Friday, February 09, 2007

Ascaris Lumbricoides

I was on call last Friday night and was just beginning to think about going to my call room and trying to get a nap when a nurse came bustling up to me with a slight look of panic on her face. The look of panic on this particular nurse's face was note new, and I am actually beginning to think it has more to do with the alignment of her nose and eyebrows that gives her this look, rather than any voluntary effort at facial expression.
Anyway, she came bustling up to me with what I interpreted at that time to be a look of panic in reaction to an actual panic-inducing situation.
"Dr. Riegel can you please come to room one? There is something on his arm that kind of looks like a worm, but it doesn't look like a normal worm."
"A worm?" I asked.
"Well, I think its a worm, but its really weird."
"On his arm?" I asked.
"Well, yeah, kind of across his arm."
I got up and followed her to the patient's bed.
By the way, this kiddo wasn't a patient I was covering that night. He had undergone a minor surgery earlier in the day and was on the pediatric surgery service, which means the surgery residents are supposed to be alerted to any problems with him. Since I happened to be in the vicinity, I was called to action, despite knowing approximately nothing about the kid.
I walked in to the room and found a chubby toddler laying in his crib, whimpering and looking frightened, as most toddlers would look when a crowd of strangers comes in his room in the middle of his quiet sleep, turns on every light in his room, and none of the faces he sees are him mother's.
Laying on the crib sheet between his arm and his trunk was a curled up fleshy colored worm.
One of the more brave nurses got a tweezers and plucked it up off the sheet, placed it in a specimen collection cup and secured the lid.
"That looks like an intestinal worm..." I said.
The looks that spread across the three nurses faces was one of shock and horror.
"A what?" one of them said.
"You mean like this came from his intestines?" I heard.
"That's really gross. Ew," another said as she quickly left the room.
I put on some gloves (I myself was a little grossed out, too, I have to admit) and started looking the muchkin over.
He looked very miserable and pathetic laying there whimpering.
We took off his diaper and fortunately saw no other worms making their great escape from his anus.
I listed to his belly and heard nothing abnormal, pushed around on his abdomen, which was covered with scars from the burn he suffered when he was 4 months old and had a nasty encounter with a cookstove in Burma.
His lungs sounded clear, no sign that the worms had taken up a home there (as they are apt to do).
He looked well nourished and well hydrated. He was a good height and weight for his age, so no evidence of symptoms of a parasitic infection.
I decided we could wait until the sun came up to alert the surgery team that the had a kid with a wormy belly.
The worm, though, once out of its nice haven of the gastrointestinal tract, was quickly withering away in our specimen cup. I had called our lab and asked how I get an intestinal worm identified. I spoke with three people before any of them knew what to tell me, the last one saying, "Well, microbiology can look at it on a slide tomorrow."
I said, "I don't think this will fit on a slide. It's about 6 inches long."
"Oh goodness." was the response. "I'm not exactly sure what we do with it then."
So I am looking at this worm, withering away in the cup, knowing that if it withers away too much the day team in the lab would have litle to examine to help us identify what was infecting our patient (we lovingly refer to the day time staff as the A Team and night staff as the B Team...I knew the day team would be able to give me a little more help).
I started looking online for pictures of intestinal worms to try and identify just what kind it was. I decided it looked like a roundworm, aka Ascaris Lumbricoides.
So, I decided we needed to feed the worm.
One of the nurses who was intially repulsed by the worm actually started to come around to the little friend and volunteered to find some sucrose (sugar water) to give the worm to see if it would help.
We took the lid off the cup and administered 10 mLs of sucrose, and within a few minutes the worm was plumping back up and wiggling around a little bit.
Admittedly, I also wanted to keep it nice and plump so I had something to show the surgery team that might shock them.
It worked.
The surgery resident the next morning was adequately disgusted by the worm and came to me for advice on treating kids for worms. I gave him the name and dosage of a medicine called Vermex, which I think is a very clever name for a worm-killing medicine.
I also advised that the patient and his five siblings be seen by a doctor ASAP as the siblings likely also have infection, and unless they all get treated they will just keep reinfecting each other with worms. Also, there can be some complications with worms living in your body, so they should get seen for that, too.
Early this week I followed up on the lab results of the worm's identitity, and it was in fact an adult roundworm.
With this patient, though, the mystery remains about how the worm ended up near his armpit. Had it crawled out of his anus, out of the diaper, along his body and nestled into that warm dark place?
Had it crawled out of his nose or mouth as they can sometimes do?
Had it been in one of his diapers that had been changed and somehow fell out of the diaper into the bed?
There really isn't any way of knowing how it got there, and the worm wasn't giving up any info, so we'll never know.
I have since done some more reading about roundworms, and found that abour 25% of the world's population have roundworm infections. That's about 1.4 BILLION people, with about 4 million people in the U.S. having these infections. It is estimated that every year 8,000-100,000 people die from complications of these infections, most of them kids in undeveloped and developing countries.
Now that's something we don't hear about every day...