WEBVTT 00:00:00.200 --> 00:00:03.100 Welcome to this video lecture entitled Cases 00:00:03.100 --> 00:00:06.533 and Parasitology presented by Blain Matheson. 00:00:07.000 --> 00:00:10.933 Blain Matheson is currently a scientist in the Institute for Clinical 00:00:10.933 --> 00:00:16.200 and Experimental Pathology at R U P Laboratories in Salt Lake City, Utah. 00:00:16.500 --> 00:00:19.400 Mr. Matheson has been studying parasitology 00:00:19.400 --> 00:00:22.733 for over 20 years, including working at the Institute 00:00:22.733 --> 00:00:27.733 of Parasitology at the Czech Academy of Sciences in the Czech Republic. 00:00:28.366 --> 00:00:32.233 The Arizona State Health Department and the CDC, 00:00:32.233 --> 00:00:36.100 where he managed the DPI website for nine years. 00:00:36.533 --> 00:00:40.666 He has published extensively on parasitology and entomology, 00:00:41.033 --> 00:00:43.666 the latter of which is also a personal hobby. 00:00:43.666 --> 00:00:46.166 Will now turn the time over to Blain Matheson. 00:00:46.166 --> 00:00:50.100 Good afternoon, everybody, and thank you very much for this invite. 00:00:50.200 --> 00:00:53.900 So today we're going to look at funding unusual cases and parasitology. 00:00:53.900 --> 00:00:57.233 And these are some of the esoteric and kind of weird 00:00:57.233 --> 00:01:01.266 and sometimes gross cases that I've seen over the course of my career. 00:01:02.633 --> 00:01:04.800 I was actually first presented these cases 00:01:04.800 --> 00:01:08.566 a couple of years ago at another meeting where I was the keynote dinner speaker. 00:01:08.566 --> 00:01:11.400 And when you ask a parasitologist to speak at dinner, 00:01:11.400 --> 00:01:14.700 you have to kind of realize you're you might be in for trouble. 00:01:15.933 --> 00:01:18.233 These are kind of weird and unusual cases. 00:01:18.233 --> 00:01:21.300 Most people who do, even people who do parasitology 00:01:21.300 --> 00:01:24.600 on a daily basis and probably not heard a lot of these cases. 00:01:24.600 --> 00:01:26.566 So they are going to be kind of weird and unusual. 00:01:26.566 --> 00:01:30.066 But I hope if anything, they are fun and entertaining for you. 00:01:32.366 --> 00:01:35.366 So with that, let's get started. 00:01:35.833 --> 00:01:38.833 So there's going to be six cases. 00:01:38.866 --> 00:01:40.700 Each one is going to be introduced like a chapter. 00:01:40.700 --> 00:01:44.333 So chapter one is something fishy is going on in Atlanta. 00:01:45.666 --> 00:01:48.233 So this first slide, 00:01:48.233 --> 00:01:52.600 the gentleman on the right, that's Henry Bishop, he was my coworker at the CDC. 00:01:52.933 --> 00:01:55.933 This is actually a Henry Bishop story. 00:01:56.366 --> 00:01:58.900 One day, Henry was, 00:01:58.900 --> 00:02:01.900 going home from the CDC, 00:02:02.166 --> 00:02:05.666 and he stopped by a local grocery store, which will remain nameless. 00:02:06.233 --> 00:02:09.466 And he was going to pick out some fresh fish for dinner. 00:02:11.100 --> 00:02:13.833 So he's looking around the fish case, 00:02:13.833 --> 00:02:17.066 and he sees something sticking up out of one of the fish filets. 00:02:17.600 --> 00:02:20.900 And, you know, being a very good parasitologist, he knew what that was. 00:02:20.933 --> 00:02:24.900 So he decided he's going to get that fish steak and bring it home. 00:02:25.800 --> 00:02:28.066 He didn't cook this particular steak for his family. 00:02:28.066 --> 00:02:30.200 This one he brought into the lab. 00:02:30.200 --> 00:02:32.433 And here's the fish fillet. 00:02:32.433 --> 00:02:34.933 And you can see the arrows pointing to a little coiled 00:02:34.933 --> 00:02:38.166 orange thing in the, in, in the cod fillet. 00:02:39.833 --> 00:02:41.533 Little closer up, 00:02:41.533 --> 00:02:44.800 you can see the, the, the coiled object there in the, 00:02:45.966 --> 00:02:49.166 in the fish fillet, you could see maybe 2 or 3 more below it. 00:02:49.900 --> 00:02:53.300 And we ended up, dissecting out this fish fillet 00:02:53.300 --> 00:02:56.300 and this is what we saw. 00:02:56.866 --> 00:02:58.100 This is what we saw. 00:02:58.100 --> 00:03:02.500 So there were seven worms in this fish fillet. 00:03:02.500 --> 00:03:05.500 And six of them, as you could see, were alive and viable. 00:03:06.966 --> 00:03:10.533 So we looked at the one of the worms microscopically. 00:03:10.533 --> 00:03:14.066 And, the picture on the left shows the anterior end of the worm. 00:03:14.066 --> 00:03:18.233 You could see in the lower left, you've got kind of these three fleshy lips. 00:03:18.233 --> 00:03:20.066 You can see two of them here. 00:03:20.066 --> 00:03:23.433 Now, normally when you see a large white worm with fleshy lips, 00:03:23.900 --> 00:03:25.500 you think Astra a slumber coyotes. 00:03:25.500 --> 00:03:28.500 That's kind of like your classic worm that presents like this. 00:03:28.866 --> 00:03:30.700 But this one is this little spine. 00:03:30.700 --> 00:03:32.266 You can see the arrow pointing to it right here. 00:03:32.266 --> 00:03:36.300 That's called a boring tooth on the posterior end of the worm. 00:03:36.700 --> 00:03:39.633 We have this, another pointy object called a micron. 00:03:39.633 --> 00:03:43.466 And these two structures are very characteristic of a group of 00:03:43.466 --> 00:03:45.000 a certain group of nematodes. 00:03:46.500 --> 00:03:48.766 And here's the, 00:03:48.766 --> 00:03:51.966 kind of the central body of the worm stained in lacto phenol. 00:03:51.966 --> 00:03:55.933 Lacto phenol is, it's not the same as a lacto phenol cotton blue. 00:03:55.966 --> 00:03:57.033 You use it in mycology, 00:03:57.033 --> 00:04:00.300 but it's it's a combination of lactic acid and phenol crystals. 00:04:00.300 --> 00:04:04.133 And you can use it for making worms translucent so you can see through them. 00:04:04.133 --> 00:04:06.466 And there's this little thumb like structure 00:04:06.466 --> 00:04:08.133 running up the esophagus of the worm. 00:04:08.133 --> 00:04:11.133 And that was also very helpful in identification. 00:04:12.766 --> 00:04:15.366 So what Henry came across in his grocery store 00:04:15.366 --> 00:04:19.300 adventure was a worm called pseudo Terranova. 00:04:19.966 --> 00:04:23.200 Now, pseudo Terranova belongs to a complex of worms 00:04:23.633 --> 00:04:27.833 that are commonly called Anna Sackett nematodes or cod worms 00:04:27.833 --> 00:04:31.400 because, as you can tell, cod they're commonly associated with cod, 00:04:31.733 --> 00:04:34.233 although there's a lot of other fish you can get them from as well. 00:04:36.266 --> 00:04:36.833 The disease 00:04:36.833 --> 00:04:40.800 is called Anna Sacchi assessed the genera most commonly seen in human infection, 00:04:40.800 --> 00:04:44.566 or Anna sacra pseudo terra nova in contra cecum. 00:04:45.133 --> 00:04:47.500 The, I'll go to the life cycle in just a second. 00:04:47.500 --> 00:04:52.166 But marine mammals and in some cases birds are the normal definitive host. 00:04:52.666 --> 00:04:55.800 Humans are we're kind of accidental dead end hosts 00:04:56.366 --> 00:04:59.800 after eating undercooked fish and mollusks, for example, squid. 00:05:00.166 --> 00:05:01.333 These are all marine fish. 00:05:01.333 --> 00:05:04.833 So your freshwater lake fish are not going to have these worms in them. 00:05:05.866 --> 00:05:07.033 You guys are up in Minnesota. 00:05:07.033 --> 00:05:10.300 There's another worm you got to worry about in your lake fish. But, 00:05:11.566 --> 00:05:15.900 which is the the the fish tapeworms die, fill a bathroom and it's relatives. 00:05:16.366 --> 00:05:18.466 But this is a nematode we're looking at right now. 00:05:20.233 --> 00:05:23.233 The most common clinical presentation is, 00:05:24.700 --> 00:05:27.633 gastric pain or sometimes intestinal pain. 00:05:27.633 --> 00:05:30.833 The most common lab presentation is the, 00:05:31.166 --> 00:05:36.300 a worm submitted that was supposedly coughed up or or vomited up 00:05:36.300 --> 00:05:40.033 or crawled out of the nose or the mouth of the patient. 00:05:40.033 --> 00:05:43.133 And believe it or not, that's actually that's 00:05:43.566 --> 00:05:46.700 that's actually good because it means the worm is now out of the body. 00:05:46.700 --> 00:05:48.633 It's no longer and it's no longer in the body. 00:05:48.633 --> 00:05:52.733 So it's gross as that may sound, it's the best clinical outcome for the patient. 00:05:53.566 --> 00:05:56.266 We had a case when I was at the CDC where a lady woke up, 00:05:56.266 --> 00:05:58.033 and there was crawling on the side of her pillow 00:05:58.033 --> 00:06:00.833 because it came out during the night when she was sleeping, 00:06:00.833 --> 00:06:04.166 and she woke up and saw this little worm creeping across her pillow. 00:06:05.500 --> 00:06:07.800 Removal is curative. 00:06:07.800 --> 00:06:12.166 You don't really need to identify the genus or species for clinical purposes. 00:06:12.200 --> 00:06:12.833 An anesthetic. 00:06:12.833 --> 00:06:13.733 It is a nanosecond. 00:06:13.733 --> 00:06:15.900 No matter what genus it belongs to. 00:06:15.900 --> 00:06:19.466 So just as long as you can identify it in this group of worms, that's sufficient. 00:06:20.666 --> 00:06:21.900 So here's the life cycle. 00:06:21.900 --> 00:06:24.933 As I said, marine mammals and in some cases, 00:06:24.933 --> 00:06:27.933 fish eating birds serve as the normal definitive host. 00:06:28.400 --> 00:06:33.900 They shed eggs into the ocean water and the eggs are shed fully emanated. 00:06:33.900 --> 00:06:37.800 So what that means is they they already contain an infectious third and star larva 00:06:38.366 --> 00:06:41.700 that egg hatches and infects a crustacean. 00:06:42.533 --> 00:06:45.133 And the crustacean really just serves as a pair of tentacles. 00:06:45.133 --> 00:06:48.766 And what that means is it doesn't develop into the next stage of the crustacean. 00:06:49.300 --> 00:06:53.200 It just kind of uses it as, as a distribution apparatus. 00:06:53.700 --> 00:06:56.300 And then the crustacean is eaten by a fish, 00:06:56.300 --> 00:06:59.100 the worm that insists in the muscle of the fish and the definitive 00:06:59.100 --> 00:07:02.100 host becomes infected after it eats, 00:07:02.466 --> 00:07:06.666 fish harboring these L-3 larvae and humans are basically the same thing. 