BE WARNED: THIS BLOG CONTAINS A REAL PATIENT HISTORY OFFERED FOR ADVICE AND SUGGESTIONS, WITH THE EXPRESS CONSENT OF THE PATIENT. THE DETAILS AND PICTURES OF THIS CASE, A PARASITE CASE, MAY BE GRUESOME.
Today during a scorching sunny afternoon, Christmas came the Southern Wind–here’s how:
When we first left Miami for Haiti, we left behind 5 pallets of additional medication and supplies that we could not fit onboard. We planned to return to Miami and pick them up after finishing in Haiti, and then continuing on to Central America.
From Haiti, we connected with Clinica Esperanza and Barefoot Cay Marina in Roatan, so
we came directly here instead of going back to Miami. We saved a lot of fuel and time but it meant we had to ship our pallets here to Roatan. Fortunately, Gary and Donna Evans arranged for Roatan Rotary Club to sponsor the shipping by providing part of Rotary’s yearly donated shipping allotment from Hyde Shipping here on the island. We also had to coordinate someone willing to drive a truck from the warehouse in Miami that was kind enough to hold our supplies to the Hyde Shipping warehouse in Miami…all the while seeing patients, planning our Haiti mission, fueling, securing the boat for sea, coordinating our 40-foot container from Direct Relief International for the island clinics and for Haiti. It has been BUSY.
However, health care is always our primary mandate, and when we are in danger of being overwhelmed by everything we have to do, we ask for help. Especially any clinicians reading this, this patient has suffered significant symptoms for months and has given permission to post his case for review by any of our medical followers.
Please post comments or questions for more details about the case directly on this page where we can all see them and brainstorm together. All posts are visible only after review and approval by Floating Doctors to protect patient dignity and confidentiality.
Patient: 27 year-old Caucasian male; 6’2”, 180lbs
*No prior medical history of note, no medications, no allergies
- Cardio : BP: 125/85, HR 74 (regular)
- Respiratory: Lungs clear, good air entry across both fields, no creps/wheezes
- GIT: Abdo soft and non-tender, non-distended
The patient had spent 7 months in Honduras working as a volunteer co-pilot on a non-profit emergency helicopter service, with frequent trips to the mainland while transporting patients.
3 months ago, a few weeks before his return to the US, he had complained of occasional vague stomach cramps (sometimes acute) and diarrhea. The night before returning to the US, he took a single dose of albendazole and subsequently had what he referred to as an episode of extreme cramping and “explosive worm diarrhea.” The worms he described were 6-8 inches long and very mucous-like. He continued taking a daily dose of 400mg of albendazole for the next few days, but continued to pass similar worms. He went on a strict fruit diet, eliminated fats and although the symptoms seemed to lessen he still passed stringy worm-like strands, some longer than 12” (in the initial days of treatment). After several days, he went to his local doctor and subsequently sent this email:
“I went to the doc yesterday and got a scrip for Flagyl. I never saw the doctor but the nurse
talked to the doc and he prescribed it. I’ve been on it for, now, two days. I’m coughing up some terrible stuff. One time (within the last week), while in the shower I blew my nose in my hands. In the mucus there appeared to be a worm about 1/2 inch long. It was either a worm or the most congealed mucus I’ve ever seen. Figuring I was exhibiting symptoms of hypochondria, I chalked it up as my mind playing tricks on me. Today, about a week later, after taking the Flagyl for two days, I’m coughing up some horrible stuff, which looks similar, but not exactly the same, as the worms in my stool. It’s stringy, if stretched out about 6-8 inches long. From what I’ve ever seen, mucus isn’t generally this stringy with elastic properties. When running the sink full of water, swirling one around rinsing it off, and then picking it out of the water with my finger, it’ll run over my finger like a spaghetti noodle would. It doesn’t look like a spaghetti noodle, (much smaller in diameter) but acts in a similar fashion when running one over your finger.”
He augmented his treatment with Pyrantel Pamoate equine anthelmintic, taking the same dose as for a 250-lb pony (900mg) daily for three days off 4 days, then repeating, and was also prescribed mebendazole 100mg twice daily for three days, then 4 days off, then repeating the regimen for a month along with the flagyl (metronidazole). He also ate enormous amounts of fruit and had a colonic irrigation (though he saw no worms come out during the evacuation, only the next day), and is taking 15,000mg of garlic daily.
He has not had blood work or an ova and parasites study (stool sample). He has been advised to collect one of the worms and bring it to his hospital or GP for parasitology, and to have a full blood count with differential to look for raised eosinophils. Results will be posted as soon as available.
The ‘worms’ pictured do not look at all typical. Could they be some kind of mucous shedding of the intestine post infection or from the treatments he has given himself…even the garlic? If so, what about the episodes of coughing and similar, smaller mucous strings from his nose? He has tried most of the heavy-hitters for parasites…even horse worming medication (not on my advice!).
