A Gut Feeling

A CLINICAL PROBLEM-SOLVING article by Eddy Fan from University of Toronto, Canada.
A 72-year-old man presented with a 3-month history of watery diarrhea. This condition was associated with intermittent fevers, abdominal pain, and weight loss of 15 lb.
The patient was originally from the Philippines and had immigrated to Canada 8 years earlier. His most recent visit to the Philippines was approximately 9 months before presentation.
Specimens from random colonic biopsies were consistent with nonspecific chronic inflammation with marked eosinophilia. A biopsy of the terminal ileum captured fragments of an adult helminth embedded within the mucosa. The pathology report stated the fragment had features suggestive of a cestode scolex, but the exact species could not be determined.
Because of the low likelihood that infection with a cestode was causing the patient's symptoms and the lack of confirmatory stool testing for an active cestode infection, no antimicrobial therapy was initiated. The patient's symptoms improved. But four weeks later, his diarrhea worsened with associated episodes of first presyncope, then hypotension, for which he was admitted to the hospital.
An important component of clinical problem solving is the concept of “context specificity”; successful clinical reasoning is strongly related to having the appropriate context knowledge. In this case, lack of “context specificity” led to the failure to correctly identify the helminth on initial pathological examination. The discussion also suggests having an effective internet search might have helped with a difficult diagnosis in patient with life-threatning diarrheal illness.

「フィリピン毛細線虫(Capillaria philippinensis)感染」ということだが、ここまで来ると、ネット検索に頼るしかない。コメンテーターも“Philippines” 、“endemic”、 “parasite”、“chronic diarrhea”でググっている。