00:07:06.666 --> 00:07:08.233 We get it when we eat undercooked, 00:07:10.166 --> 00:07:11.333 an unfrozen raw 00:07:11.333 --> 00:07:14.900 seafood containing the infectious LS3 worms. 00:07:15.433 --> 00:07:18.800 Now, these worms will not develop to maturation in the human host. 00:07:18.800 --> 00:07:20.933 We're dead end host. 00:07:20.933 --> 00:07:23.933 Either they're going to come out of the body, or they're going to. 00:07:23.933 --> 00:07:28.200 And they're going to become calcified somewhere and just eventually die. 00:07:28.500 --> 00:07:29.733 So, for example, you'd never, 00:07:29.733 --> 00:07:32.866 if you suspected this disease, you would never look for eggs in stool 00:07:32.866 --> 00:07:36.100 because they don't reach sexual maturity in the human host. 00:07:37.733 --> 00:07:40.700 The four being clinical manifestations are gastric, 00:07:40.700 --> 00:07:45.233 intestinal, ectopic and, allergies gastric. 00:07:45.333 --> 00:07:49.200 So in the normal definitive host they live in the egg the gastric mucosa. 00:07:49.200 --> 00:07:53.200 So when a nematode is when you eat one of these, sometimes they'll proceed. 00:07:53.233 --> 00:07:55.866 They'll try to proceed to burrow into the gastric mucosa. 00:07:55.866 --> 00:08:00.033 So patients will present with this kind of upper sharp GI pain. 00:08:00.533 --> 00:08:04.233 The intestinal presentation is kind of the same thing except the worm has gone 00:08:04.233 --> 00:08:07.800 farther down the alimentary canal before it starts to burrow into the body. 00:08:08.333 --> 00:08:10.233 So usually a lower GI pain, 00:08:11.733 --> 00:08:13.700 and on some occasions the 00:08:13.700 --> 00:08:18.433 worms will actually penetrate, the, intestinal or gastric mucosa. 00:08:18.966 --> 00:08:21.633 And then, like most nematodes that are in the wrong host, 00:08:21.633 --> 00:08:24.633 they'll just kind of start wandering aimlessly around the body. 00:08:24.700 --> 00:08:27.933 So they might up in the umbilicus, the peritoneum, the spleen. 00:08:28.533 --> 00:08:30.066 They've ended up in lymph nodes. 00:08:30.066 --> 00:08:33.066 I've even seen one case in the pyramid trim. 00:08:33.200 --> 00:08:36.333 They usually die at these ectopic sites, and they're kind of 00:08:36.333 --> 00:08:38.133 diagnosed incidentally. 00:08:38.133 --> 00:08:41.133 For example, a patient will have some calcified structure. 00:08:41.266 --> 00:08:43.333 The doc may suspect a tumor of some kind. 00:08:43.333 --> 00:08:44.800 So they calcify it. 00:08:44.800 --> 00:08:45.233 I'm sorry. 00:08:45.233 --> 00:08:48.233 They they biopsy it, slice it, section it, 00:08:48.600 --> 00:08:52.700 and then in on histo path they see a dead calcified nematode. 00:08:53.333 --> 00:08:55.900 You can also get allergic reactions from these worms. 00:08:55.900 --> 00:08:59.166 And sometimes when people say they're allergic to fish, 00:08:59.166 --> 00:09:01.700 you got to kind of ask yourself, are you allergic to the fish? 00:09:01.700 --> 00:09:04.366 Are you allergic to worms in the fish? 00:09:04.366 --> 00:09:07.366 And, the symptoms can range from anywhere from just, 00:09:07.400 --> 00:09:10.866 mild urticaria to angioedema to even anaphylactic shock. 00:09:11.666 --> 00:09:15.133 These, this condition often develops in people that handle fish 00:09:15.133 --> 00:09:16.100 on a regular basis. 00:09:16.100 --> 00:09:19.566 So food preparers, people who work in fish markets, 00:09:19.833 --> 00:09:22.866 you know, they scratch their eyes, they might get a, conjunctivitis 00:09:22.866 --> 00:09:27.000 or even a contact dermatitis from handling these infected fish. 00:09:29.133 --> 00:09:33.266 So a diagnosis, the traditional, as I said, is morphology or microscopy. 00:09:33.266 --> 00:09:37.600 That's where the patient coughs up the worm and it's brought to the lab. 00:09:37.600 --> 00:09:40.766 So if you ever get an inch, inch and a half long white worm 00:09:40.766 --> 00:09:42.966 that looks like a baby, ask gross young ass. 00:09:42.966 --> 00:09:45.100 Gross. But it was coughed up 00:09:45.100 --> 00:09:48.100 by someone you should be thinking and and a second nematode. 00:09:48.900 --> 00:09:50.966 There is serology available. 00:09:50.966 --> 00:09:55.433 You'd start with the skin prick test, and then it's confirmed as radio immunoassay. 00:09:55.733 --> 00:09:59.900 When they perform the serology test, they do a skin prick test for the worm, 00:09:59.900 --> 00:10:01.766 but they also do it for the fish to make sure 00:10:01.766 --> 00:10:05.066 that the reaction is actually to the worm and not to the fish. 00:10:05.700 --> 00:10:09.333 There are no real molecular assays for this, this disease. 00:10:09.333 --> 00:10:12.833 If if you want to try to link the fish to the 00:10:12.833 --> 00:10:16.166 to the, to the worm, you can do maybe some epi studies. 00:10:17.300 --> 00:10:17.866 But really 00:10:17.866 --> 00:10:20.866 it serves no clinical real no clinical function. 00:10:22.933 --> 00:10:25.300 And just, reinforcing those structures. 00:10:25.300 --> 00:10:28.300 I showed you the boring tooth, 00:10:28.333 --> 00:10:31.566 in the lips or the the micron on the posterior. 00:10:31.566 --> 00:10:33.933 And now the micron. 00:10:33.933 --> 00:10:37.166 All species of pseudo turnover can have a micron contour. 00:10:37.166 --> 00:10:38.033 Cecum never does. 00:10:38.033 --> 00:10:39.333 And some and the sacks do. 00:10:39.333 --> 00:10:41.733 So you may not always see the micron. 00:10:41.733 --> 00:10:43.233 It's also prone to breakage. 00:10:43.233 --> 00:10:44.866 So is the boring tooth. 00:10:44.866 --> 00:10:48.333 So if you don't see these structures on the worm you haven't eliminated in out 00:10:48.333 --> 00:10:54.000 a second nematode, but generally a 1 to 2 inch worm that's presented as coughed up, 00:10:54.666 --> 00:10:57.266 with the three fleshy lips like screw 00:10:57.266 --> 00:11:00.266 is going to be a nanosecond nematode. 00:11:03.133 --> 00:11:06.066 And then this structure that I kind of alluded to earlier, 00:11:06.066 --> 00:11:08.833 this thumb like structure that's called a cecum, 00:11:08.833 --> 00:11:10.833 that tells us that this is pseudo terranova. 00:11:10.833 --> 00:11:15.166 If this was another genus like an a Sarkis, you wouldn't see the cecum again. 00:11:15.166 --> 00:11:17.033 Genus level IDs not important. 00:11:18.300 --> 00:11:20.933 At the CDC we have the means to I.D. 00:11:20.933 --> 00:11:21.366 it further. 00:11:21.366 --> 00:11:25.166 So we're going to identify things as far as we possibly can. 00:11:27.533 --> 00:11:28.166 All righty. 00:11:28.166 --> 00:11:32.800 So now that I got your, appetite started with the fish, appetizer. 00:11:33.866 --> 00:11:35.900 Chapter two, tracking 00:11:35.900 --> 00:11:38.900 worms in the bacteriology lab. 00:11:39.166 --> 00:11:43.666 So this is actually a case we had here in Utah, a homeless man in his 50s, 00:11:43.666 --> 00:11:47.366 presented with four days of abdominal pain, vomiting, and constipation. 00:11:47.833 --> 00:11:50.833 Unfortunately, he was, he was a victim of, 00:11:51.233 --> 00:11:55.333 physical assaults, while sleeping in a park here in Salt Lake City. 00:11:55.800 --> 00:11:59.833 He was an African immigrant, but he hadn't been to Africa for nearly 25 years. 00:11:59.833 --> 00:12:03.066 The initial diagnosis was cholangitis and pancreatitis. 00:12:03.733 --> 00:12:05.700 He did have gallbladder distension. 00:12:05.700 --> 00:12:08.900 His, biliary duct dilation and dilation 00:12:08.900 --> 00:12:12.233 of the common bile duct, but without visible obstruction. 00:12:12.733 --> 00:12:15.566 The pancreatic duct was not dilated. 00:12:15.566 --> 00:12:18.766 They didn't irk pee, and his upper GI was normal. 00:12:20.100 --> 00:12:23.400 They did a dual phase CT and there was near total thrombus. 00:12:23.400 --> 00:12:26.400 Conclusion of the portal vein system. 00:12:26.400 --> 00:12:30.200 With the gallbladder distention was confirmed 00:12:30.600 --> 00:12:33.566 and he was diagnosed with scoliosis status 00:12:33.566 --> 00:12:36.233 and a biliary tube was, 00:12:36.233 --> 00:12:39.233 percutaneous biliary tube was placed. 00:12:40.200 --> 00:12:41.900 It was believed that the for the portal 00:12:41.900 --> 00:12:45.000 vein thrombosis was secondary to the earlier cystitis. 00:12:45.000 --> 00:12:48.000 So the patient was anticoagulation. 00:12:48.000 --> 00:12:49.900 The blood cultures were negative. 00:12:49.900 --> 00:12:53.266 But biliary fluid culture, grew 00:12:53.300 --> 00:12:57.000 two species of ventral backdoor and a cam and a Candida candidate. 00:12:57.000 --> 00:12:58.600 Labrada. 00:12:58.600 --> 00:13:02.466 However, on the one of the agar plates, the technologist 00:13:02.466 --> 00:13:05.933 noticed these squiggly tracks running across the agar plate. 00:13:07.000 --> 00:13:09.400 And those of you who've done parasitology 00:13:09.400 --> 00:13:12.400 know what that usually points to. 00:13:12.900 --> 00:13:16.166 And so we went ahead and did an own PE exam on the biliary fluid. 00:13:16.166 --> 00:13:20.600 And sure enough, we found this, this larval worm in the biliary fluid. 00:13:21.966 --> 00:13:24.433 And if you're familiar with the tracks, you're 00:13:24.433 --> 00:13:27.166 probably guessing what this worm is. 00:13:27.166 --> 00:13:28.933 And this was strongyloides. 00:13:28.933 --> 00:13:30.633 Structuralists. 00:13:30.633 --> 00:13:34.533 Now, what's interesting is that picture I just showed you here. 00:13:34.533 --> 00:13:38.866 This is the did data form larva, the il1 larva that you typically see in stool. 00:13:39.433 --> 00:13:42.100 They don't migrate out of the GI tract. 00:13:42.100 --> 00:13:44.400 And we'll go over the life cycle and just the sex. 00:13:44.400 --> 00:13:47.900 So what is that doing in biliary fluid? 00:13:48.600 --> 00:13:50.933 There were some other interesting questions too. 00:13:50.933 --> 00:13:54.433 One, the patient hadn't been in an endemic area for 25 years 00:13:54.900 --> 00:13:56.366 now, that doesn't mean anything. 00:13:56.366 --> 00:14:00.133 If you know your strategy life cycle, you can get auto infection 00:14:00.133 --> 00:14:01.200 the last decade. 