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

*Basic Exam:

• 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