After >15 days, they reach the portal blood in the liver

8. In the hepatoportal circulation, they meet their partner (they’re monogamous!)

9. They mature into adults and the pair migrate to the inferior mesenteric venules and lay eggs

FUN FACTS

Egg Size: 115–175 µm long and 45–47 µm wide, 150 µm diameter on average

Adult Male: 0.6-1.1cm long, 0.1cm wide; white

Adult Female: 1.2-1.6cm long, 0.016 wide (thinner and longer); darker in color due to hemozoin pigment

Distribution: sub-Saharan Africa, Brazil, Venezuela, Suriname, Caribbean, Arabian peninsula

Intermediate host: Biomphalaria snails

Treatment: Praziquantel (reinfection after treatment is common)

TAXONOMY

Kingdom: Animalia

Phylum: Platyhelminthes

Order: Diplostomida

Family: Schistosomatidae

More information:

1. CDC - DPDx - Schistosomiasis Infection
2. Pulmonary Schistosomiasis – Imaging Features - PMC (nih.gov)
3. Schistosoma mansoni Eggs in Spleen and Lungs, Mimicking Other Diseases - PMC (nih.gov)
4. Frontiers | Schistosomes in the Lung: Immunobiology and Opportunity | Immunology (frontiersin.org)
5. How IVI is confronting schistosomiasis in Madagascar - IVI
6. Madagascar.pdf (stanford.edu)
7. Schistosomiasis (1990): Entire title - YouTube

Case of the Week 681

This week's case was generously donated by Tracie Rose from Seattle. The following objects were seen in a Papanicolaou-stained preparation of aspirate fluid from a liver cyst. the patient is from Afghanistan. 

Identification? 

Answer to Case 681

 Answer: Echinococcus sp. invaginated protoscolices

Given the clinical history of a cystic lesion in a patient from Afghanistan, the causative agent is probably E. granulosus. 

The protoscolices are somewhat degenerated, but you can still make out the internal row of hooklets:

The protoscolex will evert if ingested by the canine definitive host and form the scolex of the adult tapeworm. Thanks again to Tracie Rose and her lab for donating this case!

If you liked seeing parasites stained with the Papanicolaou (pap) stain, you can also check out this previous case of Schistosoma haematobium eggs in urine. The pap stain is really quite beautiful!

Case of the Week 680

 This week's case is from Drs. Harsha Sheorey and Lauren McShane from Australia. The following were seen in bronchial washings from an immunocompromised patient (fluorescent prep for fungi and wet preps):

Here are the culture plates from the bronchial washings.

The patient also has Gram negative bacteremia. 

Diagnosis? As a bonus, what forms are we seeing in the respiratory specimens?

Answer to Case 680

 Answer: Strongyloides stercoralis hyperinfection

This impressive case shows numerous L3 (or possibly L4) S. stercoralis larvae from bronchial washings, and the accompanying culture plates showing bacterial colonies growing in the wake of migrating larvae. 

Thanks again to Harsha and Lauren for donating this case!