Playlist for the Apocalypse and Other Rays of Hope…

While washing my hands in an airport restroom, “Until the End of the World” by U2 (Achtung Baby, 1991, Island Records) was playing over the toilet speakers. As I watched several people incorrectly wash their hands during this current pandemic, the songs lyrics (which I have known by heart since 1991) rang through my brain and struck a new chord with me. There are plenty of doomsday songs that actually make us happy (Prince’s 1999, from 1999, 1982, Warner Bros.; R.E.M.’s “It’s the End of the World as We Know It,” from Document, 1987, I.R.S. Records) despite the dark images in the lyrics. And then here are a whole host of doomsday songs that are dark and brooding (“Man Comes Around” by Johnny Cash, “Waiting for the End of the World” by Elvis Costello, “It’s Not the End of the World but I Can See it from Here” by Lostprophets, and “Preaching the End of the World” by Chris Cornell, etc.). It turns out you can write a doomsday song after a breakup with your partner (“The End of the World” by Skeeter Davis) or in response to nuclear war fears (“Everyday is Like Sunday”by Morrissey).

What struck me in my new feeling of U2’s track was the dichotomy of viewpoint by the two principal voices in the song. The speaking voice is in it for the short game, in it for “me.” The listener in the song is in it for the long game, in it for “we.” Considering both the inspiration for the song personally for Bono as well as the historical character about which the song is based, this might be kind of obvious to most of us. However, in 2020, as we face what can only be described as a venomous divergence of voices, the lyrics force me to think about individuals’ motivations, agendas, messages, points of view, and goals when they speak, text, post, or otherwise communicate their opinions and that such opinions come in two flavors. There are those that are in this for themselves. There is no other valid observation than selfishness, conceit, arrogance, and disrespect for others. There are those that are in this for everyone. There is no other valid observation than collaboration, caring, selflessness, humility, and respect.

Considering that, regardless of your moral compass or who your parents were, most children are theoretically raised to be like the latter but the innate, instinctive traits of our evolution are really the former. Thus, as many great philosophers and thinkers have concluded, the intellectual evolution of the human mind and personality is such that seeing and caring for “the other”, even more than for ourselves, is a mark of high achievement while base, crude attacks on “the other” are marks of devolved, unintelligent individuals. Notice that there is no good and evil in this argument. There is only awareness of self and awareness of others and choosing one over the other. Naturally, the best life is to balance our care for ourselves and our care for others, which, some would argue, is one of the most valuable aspects of organized religion. As I am a non-religious person—despite the fact that the U2 track is one of my favorites—I strive to achieve that balance through a universal moral compass perspective which includes a great deal of importance on the safety, security, health, well-being, and happiness of others.

COVID-19 and its viral cause, SARS-CoV-2, have sent incredible ripples, waves, and tsunamis across every aspect of human life in the last 6 months. Pandemic preparedness and responsiveness is a “we” activity. China very much had a “we” approach to health (among many other sectors) which was evident by their incredible response to SARS originally in 2002. Some would argue that had SARS emerged in any other country, it would have gone pandemic at a much faster rate with horrible consequences; yet, emergence in China meant the virus was facing a huge pre-programmed response. But importantly in the 2002 outbreak, CDC officials from the US were relocated to China and work closely with the Chinese government to plan, implement, and execute daily changes to the management of the outbreak. Relationships being what they are, China did not interact as closely with the US for COVID-19 and, thus, the response was not as successful. In healthcare, as in many areas of human life, we are stronger together, and we will be more successful with transparency and communication than with secrecy and seclusion. The health of humanity should not be a geopolitical issue.

The diagnostic medical team (DMT), composed of pathologists and laboratory professionals, is the backbone of modern healthcare. However, these are also people who have underlying conditions, have elderly parents, have to ride the train to work, etc. Everyday, even when there isn’t a pandemic, members of the DMT place their own personal health and safety on the line to provide patients with rapid, accurate diagnoses and continuous care. Fortunately, laboratorians are well versed in protecting themselves within the laboratory from potential risks; however, in a pandemic situation, they must also protect themselves from external risks, else the laboratory staffing falls below the levels that insure high quality patient care is available.