00:14:01.200 --> 00:14:04.200 So someone who hasn't been infected for 25 years 00:14:04.300 --> 00:14:07.500 could still have the worm, reproducing in their GI tract. 00:14:08.100 --> 00:14:09.400 He wasn't immuno competent. 00:14:09.400 --> 00:14:10.800 He wasn't on steroid therapy. 00:14:10.800 --> 00:14:13.400 So there was no reason to suspect that this was disseminated. 00:14:13.400 --> 00:14:14.333 Strongyloides 00:14:15.466 --> 00:14:17.566 in his serology was negative. 00:14:17.566 --> 00:14:19.300 Now, that's not always surprising. 00:14:19.300 --> 00:14:23.633 The serology for, Strongyloides is about 80% sensitive. 00:14:23.966 --> 00:14:26.400 It's not a very good assay. 00:14:26.400 --> 00:14:29.066 At least the, the Elisa screen is not. 00:14:29.066 --> 00:14:32.066 So a negative serology doesn't mean anything. 00:14:32.066 --> 00:14:33.966 The doctor in order. Stool Owen pees. 00:14:33.966 --> 00:14:36.666 They figure the guy's got strategy. We'll treat him for strategy. 00:14:36.666 --> 00:14:39.233 Doesn't matter if it's in the stool or not. 00:14:39.233 --> 00:14:42.566 And he was administered ivermectin daily for two weeks, 00:14:42.866 --> 00:14:45.600 without complication. 00:14:45.600 --> 00:14:48.866 So before we get into what was the strongyloides rub? 00:14:48.866 --> 00:14:51.166 Did a form larva doing in the biliary fluid. 00:14:51.166 --> 00:14:54.166 Let's go over the life cycle pretty quick. 00:14:55.300 --> 00:15:01.000 So, adult females only there's no adult males in the human host. 00:15:01.000 --> 00:15:02.333 The reproduced parts of the 00:15:02.333 --> 00:15:06.100 person are genetically, they lay eggs in the lumen of the intestine 00:15:06.100 --> 00:15:09.166 and in most cases, those eggs hatch while still in the intestine. 00:15:09.633 --> 00:15:13.933 And then you get these rubbed into former L1 larvae in the lumen of the intestine. 00:15:14.466 --> 00:15:16.500 And these larvae can do one of three things. 00:15:16.500 --> 00:15:18.300 They can be shed in stool and when shed. 00:15:18.300 --> 00:15:20.933 And still they take two different pathways. 00:15:20.933 --> 00:15:25.300 They can either become this flare of form L3 larva, third instar larva 00:15:25.833 --> 00:15:28.833 which penetrates the skin to infect a new host. 00:15:29.200 --> 00:15:31.300 Or it can go all the way to adults. 00:15:31.300 --> 00:15:33.366 You can have separate male and female adults. 00:15:33.366 --> 00:15:35.300 They reproduce normally. 00:15:35.300 --> 00:15:36.433 Female lays eggs. 00:15:36.433 --> 00:15:38.200 The eggs produce the rubbed into form. 00:15:38.200 --> 00:15:41.500 The road to the form becomes a flower form, and this fuller 00:15:41.500 --> 00:15:44.500 form larva penetrates the host. 00:15:44.600 --> 00:15:48.300 There's only one free living cycle, so if the progeny of these worms 00:15:48.300 --> 00:15:52.966 here don't infect a host, this particular generation dies out 00:15:54.300 --> 00:15:56.400 once in the host, the flower form 00:15:56.400 --> 00:16:00.033 larva migrates randomly and ends up in the small intestine, 00:16:00.533 --> 00:16:03.066 where it becomes adults and adult 00:16:03.066 --> 00:16:06.066 females and produces eggs and larvae. 00:16:06.633 --> 00:16:08.166 If you look at some of the older literature, 00:16:08.166 --> 00:16:11.166 they mention this, this pathway through the lungs. 00:16:11.233 --> 00:16:15.600 It's now generally believed that the the migration to the small intestine 00:16:15.600 --> 00:16:20.033 is random and that a long migratory phase is not necessary. 00:16:20.766 --> 00:16:23.766 The third thing that these larvae can do is they can become, 00:16:24.633 --> 00:16:28.200 flower form larvae in the intestinal tract where they auto infect. 00:16:28.200 --> 00:16:31.200 And you get this perpetuating, 00:16:33.600 --> 00:16:36.433 life cycle that, as I said, can last decades. 00:16:36.433 --> 00:16:40.233 Kind of the fourth thing it can do is if your patient is immunocompromised, 00:16:40.700 --> 00:16:41.700 these flower form 00:16:41.700 --> 00:16:45.300 larvae will migrate around the body and cause disseminated strongyloides. 00:16:45.733 --> 00:16:49.733 The most common side of disseminated through Angelo Diocese is the lungs. 00:16:49.733 --> 00:16:51.700 But they can also get in the kidneys. 00:16:51.700 --> 00:16:53.666 They can get to the brain, they can get to the eyes. 00:16:53.666 --> 00:16:55.100 They can get to the skin. 00:16:55.100 --> 00:16:57.466 They can pretty much get anywhere. 00:16:57.466 --> 00:17:00.466 But the lung is one of the most common sites of infection. 00:17:00.566 --> 00:17:03.666 But it's only the fully reformed larva that migrates. 00:17:03.666 --> 00:17:04.966 So what was this? 00:17:04.966 --> 00:17:08.100 Rob did a form larva doing in the biliary fluid. 00:17:10.600 --> 00:17:11.500 And another question 00:17:11.500 --> 00:17:14.666 was, was it causing the Tullio cystitis? 00:17:14.666 --> 00:17:15.566 Was it doing it alone. 00:17:15.566 --> 00:17:18.000 Was it doing it with the back door or just. 00:17:18.000 --> 00:17:19.633 There were lots of questions. 00:17:19.633 --> 00:17:24.633 So we came up with three possible hypotheses on how the L-1 larvae of 00:17:24.633 --> 00:17:28.100 strongyloides can get to the gallbladder without true dissemination. 00:17:28.900 --> 00:17:31.666 One was the reflux of duodenum contents 00:17:31.666 --> 00:17:34.666 through a dysfunctional sphincter of o.d. 00:17:34.766 --> 00:17:36.866 The patient was on a drug called tramadol. 00:17:36.866 --> 00:17:40.233 And there's some there's some anecdotal data that suggest tramadol 00:17:40.233 --> 00:17:44.533 can cause some or less relaxation of the, sphincter of o.d, 00:17:45.000 --> 00:17:48.666 which is the opening to get from the small intestine up there. 00:17:48.666 --> 00:17:51.900 And so they were they thought that maybe if it was relaxed, 00:17:51.900 --> 00:17:55.466 the worms just naturally migrated to other possibilities. 00:17:55.466 --> 00:17:58.766 When the IRC, p and biliary stunt was, 00:17:59.666 --> 00:18:01.666 placed, they went through the small intestine 00:18:01.666 --> 00:18:06.766 and they just inoculated the, the deformed larvae into the, 00:18:08.400 --> 00:18:10.200 the biliary system. 00:18:10.200 --> 00:18:13.066 And the third was just natural low level migration. 00:18:13.066 --> 00:18:16.933 Well, we finally came to the conclusion that it was probably true that this, 00:18:17.400 --> 00:18:21.566 that the, the strongyloides in the biliary system was just incidental. 00:18:21.566 --> 00:18:25.000 And it wasn't actually a cause of any of the of any of the, 00:18:25.166 --> 00:18:28.833 clinical presentations at this patient was experiencing. 00:18:30.933 --> 00:18:33.000 And for those of you who do O and PS, 00:18:33.000 --> 00:18:36.800 just to refresh our, morphology or microscopy, this is the rub. 00:18:36.800 --> 00:18:39.466 Did a form L1 larvae and stool. 00:18:39.466 --> 00:18:42.000 You can identify them by a short buccal canal. 00:18:42.000 --> 00:18:45.000 It doesn't show up well in this picture, but what does show of well 00:18:45.500 --> 00:18:47.400 is about two thirds the way down the body. 00:18:47.400 --> 00:18:49.800 You get this kind of 00:18:49.800 --> 00:18:54.800 crescent shaped or kidney bean shaped structure called, genital mortem. 00:18:54.800 --> 00:18:57.800 That's very indicative of strongyloides. 00:18:58.133 --> 00:19:01.166 In the rare cases where you might see L1 larvae of hookworm 00:19:01.166 --> 00:19:04.633 in stool, you would never see such a prominent general per mortem. 00:19:04.633 --> 00:19:06.766 So that's one of the main features you want to look for. 00:19:07.900 --> 00:19:08.800 In disseminated 00:19:08.800 --> 00:19:13.133 cases you get the flora form larvae and they have kind of a different morphology. 00:19:13.133 --> 00:19:15.600 There are a lot longer and more slender. 00:19:15.600 --> 00:19:18.266 There, upwards of about 600 microns. 00:19:18.266 --> 00:19:20.500 So you don't really pay attention to the buccal canal 00:19:20.500 --> 00:19:22.733 and you're not going to look at it for genital per mortem. 00:19:22.733 --> 00:19:26.266 One thing you are going to look for is this equal distance of, 00:19:26.533 --> 00:19:30.833 esophagus, which is the dark blue, and then the intestine, which is light blue. 00:19:30.833 --> 00:19:36.100 So the body is kind of cut in half by the, esophageal intestinal juncture. 00:19:36.600 --> 00:19:39.633 Also, if you look at the tip of the tail under high magnification, 00:19:39.633 --> 00:19:43.100 it's got a little notch, a little cleft at the tip of the tail. 00:19:43.100 --> 00:19:46.133 That's also indicative of the of the L-3 larvae. 00:19:48.900 --> 00:19:50.400 Okay. 00:19:50.400 --> 00:19:53.400 Wriggling right along with these worms. 00:19:53.400 --> 00:19:56.400 Chapter three worms you can get from your garden. 00:19:56.733 --> 00:19:59.700 My friend Bobby Pritt, who's up there at the Mayo Clinic in Minnesota, 00:19:59.700 --> 00:20:02.433 she has a case. This talk she likes to give called worms. 00:20:02.433 --> 00:20:05.200 You you can't get from your garden. 00:20:05.200 --> 00:20:06.333 Alluding to the parasites. 00:20:06.333 --> 00:20:09.666 Well, this is a parasitic worm, but you actually can get it from your garden. 00:20:10.266 --> 00:20:13.266 And we're not talking about earthworms. 00:20:13.600 --> 00:20:16.833 So our presentation is an 18 month old female. 00:20:17.233 --> 00:20:19.666 This case was from Florida. 00:20:19.666 --> 00:20:24.733 She presented to her pediatrician after a pinkish white worm, 00:20:26.000 --> 00:20:28.200 worm like object about 2 to 3in 00:20:28.200 --> 00:20:31.200 long, was seen in the diaper, by the parents. 00:20:31.200 --> 00:20:35.200 Upon changing, they did three of them parasite exams, 00:20:35.200 --> 00:20:37.666 all of which were negative. 00:20:37.666 --> 00:20:40.266 About three months later, another worm was seen, 00:20:40.266 --> 00:20:43.700 although this one was larger and followed two days later by another worm. 00:20:44.033 --> 00:20:49.100 So whatever this girl has, she's passing it on a regular basis. 