Does anyone recognize these as worms or other pathology, or have suggestions for further treatment or investigations? The patient has no medical insurance so cost will be a factor in patient ability to comply with investigations. Taking the worm to a doctor so it can be sent to a specialist and analyzed if necessary is definitely the next step, but any advice or ideas would be appreciated.
Our 40-foot container from Direct Relief is supposed to be cleared through customs Thursday!
Then we can distribute everything, load the boat and depart at the first weather window to Jamaica for fuel and back to Haiti!
All Photos (Except The 3 Worm Pics) Courtesy of Dan Chomistek
July 22, 2010. Isla Roatan, Honduras.
Our passage from Jamaica to Roatan was without incident. We had a following wind and sea, so we made pretty good time, although the last few hours were literally a race against the sun. As we approached Roatan, we made contact with Barefoot Cay, and they said, if we got there in daylight, they would send a panga out to guide us through the narrow channel to their dock. If we couldn’t get there in daylight, they suggested we stand offshore, and they would bring us in the next morning. Needless to say, we pushed hard to arrive in daylight. We goosed the engines, and I tried to squeeze another knot or two out of the steering wheel. We arrived at twilight, picked up the panga ahead of us and followed it in to the dock, parking the boat as the full dark of the new moon began to descend. What a relief! Coming into an unknown dock in the dark in a 144,000-pound vessel is always a little tense. We tied off the lines and shut down the engines and unclenched after another successful crossing of just over 800 miles. It is beautiful here—we are incredibly fortunate that Barefoot Cay is hosting us at their dock. It is the perfect place for us to use as our base here in Roatan. Besides being a gorgeous facility, it is located about a third of the way from the island’s west end, so it is central to everywhere we are working. I had originally planned to give everyone a week or two off to rest and recover from everything we saw and did in Haiti and to get some maintenance done on the boat, but our destiny had other ideas.
On arrival, we rendezvoused with four incoming volunteers—two nurses, Annee and Sirin, who have just finished their Masters degrees in nursing, an EMT named Martin, who is in the middle of applying to medical school, and Ash Leigh, an Occupational Therapist. A few days later my old classmate Maddie, an educator in one of the toughest school districts in south central Los Angeles, also joined us. Our initial plan was to work with the Clinica Esperanza, but in the two weeks we have been here we have expanded our mandate. Within 5 days our new volunteers and Haiti team were working in Clinica Esperanza, the Centro de Salud in Los Fuertes and the V.O.M Clinic, a PT/OT clinic for children with cerebral palsey, movement and behavioral disorders, and people with injuries or post-stroke deficits.
We are also the new flight crew for the Aeromedical helicopter, the only civilian emergency medical helicopter service in Honduras, available not just for tourists, but also for members of the community here. Sirin—who is also a CPR/BLS/EMS educator—is working with Maddie and the local Fire Department to do life support training for the fire and ambulance crew, some of who started working as firemen when they were 14 years old and have little formal training.
We have arrived in the middle of a nationwide Dengue Fever outbreak, so we have plenty of work to do. I did learn a couple of great clinical diagnostic tricks for Dengue. It is a hemorrhagic fever that causes bleeding. Like many terrible diseases, it has very non-specific initial signs-fever, malaise, aching, tiredness, etc. You can put a blood pressure cuff on someone’s arm, pump it up and leave it for two minutes. If they develop petechiae (little bleeds) on their arm, it is probable for Dengue. Also, intraocular pressure seems to increase, so gentle pressure on the eyes, with eyelids closed, produces a lot of tenderness in Dengue patients. I’ve had a few confirmed cases already, so we give supportive care and help people try and ride it out safely, but Dengue is not called ‘Breakbone Fever’ for nothing—it HURTS!
What has struck me most poignantly here is that, although Honduras is a poor Central American country, EVERYONE we have met here and every business we have connected with seems to be involved in some way with ensuring there is some access to health care for themselves and their fellow islanders. Barefoot Cay supports Clinica Esperanza. The local gym (which we are allowed to use as guests of Barefoot Cay) is organizing an American Gladiators-style competition to raise money for Esperanza. There is an island marathon being planned for the V.O.M Clinic. The Rotary Club here supports the Los Fuertes Clinic. Many of the islanders pay about $10 a month to support the helicopter service. It is amazing. Honduras is a place which has little. It has been very hard-hit by the economy in the US. It received terrible press when their military arrested the previous president and essentially evicted him to avoid him seizing power. But the people here are an surprising example of what we are trying to promote—taking personal responsibility for health and access to health.
It just goes to illustrate what I have always observed—people who know true need also understand the value of helping each other in a way that people living in more prosperous countries can never know. And especially here, on a 30 mile long island, it is like being on a boat with 60,000 people—everyone is in the same boat, and only by pulling together, can they survive the storms and squalls of fortune.
It is inspiring to see, and I am proud and humbled that we get to be a part of it.[flickr-gallery mode=”photoset” photoset=”72157624523709627″]
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