COVID19 testing by RT-PCR of SARS-Cov-2, for example, is a high complexity laboratory test that is often performed by a select number of laboratorians and not by all laboratory staff. When we hear discussions of laboratory testing for COVID and money for such testing or availability of kits, it must also be noted that the laboratory is the only segment in the system who can take money and tests and turn it into data that saves lives—but only if they have sufficient people to make this happen. Healthcare facility leadership and national leadership must support those teams by providing all necessary resources to meet the needs of patients including the laboratory direct and indirect needs. Expanding the ability of personnel in the laboratory to meet this emergent need through cross-training and potential emergency staffing coverages is essential to successfully navigating this pandemic.

The DMT is always practicing the “we.” But now that the pandemic requires transparency and communication for success, the entire health system must amplify the practice of “we” and advocate with external leaders for every member of the healthcare team, but especially the laboratories. It is no time for “me” in this situation. Hand washing, social distancing, and self-quarantine may seem like things that protect “me” but it is clear that the goal is rooted in protecting “we.” Flattening the curve may prevent the healthcare systems from becoming overburden; however, laboratories are going to be massively overburdened regardless. Asymptomatic, symptomatic with other diseases, and true cases of COVID19 all have to be tested and there isn’t a precedent for the pace the disease is moving. Laboratories are coming online this week (March 16th) with testing that needed to be available in January. Laboratory staff must be enabled and mobilized to meet this current needs. We are all behind the curve on this one, but I have full confidence in our DMTs to get this done if they can be supported. There will be struggle but the tenacity and perseverance of our nation’s laboratory professionals and pathologists will see this through to its end. Because we, the DMT, don’t have a choice but to always consider the “we” in our daily practice, our patients WILL BE tested and diagnosed. We will beat this together and in being together, we will be stronger.

milner-small

-Dan Milner, MD, MSc, spent 10 years at Harvard where he taught pathology, microbiology, and infectious disease. He began working in Africa in 1997 as a medical student and has built an international reputation as an expert in cerebral malaria. In his current role as Chief Medical officer of ASCP, he leads all PEPFAR activities as well as the Partners for Cancer Diagnosis and Treatment in Africa Initiative.

A Day in the Life

Who are medical laboratory scientists? We call ourselves clinical laboratory scientists, medical technologists, med techs, medical laboratory technicians, MLTs, or simply “techs.” Around the clock each day we provide vital information to physicians. We perform a variety of laboratory procedures from identifying microorganisms to providing blood for emergency transfusions. We’re trained in clinical chemistry, hematology, microbiology, and transfusion medicine. We are dedicated to delivering accurate and precise, high quality results to physicians. These providers rely on us for the diagnosis and monitoring of patients. I’ve heard it said that “without the lab, you’re just guessing.” We are a somewhat unknown but very important part of the medical field.

Many of us joined this profession because we are organized, have a strong attention to detail, are intrigued by science, and want to help others. We want to work in the medical field, but may not really want patient contact. In my case, I knew I loved biology, chemistry and math, had an analytical mind, and pay a great deal of attention to detail, but I didn’t really want to deal with “people,” so I thought I had found the perfect profession. Working in a lab, in the basement, I wouldn’t have any patient contact. Little did I know that for many years I’d be looked up to as an “expert phlebotomist;” the tech the phlebotomists would come to when they missed a “tough stick.” I was often called to the floors and the outpatient lab to draw patients. I worked 3rd shift where we were our own phlebotomists. And little did I know that I’d discover a love of teaching, and actually enjoy standing in front of a group of students, teaching them. I never thought I’d enjoy public speaking, but now I speak at conferences and symposiums and love sharing my love and knowledge of Hematology and Transfusions Medicine with my audiences.

I’ve been teaching for years, but continue working in the laboratory as well, because I feel the best teachers are the ones with first hand, current experiences to share. When I work with my students, I like to coach them to think problems through and to solve puzzles instead of simply memorizing facts. Med techs often choose the profession because they have a strong ability in science, but also keen investigative instincts, and enjoy the challenge of solving puzzles. We graduate with a plethora of knowledge, but it doesn’t stop there. We need to take this with us to our jobs, build on it, and use it every day to learn to think through and solve these puzzles and problems quickly and accurately. It’s a profession where you never stop learning.

So, where is this going? Graduation is coming, and a new set of med techs will be set forth into the labs of the world, armed with knowledge and ready to learn yet even more. So, what is it really like working in a hospital lab? Here’s a little glimpse of a typical day in the Hematology lab.