00:20:50.300 --> 00:20:50.700 Although the 00:20:50.700 --> 00:20:54.200 on PE exams continued to be negative, the, 00:20:54.566 --> 00:20:57.566 the pediatrician sent worms to a couple labs. 00:20:57.566 --> 00:21:01.800 One was a local hospital and another was a commercial reference lab. 00:21:01.800 --> 00:21:07.300 And, both were reported as segmented, were not consistent with the human parasite. 00:21:07.300 --> 00:21:10.100 Now, when I see that, I read that as earthworm. 00:21:10.100 --> 00:21:14.466 But when you see the morphology and you realize we're not looking at an earthworm, 00:21:15.966 --> 00:21:17.900 there was no international travel. 00:21:17.900 --> 00:21:21.800 The, the family eat organic fruits and vegetables that they grew in their garden. 00:21:22.466 --> 00:21:25.833 They had no pets, so there were no known animal contacts. 00:21:26.300 --> 00:21:28.466 The mother, who was, 00:21:28.466 --> 00:21:32.200 an avid gardener, did know a millipede infestation in the garden, 00:21:32.666 --> 00:21:35.666 but otherwise nothing unusual with regards to insects. 00:21:38.933 --> 00:21:41.166 So this is one of the worm like objects. 00:21:41.166 --> 00:21:44.166 This one you can see is about 14cm. 00:21:44.633 --> 00:21:48.733 It kind of looks like asterisks, but notice how it's not really. 00:21:49.233 --> 00:21:52.566 You know, if you've seen an adult ask, it's very even the length to width 00:21:52.566 --> 00:21:55.566 ratio is very, very even from one end to the next. 00:21:56.000 --> 00:21:57.933 This is kind of thicker on this end. 00:21:59.333 --> 00:22:00.466 It's kind of wrinkly. 00:22:00.466 --> 00:22:02.533 You kind of see pseudo segmentation. 00:22:02.533 --> 00:22:05.700 You see these little dips and divots in the cuticle. 00:22:05.700 --> 00:22:09.966 So it's not it doesn't have that smooth, even consistent morphology 00:22:09.966 --> 00:22:12.966 you see with, with adult asterisk lumber, coyotes. 00:22:14.533 --> 00:22:15.900 Here's that same worm. 00:22:15.900 --> 00:22:17.766 You can see kind of the anterior end. 00:22:17.766 --> 00:22:21.233 There's this little, there's this little retraction 00:22:21.233 --> 00:22:24.233 on the anterior end, like, kind of like its mouth is puckered up. 00:22:24.566 --> 00:22:27.900 Remember, with asterisks, you usually see these big three fleshy lips. 00:22:30.100 --> 00:22:32.666 So we dissect it into that anterior end. 00:22:32.666 --> 00:22:35.733 And, there was this little structure, 00:22:36.733 --> 00:22:39.733 all of a sudden, once we remove some of the flesh from the, 00:22:39.933 --> 00:22:45.000 anterior end of the worm, and there's this bulbous, Roth's the lemon. 00:22:45.000 --> 00:22:45.900 Notice you could see. 00:22:45.900 --> 00:22:47.933 I hope the resolution comes through for you. 00:22:47.933 --> 00:22:52.500 You can see there's these little, spines around the rostrum, and that's. 00:22:52.500 --> 00:22:54.900 That's important in the biology of this animal. 00:22:57.000 --> 00:22:58.933 We also decided to slice it open. 00:22:58.933 --> 00:23:01.933 We know the old PE exam was negative, but this particular 00:23:01.966 --> 00:23:05.266 group of worms doesn't often shed eggs. 00:23:05.266 --> 00:23:06.366 And human feces. 00:23:06.366 --> 00:23:07.900 Sometimes it does, but it's rare. 00:23:07.900 --> 00:23:09.366 So we decided to cut it open. 00:23:09.366 --> 00:23:12.933 And sure enough, it was loaded with these very large 00:23:13.366 --> 00:23:16.366 dark eggs with a thick shell. 00:23:18.133 --> 00:23:21.133 And we identified this as, 00:23:22.833 --> 00:23:24.933 macro canter incus engines, 00:23:24.933 --> 00:23:28.066 which belongs to a group of worms called acanthus cephalopods. 00:23:29.733 --> 00:23:32.333 So when you learn parasitology, you're taught 00:23:32.333 --> 00:23:34.200 there's three groups of parasitic worms. 00:23:34.200 --> 00:23:37.566 Your nematodes are your roundworms, your tomatoes are your flukes 00:23:38.000 --> 00:23:38.600 in your cyst. 00:23:38.600 --> 00:23:40.033 Those are your tapeworms. 00:23:40.033 --> 00:23:42.000 Well, there's actually a fourth group of worms, 00:23:42.000 --> 00:23:45.400 and they're thorny headed worms or acanthus cephalopods. 00:23:45.400 --> 00:23:50.366 And they're pretty rare in, in in human medicine, or at least 00:23:50.366 --> 00:23:54.600 they're rarely reported, given the fact that they look kind of like junk. 00:23:54.633 --> 00:23:57.600 I've seen these almost dismissed as, 00:23:57.600 --> 00:24:00.800 chewed up bubble gum before that was bristly passed and stool. 00:24:00.800 --> 00:24:03.166 So it's quite possible that they're 00:24:03.166 --> 00:24:06.166 they're getting misidentified as mucus casts or bubble gum. 00:24:06.166 --> 00:24:09.400 And maybe they're more common than we see, given 00:24:09.400 --> 00:24:12.400 the unusual life cycle, it's unlikely. But, 00:24:13.433 --> 00:24:16.433 they do pop up every now and then. 00:24:16.700 --> 00:24:19.500 There are large pseudo segmented worms. 00:24:19.500 --> 00:24:22.233 They have that armed raw slime I told you about. 00:24:22.233 --> 00:24:26.066 There's often an absence of eggs and stool, but not always. 00:24:26.366 --> 00:24:29.633 What's interesting is this particular species uses millipedes 00:24:29.633 --> 00:24:33.000 as an intermediate host, and we'll go over the life cycle in just a minute. 00:24:33.600 --> 00:24:34.833 If you remember, at the beginning, 00:24:34.833 --> 00:24:37.900 I said the parent noticed a millipede infestation in the garden. 00:24:38.500 --> 00:24:42.400 Well, this particular macaw can't drink because, species engines 00:24:42.866 --> 00:24:47.033 uses raccoons as a definitive host, and millipedes is an intermediate host. 00:24:47.033 --> 00:24:52.266 So we speculate the child was, when the parent was out in the garden. 00:24:52.266 --> 00:24:54.400 Maybe they had the kid out there with them. 00:24:54.400 --> 00:24:57.500 The kid was putting millipedes in its mouth and getting infected. 00:24:59.233 --> 00:25:01.800 So here's the lifecycle of an acanthus. 00:25:01.800 --> 00:25:05.800 And most of the species that infect humans have two host life cycles. 00:25:06.566 --> 00:25:10.666 Most of the case reports in the literature are macro cam trinkaus heron nature's, 00:25:10.700 --> 00:25:14.233 which is an Old world pig parasite, and model performance 00:25:14.233 --> 00:25:17.566 model performance, which is a rat parasite that occurs all over the world. 00:25:17.966 --> 00:25:20.966 Macro canter through nature's probably occurs all over the world 00:25:20.966 --> 00:25:23.866 now too, because pigs have been imported everywhere 00:25:23.866 --> 00:25:27.500 but here in, or in eastern North America, we have an endemic 00:25:27.500 --> 00:25:31.200 species called macro cantering because engines and 00:25:32.366 --> 00:25:35.500 amaru nature's tends to use beetle larvae as an intermediate 00:25:35.500 --> 00:25:38.500 host model, a form as tends to use cockroaches. 00:25:38.666 --> 00:25:42.866 And while it's not illustrated here, the engines uses millipedes, 00:25:43.400 --> 00:25:47.200 and so the eggs are eaten by the insect intermediate host, and it goes through 00:25:47.200 --> 00:25:50.200 some developmental cycles to become a sister camp. 00:25:50.466 --> 00:25:53.600 And that's the infected stage for the definitive host. 00:25:53.600 --> 00:25:57.200 So what's happening is kids are putting bugs in their mouth 00:25:57.200 --> 00:25:58.833 and they're eating these infected insects, 00:25:58.833 --> 00:26:01.833 and they're getting infected with these acanthus effluence. 00:26:02.133 --> 00:26:06.000 Almost all the cases of these diseases are in children. 00:26:07.166 --> 00:26:07.500 And I 00:26:07.500 --> 00:26:10.500 speculate there's two reasons for that. 00:26:10.766 --> 00:26:13.233 One is kids are likely to put bugs in their mouths. 00:26:13.233 --> 00:26:16.300 You know, kids like the kids learn by test eating. 00:26:16.300 --> 00:26:17.566 And so if something crawls, 00:26:17.566 --> 00:26:20.400 they're likely to just pick it up and put it in their mouth. 00:26:20.400 --> 00:26:23.400 But the other thing is, because these are in children, 00:26:23.433 --> 00:26:27.233 diapers make really good collection apparatus and so on. 00:26:27.233 --> 00:26:30.666 The stewed parrot, we'll see these very large white worms and their kids, 00:26:32.000 --> 00:26:34.566 well, in the kid's stool while changing a diaper, 00:26:34.566 --> 00:26:36.866 I have a feeling that once a kid gets diaper trained, 00:26:36.866 --> 00:26:39.066 they may still get infected, but none of the evidence 00:26:39.066 --> 00:26:40.966 has been flushed down the toilet. 00:26:40.966 --> 00:26:43.966 So most of the case reports for this, 00:26:44.033 --> 00:26:47.566 disease is going to be in diaper aged children. 00:26:47.966 --> 00:26:51.933 Me and a couple of colleagues are writing a mini review on acanthus ices 00:26:51.933 --> 00:26:55.300 for the Journal of Clinical Micros, so that may be out by the end of the year. 00:26:55.633 --> 00:26:58.633 So soon there'll be a, updated reference on this disease, 00:27:00.300 --> 00:27:03.300 for your lab referral. 00:27:03.433 --> 00:27:05.100 This is the other common species. 00:27:05.100 --> 00:27:06.300 This is model performance. 00:27:06.300 --> 00:27:07.200 Model performance. 00:27:07.200 --> 00:27:10.200 You could see it also has the pseudo segmentation. 00:27:10.700 --> 00:27:13.600 The worms are a little skinnier than macro count drinkers. 00:27:13.600 --> 00:27:16.600 The eggs are a little bit larger but they have a thinner shell. 00:27:17.133 --> 00:27:19.533 This one is more like this one seems more likely 00:27:19.533 --> 00:27:22.066 to have patent infections than humans, meaning this one. 00:27:22.066 --> 00:27:25.066 You can see eggs in an old exam. 00:27:25.500 --> 00:27:27.033 And getting back to the fact 00:27:27.033 --> 00:27:30.700 that our particular patient had six negative own P exams, 00:27:31.233 --> 00:27:35.133 you have to wonder, is it because the worm wasn't 00:27:35.133 --> 00:27:38.900 shedding the eggs or but because this worm is such an esoteric critter? 