The Curious Case of Mr. C and the Worms
Mr. C was a very pleasant 68-year-old Vietnamese man who'd been admitted to our hospital routinely over a number of years for decompensated chronic obstructive pulmonary disease. None of the many histories and physicals performed on him could explain what exactly was triggering his dyspnea. While the smiling old man did have an extensive smoking history, he had not touched a cigarette or an opium pipe in more than 10 years, and no one in his family smoked.
His chest films routinely showed hyperexpanded lungs with no obvious infiltrates, his cultures were always negative, and he was always discharged with a medrol taper, a long-acting bronchodilator, an inhaled steroid, and albuterol as needed. Occasionally he would follow up with a primary-care provider. This was the pattern for years, until the explanation for everything was finally revealed.
During his most recent admission for decompensated lung function, he complained - and this was an old-timer Asian male who never complained unless something was seriously wrong - about several days of abdominal pain, nausea, and vomiting. Examination revealed no bowel sounds, labs indicated a slight eosinophilia, and a plain film revealed air-fluid levels in dilated loops of small bowel. We were excited to see that other organ systems were finally getting attention, and promptly attended to them. After viewing Mr. C's abdominal film, I decided that he would need a nasogastric tube. I interrupted my intern, a portly young fellow, while he stuffed several different types of rich, bile-stimulating foods into his mouth in the call room.
"Hey G, turns out Mr. C has a bowel obstruction. Wanna put an NG in after you finish your fifth meal of the day?"
I smirked at him.
"Oh yes, I'm glad to do procedures in the unit."
"Good, you'll have two nurses in the ICU proctoring you, so you'll have extra incentive not to screw up."
I've noticed that my training has made me a frequent user of tough love in dealing with interns and residents. Fear makes people attentive, and such attentiveness is important in the hospital.
I took him to Mr. C's room, where the patient waited comfortably with the nurses and a translator. The translator guided the patient to swallow and breathe orally while Nurse C, speaking in her languorous British accent, urged our intern to twist the tube in.
At one point she guided him by placing her hand on his. This sudden contact with the nurse caused him to blush, and he started to babble incoherently, betraying his lack of confidence in his technique. It seemed, though, that the procedure had gone well, and after air injected into the tube was auscultated in the stomach, a plain film was ordered to check placement.
But 20 minutes later Mr. C was not responding to verbal stimuli, and was dyspneic and hypoxic. An emergency call from radiology instructed us to inspect the last X-ray done for tube placement. We all stared wide-eyed at the tube descending along the medial aspect of the right lung, through what appeared to be the right mainstem bronchus, passing a small pneumothorax, on through the diaphragm and into the abdomen, ending in what appeared to be the cecum. It made no sense at all. How could the…? What?
I intubated the patient without adverse event, and a surgeon was called to place a chest tube. Discussion then ensued.
What the heck? The tube had pierced the bronchus and the diaphragm? There was no subcutaneous emphysema, there was no free air under the diaphragm. Our portly intern was flushed in the face and silently flatulent, regretting the fatty meal he had recently refused to forego. And then …
A bloodcurdling scream emanated from a female voice in Mr. C's room, piercing whatever sense of order there was remaining in that area of the unit. We all rushed to the door of the room to find Nurse S jumping onto a chair, bug-eyed with fear.
"Worms! There are worms in his mouth!"
It was an "ah ha!" moment for me as suddenly a plausible explanation for Mr. C's recurring condition thundered into my head. My suspicion would shortly be confirmed. We walked apprehensively to his bedside and gazed at what appeared to be about a dozen tiny wiggling creatures, each about two millimeters in length, in the patient's mouth, several dancing on his lower lip.
"Strongyloides stercoralis" announced a tiny, yet confident voice behind us. The chief of medicine, Dr. K, was a small woman with a large presence. "We have what appears to be a parasitic infection and pneumonia in a patient with a bowel obstruction, likely caused by said organism, which is getting an extraordinary amount of help in its evolutionary task of dissemination by the presence of a fistulous nasogastric tube conveniently located to permit trans-diaphragmatic transport."
It made sense. A chronic parasitic infection explained the pneumonitis and the bowel obstruction. The patient had traveled to Vietnam sometime in the recent past, and was interacting with products and people from his homeland.
The next day during morning rounds, another scream was heard from Mr. C's room. As we moved toward the room, we watched in befuddlement as Nurse S, still recovering from yesterday's excitement, rushed bawling from Mr. C's room, screaming "Worms!" We walked into the room to witness M, a wily and mischievous respiratory therapist, cleaning up the ramen noodles that were spread all over his chest. He gave us a smirk and shrugged. "Ha ha - looks like the worms are taking over!"
Dushyant Viswanathan, MD, is an internist practicing in Baltimore. He attended residency in internal medicine in the University of Maryland Medical System, and now works in both inpatient and outpatient settings.
This article originally appeared in the May 2011 issue of Physicians Practice.