It starts a lot like the Beatles tune: “Woke up, fell out of bed, dragged a comb across my head. Found my way downstairs and drank a cup, and looking up I noticed I was late…” Which reminds me, I remember reading somewhere that medical technologists are the profession that drinks the most coffee. But, so much for being side tracked. Waking up at the crack of dawn, rushing in the door, clocking in before 7 am, on a typical morning we all check the schedule to see where we are scheduled for the day and to see who called out sick. On this day, there was only one sick call, which necessitated a little juggling of the schedule because we were already short staffed. (We can’t wait for you new grads to start!) That was our first problem of the day solved. And then we got a call that the 2nd heme tech was stuck in traffic. Techs are very adaptable, and can think on their feet. Looking around, I suddenly noticed I was alone in Hematology, and our CellaVision was down. On top of sick and late calls, the overnight tech had left early. I jumped right in. I took inventory of the situation, and saw messages about 2 pathology review fluid slides that were left from the previous shift. I took out QC to warm up, started finishing up the morning run and worked on the CellaVision. Soon my partner for the day arrived, just in time to hear the XN analyzer start beeping. Did I mention that techs are really good at multi-tasking?

I got the CellaVision up and running again: second problem of the day fixed. After shutting off the alarm on the XN, we began investigating, reran the specimen, called the floor, and discovered it was a contaminated sample: third problem of the day solved. We had a morning of calling critical labs to the providers, trekking across to the other building to bring the pathology reviews to the pathologists, and handling sample barcode issues. I took a quick look at the clock and realized it was 9:30 am, and we had just finished the morning QC and maintenance. Time for that coffee! (I actually am apparently one of the few med techs who doesn’t drink coffee, but I managed a quick break and a cup of tea.) Our hematology techs assist with bone marrow collections, making the slides, processing them and bringing the slides to the pathologists, then to surgical pathology and cytology. The whole process can take 1 ½ – 2 or more hours, and this day was our lucky day. We had two scheduled bone marrows, and another one that was a surprise. Three bone marrow and only two techs in the department!

While we were up in oncology and interventional radiology and processing bone marrows, the CellaVision acted up again, and I had to call service. I left a message for evening shift that service would be coming in that afternoon. A reagent ran out and I had to fill out the reagent replacement log. One other things that med techs do very well, is documenting what we did. There is a saying in the lab that “if it’s not documented, it didn’t happen.” We had a couple racks of unreceived specimens delivered to the department, and had to resolve the unregistered samples. Stats kept coming in, we had a T4T8 to run, and lunch time came and went, with neither of us getting a real lunch. Body fluids started coming in, three in a row. And guess what? One of them needed a pathology review! Med techs also get plenty of exercise when the pathologists are in a different building than the lab. The next phone call I got was from a second-shift tech who was running late. It seemed like the start of the day all over again! Before we knew it, it was 3:30 and time to go home.

We had a full day, a great day. It makes me feel good to know that we are doing such vital work. I feel proud that our team works well together. Not every day is quite this busy, but the busy ones are when we learn the most.

To all the students I have worked with this year, and all students everywhere, welcome to the lab! We need curious minds, and new techs who are ready to unravel the puzzles and solve the problems we see every day. We need new “diagnostic detectives.” I am very proud every year to see or new graduates accept the challenge and become medical laboratory professionals. 2020 Graduates, welcome to our world!

-Becky Socha, MS, MLS(ASCP)CM BB CM graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

Biomarker Testing for Cancer Patients: Barriers and Solutions Part 4

This month we will continue discussing the common barriers to biomarker testing for cancer patients in the community. 

As you may recall, these are the top 10 barriers that I’ve seen to biomarker testing in the community:

  1. High cost of testing.
  2. Long turnaround time for results.
  3. Limited tissue quantity.
  4. Preanalytical issues with tissue.
  5. Low biomarker testing rates.
  6. Lack of standardization in biomarker testing.
  7. Siloed disciplines.
  8. Low reimbursement.
  9. Lengthy complex reports.
  10. Lack of education on guidelines.

Despite being unique hurdles, a few of these barriers can be addressed together.  If you are able to standardize biomarker testing despite the barriers that come with being in siloed disciplines, biomarker testing rates will go up. Sounds easy right! I am a firm believer in the multidisciplinary approach to precision medicine, because I have seen it work in my institution. I have also spoken with organizations where there is no collaboration among the multidisciplinary team (MDT) and observed what happens when the team is not working together. In these cases biomarker testing is often not being performed according to guideline and relationships between the pathology and oncology are strained.