00:27:39.266 --> 00:27:42.800 Maybe the technologist didn't know what to look for because they. 00:27:42.866 --> 00:27:46.500 My guess is they weren't trained in and identifying these eggs. 00:27:46.500 --> 00:27:48.633 I mean, they stand out so they look like a structure 00:27:48.633 --> 00:27:51.000 that you would think they would get your attention. But 00:27:51.000 --> 00:27:55.633 it's quite possible they were overlooked as, pollen or some other artifact. 00:27:57.766 --> 00:27:58.233 Alrighty. 00:27:58.233 --> 00:28:01.233 Chapter four is hoarders, horses and headaches. 00:28:05.633 --> 00:28:08.066 Our patient, this time she's a 60. 00:28:08.066 --> 00:28:10.400 She was a 65 year old female. 00:28:10.400 --> 00:28:13.766 She was admitted to the hospital with fever, nausea and vomiting. 00:28:15.000 --> 00:28:16.933 She was recently treated as an outpatient 00:28:16.933 --> 00:28:19.933 for a UTI caused by Klebsiella. 00:28:20.366 --> 00:28:22.166 Her PMA, which includes 00:28:22.166 --> 00:28:25.166 chronic back pain, bipolar disorder, hypertension, 00:28:25.233 --> 00:28:28.333 straw arthritis and compression fracture. 00:28:28.333 --> 00:28:31.200 She was described as a hoarder, so she didn't live in the best 00:28:31.200 --> 00:28:33.000 sanitary conditions. 00:28:33.000 --> 00:28:37.666 She was a smoker, but denied alcohol use and denied, illicit drug use. 00:28:38.066 --> 00:28:40.933 She did have a couple pet dogs. 00:28:40.933 --> 00:28:43.933 While hospitalized, she started getting blurry vision 00:28:43.933 --> 00:28:47.500 in her left eye and her left temporal area was getting tender. 00:28:47.900 --> 00:28:52.066 Her mental health continued to decline, and after about a month, 00:28:52.066 --> 00:28:57.000 she was pronounced brain dead and, eventually did die prior to death. 00:28:57.000 --> 00:29:00.100 Her CT and MRI did not show any follicle lesion. 00:29:00.100 --> 00:29:02.600 No cysts, nothing. Calcified 00:29:04.133 --> 00:29:05.933 cultures, for brain 00:29:05.933 --> 00:29:08.933 tissue were negative for bacteria and viruses. 00:29:09.933 --> 00:29:12.933 So they also processed some of the brain tissue 00:29:13.300 --> 00:29:16.433 and sent it to pathology where it could be examined by histo path. 00:29:16.466 --> 00:29:19.000 And this is what they saw. 00:29:19.000 --> 00:29:22.333 So if you're not familiar with brain histo 00:29:22.333 --> 00:29:26.300 past this, this is this is a worm in lateral section. 00:29:26.800 --> 00:29:28.433 These are cross-sections of worms. 00:29:28.433 --> 00:29:31.266 These are worm larvae. 00:29:31.266 --> 00:29:33.433 Here's cross-section here's lateral sections. 00:29:33.433 --> 00:29:37.366 This this lady's brain was full of worms. 00:29:37.433 --> 00:29:40.433 Okay. And here's a couple more. 00:29:41.000 --> 00:29:43.233 You can see a nice bulbous esophagus. 00:29:43.233 --> 00:29:47.800 Here's a cross-section showing a uterine tube in the intestine of the worm. 00:29:48.266 --> 00:29:49.533 This is a lateral section. 00:29:49.533 --> 00:29:50.866 These are developing eggs. 00:29:50.866 --> 00:29:53.900 So the worm was producing eggs in the patient's brain. 00:29:55.866 --> 00:29:56.800 Here's a couple more. 00:29:56.800 --> 00:29:59.366 It shows you the nice bulbous esophagus. 00:30:00.800 --> 00:30:01.600 Here's a cross. 00:30:01.600 --> 00:30:03.633 Here's a lateral section. Here's some cross-section. 00:30:03.633 --> 00:30:05.400 You have adults, you have larvae. 00:30:05.400 --> 00:30:08.433 So you have the whole life cycle going on in this patient's brain. 00:30:10.166 --> 00:30:12.866 Well, this is an unusual organism called hello. 00:30:12.866 --> 00:30:14.500 Hello, possibly. Hello. 00:30:14.500 --> 00:30:16.433 Hello, students of Alice. 00:30:16.433 --> 00:30:17.966 Notice I said organism to some. 00:30:17.966 --> 00:30:21.800 I did not say parasite because technically this worm is not a parasite. 00:30:22.333 --> 00:30:26.666 It's a free living nematode associated with damp soil environments. 00:30:27.233 --> 00:30:31.400 I'm sure a lot of you are familiar with the free living amoeba, Naegleria fowleri. 00:30:31.800 --> 00:30:34.800 This is essentially the nematode version of Naegleria. 00:30:35.133 --> 00:30:37.033 It lives in the soil, it gets in the body. 00:30:37.033 --> 00:30:40.033 It has a predilection for the central nervous system, 00:30:40.200 --> 00:30:43.200 and it kills rapidly. 00:30:43.600 --> 00:30:46.600 So all species of have a health base are in the soil. 00:30:46.733 --> 00:30:50.033 There's this interesting species from South Africa called hello, cephalopods. 00:30:50.033 --> 00:30:51.300 Mephisto. 00:30:51.300 --> 00:30:54.166 It's been found 2.2 miles below the surface of the Earth. 00:30:54.166 --> 00:30:58.500 No other multicellular animal has been found that far underground. 00:30:58.766 --> 00:31:02.533 So they like dark, damp, possibly anaerobic environments. 00:31:03.133 --> 00:31:04.500 Just like Strongyloides. 00:31:04.500 --> 00:31:06.666 You have separate males and females in the environment, 00:31:06.666 --> 00:31:10.200 but only females in the parasitized host. 00:31:10.766 --> 00:31:13.366 We have no idea what the root of infection is. 00:31:13.366 --> 00:31:16.633 It could be cuts, it could be embrace, it could be ingestion. 00:31:17.500 --> 00:31:19.733 Most cases have involved the CNS, but 00:31:19.733 --> 00:31:23.566 we do know that they caused disseminated infection in England. 00:31:23.566 --> 00:31:26.733 There was a case where two patients, Scott 00:31:26.733 --> 00:31:29.833 Hal, a CFL obese from infected kidneys. 00:31:30.133 --> 00:31:32.966 So you can get this from organ transplantation. 00:31:32.966 --> 00:31:36.033 The kidney donor probably had died of Hal of several obese but a 00:31:36.033 --> 00:31:40.966 when undiagnosed and unfortunately both kidney recipients also succumbed to it. 00:31:42.166 --> 00:31:44.933 The veterinary world's a little more savvy of this disease 00:31:44.933 --> 00:31:47.666 because for some reason horses have a, 00:31:47.666 --> 00:31:50.966 have a this is this is apparently a well known disease. 00:31:50.966 --> 00:31:54.833 And horses are a not infrequent disease, not a very rare disease, 00:31:54.833 --> 00:31:57.833 at least not as rare as it is in humans. 00:31:59.333 --> 00:32:01.333 So I don't really have the life cycle because it doesn't 00:32:01.333 --> 00:32:03.166 have your typical parasitic life cycle. 00:32:03.166 --> 00:32:06.166 As I said, these worms are normally in the environment, 00:32:06.266 --> 00:32:08.233 but they get in the body somehow. 00:32:08.233 --> 00:32:11.933 They find their way to the CNS and they multiply rapidly. 00:32:12.600 --> 00:32:15.600 And, just to point out some of the structures, 00:32:15.633 --> 00:32:18.700 the you have the intestine and a single reproductive tube. 00:32:18.900 --> 00:32:22.000 Had this been strongyloides, which is morphologically similar, 00:32:22.000 --> 00:32:25.733 there would have been paired reproductive tubes in the lateral section, 00:32:25.733 --> 00:32:29.200 you could see the flexed ovary that's very characteristic of this genus. 00:32:29.866 --> 00:32:33.633 And in the mature females you could see the developing row of eggs. 00:32:40.333 --> 00:32:42.066 Okay. 00:32:42.066 --> 00:32:44.066 See we've got two more cases left. 00:32:44.066 --> 00:32:46.666 And then I've got a special epilog case. 00:32:46.666 --> 00:32:49.666 Kind of a fun thing right at the end. 00:32:49.800 --> 00:32:53.433 So our next one, Heldman theology, that's the study of worms. 00:32:53.433 --> 00:32:56.433 That's what we've been doing together so far today. 00:32:56.500 --> 00:32:57.600 What a mouthful. 00:32:57.600 --> 00:32:59.666 And given the cases I presented to you, 00:32:59.666 --> 00:33:02.566 you can probably end up where we're going here right? 00:33:02.566 --> 00:33:05.800 We've had the intestinal tract, we've had a fish, we've had the brain. 00:33:06.300 --> 00:33:09.300 Now we're going to look at the oral cavity. 00:33:09.833 --> 00:33:12.733 So our case today, 00:33:12.733 --> 00:33:15.300 is a was a 44 year old Hispanic male 00:33:15.300 --> 00:33:18.533 that presented with a lump in his throat in 2010. 00:33:19.200 --> 00:33:22.466 He was originally from Mexico, but he has spent the last 20 years 00:33:22.466 --> 00:33:27.566 in Illinois, with just his last two trips to Mexico or 2008 and 2009. 00:33:27.566 --> 00:33:30.600 He's currently a landscaper, but he's also worked on a pig farm, and 00:33:30.600 --> 00:33:31.833 he worked in a foundry. 00:33:33.900 --> 00:33:37.033 He has hypertension, but no known environmental allergies. 00:33:37.033 --> 00:33:40.400 So sometimes when someone has, like a lump in their throat or difficulty 00:33:40.400 --> 00:33:43.400 breathing or swallowing you, you might think allergies. 00:33:43.500 --> 00:33:48.533 He, on clinical examination, he had multiple, oral and lip ulcers 00:33:49.033 --> 00:33:52.633 and, integrated subcutaneous mucosal nodules. 00:33:53.100 --> 00:33:56.400 So they took biopsies of his tongue 00:33:56.400 --> 00:33:59.400 and cheek and sent it to pathology for workup. 00:34:00.166 --> 00:34:03.166 And here you can see these are the tracks, these like, 00:34:05.966 --> 00:34:09.133 these, serpentine tracks inside his cheek. 00:34:09.766 --> 00:34:12.766 And here's an ulcer on the inside of his lip. 00:34:13.333 --> 00:34:17.066 So, he had these oral lesions, and they sent him for pathology. 00:34:17.066 --> 00:34:18.100 And this is what they saw. 00:34:18.100 --> 00:34:20.700 Now, many of you, I don't know how many of you, 00:34:20.700 --> 00:34:22.800 without being able to interact with you as an audience. 00:34:22.800 --> 00:34:24.600 How many of you do much histo, pal? 00:34:24.600 --> 00:34:26.666 So I'm not going to bog you down 00:34:26.666 --> 00:34:31.500 with a lot of histo path, terminology, but these are cross-sections of a worm. 00:34:31.500 --> 00:34:34.500 So there was a nematode in his oral mucosa. 00:34:34.533 --> 00:34:36.733 And here's a kind of a cross-section of the worm. 00:34:36.733 --> 00:34:40.266 So to put this in perspective, imagine your arm was a worm, 00:34:40.266 --> 00:34:41.966 and you cut it and now you're looking down. 00:34:41.966 --> 00:34:44.600 So we're looking down the tube of a worm. 00:34:44.600 --> 00:34:47.933 And so this outer part here is the cuticle of the worm. 00:34:48.266 --> 00:34:50.000 This is its musculature. 