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Trichomonas Bow Tie Mystery

1:16:39 recording · AUTO · 3 speakers

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Brief overview

A man's amoebic liver abscesses from El Salvador also revealed an unrelated, still-localized gastric cancer.

  1. A three-week course points to parasite, not bacteriaGriffin notes a bacterial infection would be far more acute, so illness running three to four weeks shifts the differential toward parasites.
  2. Don't needle a liver lesion before excluding EchinococcusAspirating an echinococcal cyst can cause spillage, leakage and even an anaphylactic reaction, so serology and stool testing came first.
  3. Occam and Hickam: patients can have two diseasesThe amoebic abscesses responded to metronidazole, but the gastric mass was a separate adenocarcinoma found on biopsy.
Executive Summary AI
  • Daniel Griffin presents the TWIP 274 case: a man in his 60s, born in El Salvador, who lost 50 pounds in three weeks and arrived febrile to 39.1 C with a white count over 20,000 and sodium in the 120s.3:26
  • CT showed a gastric mass exophytic from the antrum with associated lymph nodes, and ultrasound found multiseptated hypodense liver lesions of 6.3 by 6.9 by 8 and 2.7 by 2.3 centimeters, after which he mentioned a three-day visit to his mother in El Salvador followed by loose stools.5:08
  • Twenty-five listeners wrote in, most of them students in Dr. Caleb Hubbard's parasitology class at New Mexico State University, and the great majority guessed Entamoeba histolytica while several argued for Echinococcus vogeli or granulosus.7:33
  • Griffin sent stool PCR and serology, started empiric antibiotics including IV metronidazole, and the stool PCR came back positive for Entamoeba while serology was still negative at three weeks; the patient felt great within 48 hours and the lesions shrank.51:56
  • A week later the endoscopic biopsy of the gastric mass returned adenocarcinoma, so the man had two diagnoses at once, though the cancer was localized with no distant metastasis and was caught earlier than it otherwise would have been.52:55
Key Quote
“I'm not a clinician either, but I think it's e-hystallitica.”
— Vincent Racaniello48:12
Key Quote
“Within 48 hours, the guy feels great.”
— Daniel Griffin52:31
Key Quote
“And a lot of times the least expensive test and maybe one of the most important tests is a good history.”
— Daniel Griffin55:23