H.R.C, a 52 yr. old white female, and newly arrived resident of New York State, was seen by her physician and then admitted to CPMC suffering from extreme fatigue. She had been on an extensive four week tour of the Middle East two months prior to her admission.
PHYSICAL FINDINGS: H.R.C. was at normal weight for height, with no distinguishing physical features other than a recently applied, temporary (i.e. removable if necessary) NY Yankees icon tattoo on the back of her left ankle and a similar NY Mets icon tattoo on her right ankle.
LAB FINDINGS: CBCs normal; differential and WBC, normal; electrolytes normal, urinalysis normal; liver function tests normal. While resting in her hospital bed on the second morning of her admission, H.R.C. experienced a sudden discomfort in her upper pharynx, got out of bed and "coughed up" the object seen in the specimen jar. She immediately got in touch with the nurse on duty, who then called her physician, and he hand carried the specimen off to the Microbiology Diagnostic Laboratory. However, before he got there, a fourth year medical student encountered him in the corridor of Babies Hospital, took one look at the contents of the jar and gave the correct diagnosis to the physician. Some day you may encounter a similar situation, and will also be able to correctly identify it.

The specimen that H.R.C "coughed up" is in the jar.

2 points	Ascaris	lumbricoides
	Genus	species

1 point -- Could H.R.C. have acquired her infection on her Middle East trip? Explain. Color

1 point -- What stage of the infection did H.R.C. ingest to acquire the parasite seen in the jar ?

1 point -- If you were H.R.C.’s physician, how would you proceed ?

A.S, a 45 yr. old, white, popular male actor was rushed from his west side duplex to the emergency room of CPMC. He was covered in perspiration and in an obvious heightened state of anxiety. A.S. admitted to recently being in the jungles of Honduras and Guatemala filming his latest sequels: "Predator Gives a Hickey", and

"Heidi Meets the Terminator" when he began to feel ill. A.S’s disease began as a headache and backache, followed by congestion, and finally fever, chills, and sweats. He was medivaced to New York City, when the symptoms subsided. A.S. then decided to wait before seeking medical assistance, but was forced to do so upon the return of the above sequence of signs and symptoms several days later.
PHYSICAL FINDINGS: An extremely muscular individual with numerous calluses on the insides of both left and right palms, indicative of a lot of "pumping up" exercises.
LAB FINDINGS: Liver function tests normal, urinalysis — elevated bilirubin; CBC: RBCs 7 million/cc; 4% normocytes, 3% reticulocytes. WBCs normal in % and numbers. A blood sample was sent to the Parasitic Diseases Diagnostic Laboratory, and a thin smear made from it was positive for parasites.

SLIDE #2 is a Giemsa-stained sample of A.S.’s blood smear. PLEASE EXAMINE UNDER OIL

2 points	Plasmodium	vivax
	Genus	species

1 point -- How did A.S. acquire his parasitic infection?

1point -- Can the parasite seen in slide 2 remain in A.S. after his blood stages are eradicated? Explain.

1 point What drug(s) would you recommend to completely eliminate this infection in

A.S. ?

R.G., a 57 yr. old, white male politician and self appointed art critic, was admitted to CPMC suffering from diarrhea of two weeks duration, and in addition, he had a deep, now nearly healed, cut on his right hand.
PHYSICAL FINDINGS: R.G was emaciated, and complained of weakness. He stated that he had experienced bouts of constipation in addition to diarrhea over the last week and a half.
LABORATORY FINDINGS: stool culture for bacteria, negative; stool examination for ova and parasites, positive. An intern with an undergraduate degree in art history from Columbia College eventually discerned from the interview with R.G. that the patient had expressed his "gut" reaction to a: …."particularly offensive" work of art currently showing at the Brooklyn Museum, entitled: "Beaver with Fecal Pellets", by punching his hand through the canvas, cutting it deeply in the process. It seems that his mother had been a lumberjack in her younger days, and was quite fond of wildlife. The painting was, in fact, painted using emulsified beaver scat as the medium. Thus, the popular work of art was heavily contaminated with the environmentally resistant stage of the infection. R.G. had inadvertently somehow contaminated himself with the parasite when he placed his cut hand into his mouth in a futile attempt to stop the cursing and the bleeding.

Slide # 1 is a stained sample of R.G.s stool. Please examine under oil.

2 points	Giardia	lamblia
	Genus	species

1 point What was the infectious stage that R.G. ingested?

1 point If left untreated, what would be the long-term pathological consequences of

infection with this agent?

1point What is the drug of choice for this parasitic infection?

W.G. Jr., a 37 yr. old, white, male entrepreneur returned from a fact finding tour of Africa, having visited numerous sites at which malaria transmission occurs. His foundation had just announced a gift of over $50 million to help alleviate the devastating effects of this intractable disease on children and pregnant women living on that ravaged continent (true story, so far). W.G. Jr. admitted to enjoying the "fruits" of the earth while there, feasting on native cuisine wherever he went. He even admitted to swimming in the Nile on several occasions. In fact, W.G. Jr. had been in denial for some time, having appeared numerous times in front of the House Anti-trust select committee several weeks prior to his trip. In both cases, he lost more than his dignity. Two months after returning to Seattle, W.G. Jr. noticed a ruby tinge to his urine and consulted with a local physician. No infections were detected (only cultures were taken), and the bleeding subsided. No cystoscopy was performed at that time. Two weeks later, while in New York City, (a metropolitan center whose very nick name was a constant source of annoyance to him), he experienced another bleeding episode and immediately sought the advice of a physician at CPMC specializing in travel medicine. After listening to him rant about the unfairness of life in general, and of government in specific, his physician recommended that he be worked up for ova and parasites. Stool samples x 3 were negative, blood smears were also negative, but a urine sample was positive.

Slide 3 is a sample of W.G. Jr.’s urine. PLEASE EXAMINE UNDER LOW POWER, THEN UNDER HIGH POWER TO CONFIRM YOUR DIAGNOSIS.

2 points	Schistosoma	haematobium
	Genus	species

1 point -- How would you treat W.G. Jr’s parasitic infection ?

1 point -- If left untreated, what would be some of the long-term pathological consequences of W.G. Jr’s parasitic infection ? List at least two.

1 point -- How would you go about controlling this infection at the community level ?

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