00:34:51.900 --> 00:34:52.700 Coming off the 00:34:52.700 --> 00:34:56.566 inner part of the cuticle is these, this kind of thickened area here. 00:34:56.566 --> 00:34:58.433 This is called a base salary band. 00:34:58.433 --> 00:35:01.400 And that's very characteristics for a group of nematodes. 00:35:01.400 --> 00:35:03.100 You might have heard about it. 00:35:03.100 --> 00:35:05.100 Trachea says best salary bands. 00:35:05.100 --> 00:35:08.100 Chicken L.A has base salary bands. 00:35:08.166 --> 00:35:10.200 This is the worms intestine 00:35:10.200 --> 00:35:14.766 and has this large gland like structure surrounding the, I'm sorry, the esophagus. 00:35:15.133 --> 00:35:18.000 There's this large gland like structure surrounding the esophagus, 00:35:18.000 --> 00:35:19.833 and that's called a stick site. 00:35:19.833 --> 00:35:22.966 So when you see sticker sites and when you see basilar bands, it's 00:35:22.966 --> 00:35:27.533 one of the droid nematodes, again, the one you're most likely to be familiar with. 00:35:27.533 --> 00:35:29.866 Our trachea. Trachea. 00:35:29.866 --> 00:35:31.766 Trick anila, trick analysis paralysis. 00:35:31.766 --> 00:35:34.333 And maybe some of that capillary is capillary. 00:35:34.333 --> 00:35:37.966 Hepatic, capillary Philippine ancestor in the same group of worms. 00:35:39.700 --> 00:35:40.033 Well, this 00:35:40.033 --> 00:35:44.100 particular nematode is in another group of worms in the genus. 00:35:44.100 --> 00:35:45.233 Oops, sorry. 00:35:45.233 --> 00:35:46.366 I'm jumping ahead of myself. 00:35:46.366 --> 00:35:48.400 There's a couple more. 00:35:48.400 --> 00:35:50.233 This is, another cross section. 00:35:50.233 --> 00:35:54.233 You can see the salary band doing, really strong here. 00:35:54.966 --> 00:35:59.266 Here's the uterine tube with, eggs you could see developing eggs 00:35:59.266 --> 00:36:00.333 inside of it. 00:36:00.333 --> 00:36:03.633 The chicory nematodes typically have single uterine tubes. 00:36:03.633 --> 00:36:06.066 This looks like the intestine over here. 00:36:06.066 --> 00:36:09.133 And then you've got the, muscles of the nice basilar banding. 00:36:09.766 --> 00:36:13.200 Well, anyway, I was getting ahead of myself there, but when you see, 00:36:14.666 --> 00:36:17.566 cured nematode features in the oral cavity, 00:36:17.566 --> 00:36:22.500 it belongs to a genus of worms called an a trick, a soma. Now. 00:36:23.700 --> 00:36:25.766 And the trick is soma cases are very rare. 00:36:25.766 --> 00:36:27.000 When we published this case, 00:36:27.000 --> 00:36:30.000 I think it was only like the fourth or fifth human case ever. 00:36:30.300 --> 00:36:33.800 And ours was the very first from the human oral cavity. 00:36:34.466 --> 00:36:39.000 Previous cases have been in biopsies and skin and soft tissue now. 00:36:39.000 --> 00:36:42.300 And the trick, I assume, is a really unusual genus of nematodes. 00:36:42.600 --> 00:36:44.833 We don't completely understand the life cycle. 00:36:44.833 --> 00:36:47.466 I have a proposed life cycle. 00:36:47.466 --> 00:36:49.000 In the next slide or two 00:36:49.000 --> 00:36:52.600 where we'll go over, but there's only a handful of species. 00:36:52.933 --> 00:36:55.933 There's and the trick Soma bucephalus, 00:36:56.066 --> 00:36:59.366 which in North America is found in the oral cavity of opossums. 00:36:59.633 --> 00:37:03.700 And this is probably the species we our patient had, because it's 00:37:03.700 --> 00:37:07.300 the only one known from North America, and it does present in the oral cavity. 00:37:08.266 --> 00:37:10.500 The problem is, is that because these worms 00:37:10.500 --> 00:37:14.533 have not been morphologically described on histo path, we don't have a 00:37:14.566 --> 00:37:18.300 we don't have any comparative information to further identify it. 00:37:18.966 --> 00:37:19.300 And there's 00:37:19.300 --> 00:37:22.566 pretty much nothing on molecular because these worms are so little known. 00:37:23.233 --> 00:37:26.233 There's a rhesus monkey parasite in Southeast Asia, 00:37:26.533 --> 00:37:29.800 and there's another one in Malaysia that gets into the eyes of tree shrews. 00:37:30.433 --> 00:37:33.866 So most of the human cases have been, in the Old world, 00:37:35.200 --> 00:37:38.200 Asia and Europe. And, 00:37:38.933 --> 00:37:41.666 they were all from skin and soft tissue. 00:37:41.666 --> 00:37:43.533 Interesting. One of them was also infected 00:37:43.533 --> 00:37:46.533 with deer flurry, which is another zoonotic nematode. 00:37:46.533 --> 00:37:49.500 But that's a vector borne disease. 00:37:49.500 --> 00:37:51.333 What's really interesting, the, 00:37:51.333 --> 00:37:54.400 this, the doc who brought this case to us, 00:37:54.566 --> 00:37:58.400 four years later, he had two more patients with the same case. 00:37:58.800 --> 00:38:00.700 I mean, what are the chances? 00:38:00.700 --> 00:38:01.800 But it's really interesting. 00:38:01.800 --> 00:38:04.966 There was an a mother and daughter, and so they went to Mexico. 00:38:05.500 --> 00:38:10.533 They stayed in this really fancy resort, and they participated in snail facials. 00:38:10.533 --> 00:38:12.666 So what a snail facial is, 00:38:12.666 --> 00:38:16.033 is you basically let these live worms crawl across your face. 00:38:16.033 --> 00:38:19.700 And the thought is that there's some kind of healing or rejuvenating, 00:38:20.500 --> 00:38:24.200 element to the, to the, the slime that they produce. 00:38:24.200 --> 00:38:24.966 I don't know, 00:38:26.400 --> 00:38:27.966 and, so they both 00:38:27.966 --> 00:38:31.133 got these snail facials and they both got an, a trick, a soma. 00:38:31.733 --> 00:38:34.500 There was enough a second daughter on the trip who did not 00:38:34.500 --> 00:38:38.266 participate in snail facials, and she did not get out a trick of Selma. 00:38:38.866 --> 00:38:43.100 But to, to make this story even more interesting is the, 00:38:43.400 --> 00:38:46.400 they didn't want to pay for the, the, 00:38:46.666 --> 00:38:49.400 the the terrarium snails 00:38:49.400 --> 00:38:53.066 that they kept on hand at the resort, which are going to be sterile and safe. 00:38:53.533 --> 00:38:55.766 So this mother and daughter actually went out into the jungle 00:38:55.766 --> 00:38:57.533 and collected their own wild snail. 00:38:57.533 --> 00:39:00.766 So they had wild type snails crawling on their face. 00:39:00.766 --> 00:39:03.366 And so, 00:39:03.366 --> 00:39:07.366 we'll come back to this in just a second, but, it brings up an interesting 00:39:07.366 --> 00:39:11.300 possibility of, a snail is an intermediate host for this parasite. 00:39:12.266 --> 00:39:14.133 So, again, 00:39:14.133 --> 00:39:18.300 we, the the there's the there's the monkey parasite. 00:39:18.300 --> 00:39:19.733 There's the tree shrew parasite. 00:39:19.733 --> 00:39:22.733 There's the opossum parasite, which is probably ours. 00:39:23.200 --> 00:39:27.700 We know they shed fully embryonic eggs in their feces, but when these eggs 00:39:27.700 --> 00:39:32.033 are fed back to the host in laboratory settings, they don't get sick. 00:39:32.433 --> 00:39:34.500 So there's a theory that there might be 00:39:34.500 --> 00:39:37.700 some kind of intermediate host somewhere in the lifecycle. 00:39:38.100 --> 00:39:40.200 And the fact that the the, 00:39:40.200 --> 00:39:44.800 the of the family of three who went to this Mexican resort, the only two 00:39:44.800 --> 00:39:49.100 that got the disease were the two that use wild type snails for snail facials. 00:39:49.600 --> 00:39:52.800 Kind of allude to the fact that maybe snails 00:39:52.800 --> 00:39:55.800 are a possible intermediate host for this parasite. 00:39:55.833 --> 00:39:56.733 We really don't know. 00:39:56.733 --> 00:40:02.233 It's still, it's still kind of a mystery on, how these, worms are transmitted. 00:40:04.800 --> 00:40:06.233 And, just to highlight 00:40:06.233 --> 00:40:09.233 some of the features I was showing you earlier. 00:40:09.966 --> 00:40:11.666 The cuticle is the outer part. 00:40:11.666 --> 00:40:13.300 That's the outer skin. 00:40:13.300 --> 00:40:16.300 The muscles or the green arrow. 00:40:16.466 --> 00:40:19.466 The esophagus is the, red arrow. 00:40:19.666 --> 00:40:23.700 This is that large gland called a stick, a site which is characteristic 00:40:24.066 --> 00:40:27.966 if you ever cut into the interior section, the long, whip like section 00:40:28.500 --> 00:40:29.366 of a tree cures. 00:40:29.366 --> 00:40:31.733 Or if you ever get an adult, you're curious. 00:40:31.733 --> 00:40:34.500 Look at the, look at the the long, 00:40:34.500 --> 00:40:37.833 slender anterior end, under the microscope. 00:40:37.833 --> 00:40:38.933 And you'll see these things 00:40:38.933 --> 00:40:43.066 that look like, like stacks of tires, like a row going down. 00:40:43.333 --> 00:40:45.266 Those are the sticker sites. That's what you're looking at. 00:40:45.266 --> 00:40:47.266 You're looking at those sticker sites, 00:40:47.266 --> 00:40:50.800 and then you've got the, the basal rebounding, which is a specialized 00:40:51.600 --> 00:40:55.333 modification of the the nerve cords and the muscles of the worm. 00:40:57.833 --> 00:40:59.566 This is another oral nematode. 00:40:59.566 --> 00:41:03.233 There's not a lot of nematodes like it in the human oral cavity. 00:41:03.766 --> 00:41:05.200 But this is the other one. Gangel. 00:41:05.200 --> 00:41:06.766 And I'm a pilgrim. 00:41:06.766 --> 00:41:09.000 And this was a case from Florida. 00:41:09.000 --> 00:41:12.000 Although I believe the disease was acquired in Georgia. 00:41:12.033 --> 00:41:12.500 This one. 00:41:12.500 --> 00:41:16.666 We know the life cycle, it's cycles between mammals and insects. 00:41:16.666 --> 00:41:19.700 So, sheep, goats, cattle, 00:41:20.166 --> 00:41:23.300 insectivores, hedgehogs, rodents. 00:41:23.300 --> 00:41:26.200 They can also love wide host range. 00:41:26.200 --> 00:41:29.066 And the infection is acquired from eating insects. 00:41:29.066 --> 00:41:31.533 So humans incidentally eat insects. 00:41:31.533 --> 00:41:34.533 And this kind of it's kind of diagnosed the same way 00:41:34.533 --> 00:41:37.800 where you get these worms migrating under the sub mucosa, 00:41:38.233 --> 00:41:41.866 although this one's usually diagnosed by extraction of the adult worm. 00:41:42.300 --> 00:41:45.866 I did include some eggs in the picture because this one 00:41:45.866 --> 00:41:48.466 you can't see eggs in on exams and storks. 