In my organization we have a lot of complexity: 12 hospitals, inhouse and external reference labs, our own private payer, and pathology and oncology groups that are not related to the organization or each other. Everyone wants to do what’s right for the patient, unfortunately if everyone is not working together to help the patient, we tend to get in each other’s way. We found that our oncologists were not getting results back on biomarker tests in reasonable amount of time to make educated treatment decisions. The oncologist chose when to order testing, which biomarker to test, and the performing lab.  This resulted in a great deal of variance in the care provided by each physician. It also added complexity in the pathology laboratory. We had to have shipping containers, portals, collection and specimen requirements that were different for every reference laboratory that the oncologists used. This delayed turnaround time even more as we navigated through the nonstandard process for biomarker testing. As you can imagine tensions were high between pathology and oncology.

Our organization began following the high performance team model some years ago.  With this model we have a “team of teams” that can effect change rapidly despite a complex organizational structure (1). Every stakeholder is represented in the meeting, without every stakeholder having to attend the meeting.  So if you have a team of oncologists that already trust their colleague they are typically comfortable allowing one oncologist to represent their best interest in the committee. We now have a vast structure of committees built on the principle of extending trust from one group into another group with stakeholder representation to build relationships between teams.

One of these committees is a Molecular Steering Committee.  I co-chair this committee along with an oncologist. It is attended by radiologists, pathologists, oncologists, administrators and even the medical director from our payer. Every stakeholder and geographic region is represented. In this committee we discuss how to standardize biomarker testing by tumor type. Although our committee is distinct from a molecular tumor board where you can discuss molecular results for cases, any forum where standardizing the biomarker process can be addressed with a multidisciplinary team is the right forum. We have built relationships between the stakeholders involved in biomarker testing and help keep each other educated on changes to guidelines across tumor types.

This committee has allowed us to develop pathology-driven reflexes for testing in specific scenarios.  Not all biomarker testing can or should be done at the time of diagnosis. However, some tumor types such as NSCLC adenocarcinoma where the tissue is limited and turnaround time is urgent, it makes a lot of sense to perform the testing as soon as we know the patient has this disease.  In these cases the pathologist orders NGS and PD-L1 testing when they determine the diagnosis. This drastically cuts down on the turnaround time (2 weeks vs 6 weeks) and has the added benefit of ensuring all patients with this diagnosis get the standardized biomarker testing that they deserve.

Having a multidisciplinary forum to discuss biomarker testing by tumor type, including which tumor types, what stage, who’s ordering (pathology vs oncology), which test, and where it is performed is necessary to bridge the gap between siloes. In some institutions this can be done without a formal committee, a phone call between oncology and pathology may suffice.  The most important thing you can do to improve your biomarker testing rates and increase standardization is to communicate across silos or disciplines to ensure everyone is in alignment on how to determine patients’ biomarkers status. 

Reference

  1.  McChrystal, T. C. D. S. C. F. S. A. (2015). Team of Teams: New Rules of Engagement for a Complex World.

-Tabetha Sundin, PhD, HCLD (ABB), MB (ASCP)CM,  has over 10 years of laboratory experience in clinical molecular diagnostics including oncology, genetics, and infectious diseases. She is the Scientific Director of Molecular Diagnostics and Serology at Sentara Healthcare. Dr. Sundin holds appointments as Adjunct Associate Professor at Old Dominion University and Assistant Professor at Eastern Virginia Medical School and is involved with numerous efforts to support the molecular diagnostics field. 

Be Safe…Be Very Safe

In the 1986 remake of the horror film “The Fly,” the character played by actress Geena Davis has a great line. When she warns another person about the extremely unsafe behaviors of the title character, she says, “Be afraid…be very afraid!” Clearly this woman in the story understands the dangers involved in hanging out with a man whose mind is slowly being dominated by a killer creature. As a lab safety professional, one of my greatest wishes is that laboratorians would understand the danger they can be in when they permit unsafe behaviors in those around them.

Coaching fellow lab workers about safer behaviors is perhaps one of the most powerful and important tools we have to improve the overall safety culture, but it is also one of the most difficult tools to use. There are a variety of reasons we don’t do well with speaking up when we notice unsafe activities. Some laboratorians are introverts, and saying something that could be perceived as forward or direct just isn’t natural for them. There are those who do not want to correct co-workers or friends since doing so might somehow damage the relationship. Others don’t say anything because doing so in the past had no noticeable results.