00:41:48.466 --> 00:41:51.466 If you've got a gravid female worm in the oral cavity, 00:41:51.600 --> 00:41:53.466 she releases eggs into the oral cavity. 00:41:53.466 --> 00:41:55.200 You you swallow them. 00:41:55.200 --> 00:41:56.800 You might, poop out the eggs. 00:41:56.800 --> 00:42:00.466 So this one can actually be diagnosed by eggs and stool. 00:42:04.766 --> 00:42:06.200 Okay. 00:42:06.200 --> 00:42:07.633 The last of our main cases. 00:42:07.633 --> 00:42:10.233 How are we doing on time? We're doing pretty well. 00:42:10.233 --> 00:42:12.833 Waiter, there's a fly in my eye. 00:42:12.833 --> 00:42:13.500 Okay. 00:42:13.500 --> 00:42:16.500 I think you guys know where this one's going. 00:42:16.500 --> 00:42:19.966 So our case presentation was a 41 year old male. 00:42:19.966 --> 00:42:22.966 He was on vacation with his wife in Kona, Hawaii. 00:42:23.400 --> 00:42:26.966 He got out of his car one day, and the insect hit him in the face. 00:42:26.966 --> 00:42:28.266 Kind of just kind of flew into his eye. 00:42:28.266 --> 00:42:29.333 He didn't think much of it. 00:42:29.333 --> 00:42:32.333 Like, some dumb bug just flew in my face. 00:42:32.500 --> 00:42:36.133 Although he immediately his eye was immediately irritated and he was tearing. 00:42:36.466 --> 00:42:39.366 They went to a local target, got some saline. 00:42:39.366 --> 00:42:40.633 They flushed his eye. 00:42:40.633 --> 00:42:44.033 His wife thought she saw something moving on the surface of his eye. 00:42:44.633 --> 00:42:45.800 They went to the ER. 00:42:46.900 --> 00:42:47.466 The slit. 00:42:47.466 --> 00:42:50.066 Slit lamp was negative. No corneal abrasions. 00:42:50.066 --> 00:42:51.600 No labs were done. 00:42:51.600 --> 00:42:55.766 They continued on their vacation, but his eyes were still irritated. 00:42:56.500 --> 00:43:00.000 He did have a past medical history of, allergic rhinitis. 00:43:00.400 --> 00:43:02.233 He had Lasik surgery a few years ago. 00:43:02.233 --> 00:43:05.233 Nonsmoker, non drinker. 00:43:05.633 --> 00:43:10.000 Well, the wife still thought she saw things moving into his eye. 00:43:10.000 --> 00:43:13.866 So, you know, when your wife says, honey, you look deeply into my eyes. 00:43:14.100 --> 00:43:15.600 Maybe she's looking for 00:43:15.600 --> 00:43:18.600 for little, worm like structures crawling around on your eye. 00:43:19.733 --> 00:43:23.800 What's funny about this is they were basically out in the nature in Hawaii. 00:43:23.800 --> 00:43:26.200 So the worm, the. 00:43:26.200 --> 00:43:30.833 Excuse me, the wife was able to actually pick one out of her husband's eye. 00:43:31.233 --> 00:43:32.300 They didn't know what to do with that, 00:43:32.300 --> 00:43:35.300 so they stuck it on the sticky end of a chapstick tube, 00:43:35.400 --> 00:43:38.166 and they brought it back to their PCP, the University of Utah. 00:43:38.166 --> 00:43:40.400 And it came to me at Air Yuppie Labs. 00:43:40.400 --> 00:43:43.933 And so I had to extract this like two millimeter long, 00:43:43.933 --> 00:43:47.533 worm like object off of a sticky chapstick tube. 00:43:47.933 --> 00:43:50.933 Anyway, while they were back in Hawaii, they went back to the E.R. 00:43:51.533 --> 00:43:54.500 and the slit lamp did reveal two more. 00:43:54.500 --> 00:43:58.500 And you could see, here's the the worm or the worm. 00:43:58.500 --> 00:43:59.900 It's not a worm. Sorry. 00:43:59.900 --> 00:44:04.166 The worm like organism on the tip of the, the wife's finger. 00:44:04.166 --> 00:44:06.500 So you could see it's really tiny. Oops. 00:44:06.500 --> 00:44:09.000 So I thought, this is a video, but it's not playing. 00:44:09.000 --> 00:44:10.833 But anyway, this is this is how big it was. 00:44:10.833 --> 00:44:13.600 So you have this 2 to 3 millimeter long object. 00:44:14.600 --> 00:44:15.900 Well, under a microscope. 00:44:15.900 --> 00:44:18.400 This is what it looks like. 00:44:18.400 --> 00:44:20.766 And what this is, is 00:44:20.766 --> 00:44:24.300 this is the larva of a botfly in a specific botfly 00:44:24.300 --> 00:44:29.333 called estrus over's, which is common name is the nasal botfly of sheep. 00:44:29.333 --> 00:44:33.666 They normally are parasites in the upper respiratory tract of sheep, 00:44:33.666 --> 00:44:36.933 deer, and goats, but humans can occasionally get them. 00:44:37.500 --> 00:44:39.466 And if you remember at the start of the vignette 00:44:39.466 --> 00:44:42.666 I said the guy, the insect flew and hit him in the face. 00:44:43.200 --> 00:44:45.433 Well, that's how they lay their larvae. 00:44:45.433 --> 00:44:47.900 They don't actually lay eggs, they lay larvae. 00:44:47.900 --> 00:44:51.333 What they do is they dive bomb the host, and in a split second they deposit 00:44:51.333 --> 00:44:52.500 larvae again. 00:44:52.500 --> 00:44:55.800 Usually it's in the nasal cavity of, of a ungulate mammal, 00:44:56.333 --> 00:44:58.200 but in this case it dive bombed. 00:44:58.200 --> 00:45:01.133 And then that split second, it hit the guy in the face. 00:45:01.133 --> 00:45:04.133 It laid a it deposited larvae in his eye. 00:45:04.800 --> 00:45:07.400 And the most common clinical presentation is the finding 00:45:07.400 --> 00:45:11.233 of these microscopic larvae on the human eye. 00:45:11.500 --> 00:45:12.666 And they're not invasive. 00:45:12.666 --> 00:45:13.966 They don't go burrow into the eye. 00:45:13.966 --> 00:45:16.966 They they don't cause blindness. 00:45:17.066 --> 00:45:18.200 We are a dead end host. 00:45:18.200 --> 00:45:21.200 Eventually the flies are going to just die and 00:45:21.500 --> 00:45:24.766 and probably be excreted through, through tearing. 00:45:25.966 --> 00:45:26.600 I don't think there's 00:45:26.600 --> 00:45:29.700 any long term or permanent damage associated with these. 00:45:30.466 --> 00:45:32.500 This was another case we had at the CDC. 00:45:32.500 --> 00:45:35.400 This was a New Yorker, but they had traveled to Israel. 00:45:35.400 --> 00:45:38.400 Here's one of the larvae crawling on the surface of the eye. 00:45:38.866 --> 00:45:40.466 Here's the underside of their eyelid. 00:45:40.466 --> 00:45:43.833 And you can see one, two, three larvae under the eyelid. 00:45:44.500 --> 00:45:47.700 So the eye is the most common clinical presentation for this, 00:45:48.166 --> 00:45:52.066 this, particular parasite, I believe there is a couple of cases of it 00:45:52.066 --> 00:45:54.766 being found in the human upper respiratory tract. 00:45:54.766 --> 00:45:57.766 But again, we're a dead end host for it. 00:45:58.400 --> 00:46:01.233 So the clinical disease is called my eye assess. 00:46:01.233 --> 00:46:05.833 That is the infestation or colonization of the human body with maggots. 00:46:06.433 --> 00:46:08.733 And there's three main clinical presentations. 00:46:08.733 --> 00:46:10.933 There's obligatory meiosis. 00:46:10.933 --> 00:46:13.066 This is caused by the true botfly flies. 00:46:13.066 --> 00:46:15.133 This is where the larvae require 00:46:15.133 --> 00:46:18.700 healthy host tissue for perpetuation of their life cycle. 00:46:18.966 --> 00:46:22.700 And the one we saw, the estrus ova does cause obligatory my ES. 00:46:22.966 --> 00:46:25.233 Humans just aren't a good host for it. 00:46:25.233 --> 00:46:27.200 Then you've got facultative my ISS. 00:46:27.200 --> 00:46:29.866 This is where the human body becomes colonized. 00:46:29.866 --> 00:46:34.766 Preexisting wounds like festering or disease wound or or burns get, 00:46:36.166 --> 00:46:37.533 get colonized by larvae. 00:46:37.533 --> 00:46:41.100 And these larvae typically feed on dead tissue. 00:46:41.100 --> 00:46:45.300 So your classic presentation may be homeless people with untreated wounds. 00:46:45.800 --> 00:46:49.166 Diabetics with untreated foot ulcers burn victims. 00:46:50.400 --> 00:46:54.300 Normally the larvae only feed on the the dead tissue. 00:46:54.300 --> 00:46:55.433 But there are a couple species 00:46:55.433 --> 00:46:58.433 that will start on dead tissue and progress with healthy tissue. 00:46:58.966 --> 00:47:00.600 And then you've got incidental meiosis. 00:47:00.600 --> 00:47:03.366 That's kind of where separate figures fly. 00:47:03.366 --> 00:47:04.966 Larvae will feed on. 00:47:04.966 --> 00:47:06.900 Well, they don't really feed on tissue. 00:47:06.900 --> 00:47:09.300 They kind of just colonize the body. 00:47:09.300 --> 00:47:12.966 Good presentation is maybe houseflies laying eggs on the opening 00:47:12.966 --> 00:47:14.700 of a urinary catheter. 00:47:14.700 --> 00:47:17.366 The fly larvae will feed on the biofilm on the catheter. 00:47:17.366 --> 00:47:19.433 They'll enter the urogenital tract. 00:47:19.433 --> 00:47:21.066 But they're not actually causing disease. 00:47:21.066 --> 00:47:23.800 They don't actually feed on the human tissue. 00:47:23.800 --> 00:47:27.766 Regardless of what kind of meiosis you have, removal is always curative. 00:47:29.466 --> 00:47:33.233 So I can't give a parasite talk and have my eye assess 00:47:33.233 --> 00:47:36.866 and not go through some, some rather fun. 00:47:37.133 --> 00:47:41.333 And to maybe some disturbing photos of examples of my ISS. 00:47:42.166 --> 00:47:43.400 If you guys have heard of Botfly, 00:47:43.400 --> 00:47:46.400 as you've probably heard of this one, this is derma Tobia harmonists. 00:47:46.600 --> 00:47:48.633 It's endemic to Central and South America. 00:47:48.633 --> 00:47:52.700 In the Caribbean, the maggots develop in boils under the skin. 00:47:52.966 --> 00:47:57.300 What's really fascinating is this is a vector borne parasite. 00:47:57.800 --> 00:48:00.833 The adult flies lay their eggs on the head of a mosquito. 00:48:00.833 --> 00:48:04.166 And then when the mosquito bites you, the egg hatches. 00:48:04.333 --> 00:48:07.066 The the warmth of your body causes the egg to hatch. 00:48:07.066 --> 00:48:09.233 It drops off the head of the mosquito 00:48:09.233 --> 00:48:11.866 and it enters your body where the mosquito bite you. 00:48:11.866 --> 00:48:15.000 So this is a fly that's transmitted by another fly. 00:48:16.466 --> 00:48:19.666 And when they pop out of the skin, they're usually thick bodied. 00:48:19.666 --> 00:48:23.100 They have these thick spines one way, you know, you have dermatol 00:48:23.100 --> 00:48:26.100 because there's no spines on the terminal three segments. 00:48:26.266 --> 00:48:29.566 Again, your patient, in order to have dermatol be your patient, is going to have 00:48:29.566 --> 00:48:32.566 to have recent travel to Latin America. 00:48:33.700 --> 00:48:34.833 This is Kuta rebirth. 00:48:34.833 --> 00:48:37.866 This is when we get in North America, northern North America. 00:48:37.966 --> 00:48:40.966 You guys might get human cases in Minnesota. 00:48:41.400 --> 00:48:43.200 This is the second instar larvae. 00:48:43.200 --> 00:48:46.666 This is the third and star larvae, this particular one here, 00:48:46.766 --> 00:48:49.800 this one was found on the skin of a patient in Pennsylvania. 00:48:49.966 --> 00:48:51.900 This one was coughed up by a cat. 00:48:51.900 --> 00:48:54.233 But humans have known to cough these up. 00:48:54.233 --> 00:48:57.033 And these mature larvae about the size of a walnut. 00:48:57.033 --> 00:48:59.466 So imagine coughing up a walnut sized maggot. 00:49:00.433 --> 00:49:03.666 This is the second and star larvae, which the most common 00:49:03.666 --> 00:49:07.133 human clinical presentation is a subcutaneous boil. 00:49:07.533 --> 00:49:10.066 We're not entirely sure how humans get this disease. 00:49:10.066 --> 00:49:11.700 It's believed that when people are gardening 00:49:11.700 --> 00:49:14.700 or playing in leaf litter, kids are playing in leaf litter. 00:49:14.900 --> 00:49:18.300 They get the larvae on the skin and then they, they, 00:49:18.633 --> 00:49:21.633 gets in their oral cavity and then it migrates through the body. 00:49:21.933 --> 00:49:24.933 The normal hosts are rodents and rabbits 00:49:25.200 --> 00:49:30.066 and so what the adult flies do is they lay their eggs on burrow entrances 00:49:30.066 --> 00:49:33.933 or like paths where the with the rodents and rabbits are running along, 00:49:34.400 --> 00:49:37.700 and then they the, the, the mammals pick up the parasite 00:49:38.000 --> 00:49:40.300 through skin contact and then they preen themselves 00:49:40.300 --> 00:49:43.300 and they ingest them, and then they migrate through the body. 00:49:43.966 --> 00:49:48.300 The flies don't actually lay the larvae or the eggs on, on the host's body. 00:49:49.833 --> 00:49:51.033 And this is what they, 00:49:51.033 --> 00:49:53.933 this is a rat that's infected with Kuda Libra. 00:49:53.933 --> 00:49:54.900 Notice this one here. 00:49:54.900 --> 00:49:57.900 There's a there's a squirrel parasite in the east called, 00:49:58.266 --> 00:50:00.066 cute, horrible, emasculated. 00:50:00.066 --> 00:50:01.666 And you can tell by the name. 00:50:01.666 --> 00:50:03.533 By the by the name. 00:50:03.533 --> 00:50:06.533 What part of the body it likes to feed on? 00:50:06.600 --> 00:50:09.866 To any any, men in the audience? 00:50:09.866 --> 00:50:10.533 Don't worry. 00:50:10.533 --> 00:50:13.000 To my knowledge, no humans have presented like this. 00:50:13.000 --> 00:50:13.966 It's just in the rodent. 00:50:13.966 --> 00:50:16.966 So you're safe. 00:50:18.166 --> 00:50:20.433 But they usually don't kill their host. 00:50:20.433 --> 00:50:24.033 And that's one reason they often feed on the general organs of the host. 00:50:24.033 --> 00:50:27.066 Because, that's not really in the Central Oregon. 00:50:27.066 --> 00:50:27.600 Because you don't. 00:50:27.600 --> 00:50:30.600 If you're a good parasite, you don't really want to kill your host. 00:50:31.566 --> 00:50:33.066 This is a Obi anthropoid. 00:50:33.066 --> 00:50:34.133 Phaedra, this is, 00:50:35.466 --> 00:50:37.166 this is, 00:50:37.166 --> 00:50:39.300 a blowfly that lives in Africa. 00:50:39.300 --> 00:50:42.000 To me, this is the real human botfly. 00:50:42.000 --> 00:50:43.800 Because, 00:50:43.800 --> 00:50:46.800 this this one has a is his is, 00:50:47.633 --> 00:50:51.900 has a preference for the human host, but it'll also feed on dogs and livestock. 00:50:52.366 --> 00:50:55.366 You may see these some of these, 00:50:56.133 --> 00:50:58.033 structures in the photos I've been showing you. 00:50:58.033 --> 00:51:00.233 These are the spectacular plates. 00:51:00.233 --> 00:51:03.500 When the head of the, fly lavas down feeding on you, 00:51:03.500 --> 00:51:05.566 the spectacular plates are on the posterior. 00:51:05.566 --> 00:51:09.933 And breathing, I show them, because that's what's used for identifying. 00:51:10.200 --> 00:51:12.900 I'm not going to go to the nuances of identifying for this talk. 00:51:12.900 --> 00:51:14.433 It's kind of beyond the scope of this talk. 00:51:14.433 --> 00:51:16.600 But that's why I'm showing them, 00:51:16.600 --> 00:51:20.100 the core lobe, the Phaedra is a is an Afro tropical species. 00:51:20.100 --> 00:51:22.000 So you may see this. 00:51:22.000 --> 00:51:26.133 You may get this if you're patient, travel came back from Africa. 00:51:26.133 --> 00:51:27.966 Then they have that this was a 00:51:27.966 --> 00:51:32.300 this particular case here was diagnosed in the United States. 00:51:32.300 --> 00:51:34.533 I don't remember where it came from. 00:51:34.533 --> 00:51:37.700 I want to say it was Texas, but the patient had traveled to Cameroon. 00:51:39.066 --> 00:51:41.566 If you want to see some really gross videos, go to YouTube 00:51:41.566 --> 00:51:45.066 and search Dog and Mango Fly and you'll see 00:51:45.066 --> 00:51:48.066 some examples of this. 00:51:48.433 --> 00:51:51.366 Lou, cilia is a cosmopolitan genus of flies. 00:51:51.366 --> 00:51:53.766 These calls facultative meiosis. 00:51:53.766 --> 00:51:57.000 A lot of times when you get maggots submitted to the lab that have come out 00:51:57.000 --> 00:52:00.733 of skin lesions and wounds, it's probably going to be loose cilia. 00:52:01.133 --> 00:52:02.800 They never attack healthy tissue. 00:52:02.800 --> 00:52:04.800 In fact, they're used in maggot therapy. 00:52:04.800 --> 00:52:06.900 And I'll go over that in just a second. 00:52:06.900 --> 00:52:08.100 Here's a foot wound up. 00:52:08.100 --> 00:52:12.633 The patient had, I believe it was, like a shop accident, like a sore or something. 00:52:13.133 --> 00:52:15.766 And you can see where the maggots are, 00:52:15.766 --> 00:52:18.633 are feeding on the decomposing tissue right here. 00:52:18.633 --> 00:52:21.433 This particular patient actually got a bacterial infection 00:52:21.433 --> 00:52:24.433 because some of these maggots carry normal oral bacteria, 00:52:24.466 --> 00:52:27.266 and they can cause, bacteremia in the patient. 00:52:27.266 --> 00:52:29.766 That's probably the worst clinical outcome for getting these. 00:52:29.766 --> 00:52:33.900 Not the maggots themselves, but potential secondary bacterial infection. 00:52:35.200 --> 00:52:38.200 I see we're getting close on time, so I'll try to go a little faster. 00:52:38.200 --> 00:52:39.466 We're almost done. 00:52:39.466 --> 00:52:42.533 This is the adult loosely that's extracted from tissue. 00:52:43.066 --> 00:52:46.000 I said loosely, is used in maggot therapy. 00:52:46.000 --> 00:52:51.100 As of 2004, the FDA has approved mega therapy for non healing 00:52:51.566 --> 00:52:54.600 necrotic skin and soft tissue wounds, pressure ulcers, 00:52:54.866 --> 00:52:58.633 neuropathic foot ulcers, and non healing traumatic post-surgical wounds. 00:52:59.033 --> 00:53:02.000 I believe burn patients are also on this list. 00:53:02.000 --> 00:53:06.000 So basically these are where they take laboratory raised maggots and 00:53:06.000 --> 00:53:10.133 put them on the patients to eat, the dead tissue to clean up the dead tissue. 00:53:10.600 --> 00:53:12.033 These are all laboratory raised. 00:53:12.033 --> 00:53:15.400 So there's no concern about bacteria, bacteremia 00:53:15.400 --> 00:53:18.400 infections with these maggots. 00:53:19.366 --> 00:53:20.900 Oh, that was the last one there. 00:53:20.900 --> 00:53:23.900 So the last thing I have for you is just a little epilog. 00:53:24.000 --> 00:53:26.400 Sometimes it's a dog eat dog world. 00:53:26.400 --> 00:53:29.666 And, this was a case that was an. 00:53:29.700 --> 00:53:31.400 It was an incidental finding on a stool. 00:53:31.400 --> 00:53:33.500 Owen p here at r u p. 00:53:33.500 --> 00:53:35.700 This is a tri chrome stain stool. 00:53:35.700 --> 00:53:38.100 And so here's a structure. 00:53:38.100 --> 00:53:40.233 And here's a structure within the structure. 00:53:41.666 --> 00:53:42.300 And what this 00:53:42.300 --> 00:53:46.166 turned out to be is the the technologist reported a few parasites, 00:53:46.166 --> 00:53:50.433 including into Mabel Coli and into me behest histologic a dis bar. 00:53:51.066 --> 00:53:54.333 And what happened here was the intermediate coli 00:53:54.366 --> 00:53:58.266 trough is 088 the cyst of and to me ba histologic. 00:53:58.266 --> 00:54:00.533 At this part you could see one nucleus here. 00:54:00.533 --> 00:54:02.733 I don't know how well this resolution is coming up for you, 00:54:02.733 --> 00:54:05.300 but there's a nucleus here and a nucleus here. 00:54:05.300 --> 00:54:08.500 It's kind of like your, parasitic logical ter dunk and you know that 00:54:08.500 --> 00:54:12.433 your Duncan is your turkey, your chicken stuffed in a duck, stuffed in a turkey. 00:54:12.433 --> 00:54:16.366 Well, that was an intimate behest politica stuffed inside of an N to me. 00:54:16.366 --> 00:54:18.166 BA coli. 00:54:18.166 --> 00:54:21.333 And here's a JRT assist inside of an intermediate coli. 00:54:21.866 --> 00:54:25.766 And to me, a cola is kind of like you're hungry, hungry hippos in the GI tract. 00:54:25.766 --> 00:54:28.333 They'll pretty much eat anything. They come across. So, 00:54:31.666 --> 00:54:32.966 and again, that's just, 00:54:32.966 --> 00:54:37.033 re emphasizing the, the, the first image. 00:54:38.166 --> 00:54:40.433 So that's all I have for you today. 00:54:40.433 --> 00:54:44.400 Again, I would like to thank everyone, and my colleagues here at a group 00:54:44.400 --> 00:54:45.733 that helped make it possible. 00:54:45.733 --> 00:54:48.733 And, and these are a series of, 00:54:49.100 --> 00:54:53.766 people that contributed cases and images, that I showed you today.