The damage done by not coaching others for safety is terrible, and unfortunately, it’s easy to do. Repairing this damage, on the other hand, can be a slow and difficult process. Albert Einstein said, “The world is not a dangerous place because of those who do harm, but because of those who look on and do nothing.” That means that when we see unsafe behaviors, we have a responsibility to do take action against them. Otherwise when we do nothing, we are essentially giving permission for those dangerous behaviors to go on. That will only lead to a worsening lab safety culture, and eventually there will be increasing amounts of injuries and exposures.

With the rapid spread of COVID-19 in the Unites States, the number of questions that have arisen about lab safety has climbed exponentially. I am excited about any uptick in interest in laboratory safety issues, but I wish it didn’t take a world-wide pandemic to cause it. The Centers for Disease Control (CDC) has offered very good lab safety instruction for the processing and testing of COVID-19 specimens          (https://www.cdc.gov/coronavirus/2019-ncov/lab/index.html), and virus testing is being performed in more labs each day.

It is vital for laboratorians to remember this. While the coronavirus is not to be taken lightly, the patient specimens we handle every day contain biohazards that are far more dangerous to us than COVID-19. Hepatitis, HIV, select agents, and many other pathogens reside in the blood and body fluids processed and tested in laboratories across the country, and many of the illnesses these agents can cause are very hazardous to human health. I hope we remember that when the hype about this latest virus passes.

Use Standard Precautions when working in the laboratory. Wear lab coats, gloves, and face shields. When you see a co-worker who is not properly attired, offer them the PPE they need. If you see an unsafe practice like eating, drinking, or using cell phones in the department, end it quickly. That is how infections occur, and that is how they spread into the community. Remember, unsafe behaviors can have a direct affect on the safety of the entire team. The sooner we can help everyone to understand that, the better we will all be at coaching others. In the original 1958 version of “The Fly,” the title character is caught in a spider’s web. His famous (and often imitated) last words were, “Help me! Help meeeee!” The scientist practiced unsafe behaviors until it was too late to turn back. Don’t let that be the case for anyone in your laboratory!

Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Microbiology Case Study: 41 Year Old Male with Complaints of Abdominal Pain for One Month

Case History

A 41 year old African male presented to the ED with complaints of abdominal pain, weight loss, and decreased appetite over one month. He immigrated from Zimbabwe 10 years prior, and most recently visited 4 months ago. His past medical history is non-contributory. He was found to have microcytic anemia (Hgb 9.3 g/dL, MCV 77.0 fL), pneumonia, and focal small bowel dilation with thickening and inflammatory changes on abdominal CT.

Endoscopy revealed a large, villous, infiltrative mass in the third portion of the duodenum. On histologic examination of the duodenum biopsy, viable Schistosoma eggs were seen within the vessels in the lamina propria and associated with adenocarcinoma (Images 1 and 2). Schistosoma mansoni eggs were identified on stool ova and parasite exam (Image 3), and serology was positive for Schistosoma IgG antibody.

Image 1. 10x objective magnification of a hematoxylin and eosin stained histology slide of the duodenal biopsy with associated adenocarcinoma and multiple eggs can be visualized.
Image 2. 40x objective magnification of a hematoxylin and eosin stained slide from the duodenal biopsy of a man from Africa who presents with abdominal pain who is found to have a mass on endoscopy. Seen is a viable egg with intact miracidium and no evidence of calcification.
Image 3. 100x oil immersion objective magnification of an iodine prep from a concentrated formalin-fixed stool specimen demonstrating a Schistosoma mansoni egg with its characteristic large lateral spine.

Discussion

Although this is not a common infection to encounter in the US, prevalence in endemic areas ranges from 30-100%. Infection occurs through contact with water contaminated with human feces; common circumstances are irrigation ditches as well as bathing and washing water.1

Schistosomiasis may be an indolent infection in many immunocompetent hosts. Chronic infection requires a shift from inflammatory TH1 response to a modulatory TH2 response.2 There is also evidence that Schistosoma infection may downregulate the immune response by inducing M2 differentiation of macrophages.3 These anti-inflammatory macrophages have been associated with a microenvironment favorable to malignancy. It has also been shown that S. mansoni is a risk factor for hepatocellular carcinoma (HCC) and colonic adenocarcinoma, possibly by altering p53 activation, initiation of chronic granulomatous response that blocks venules, increasing cell turnover, and promotion of ROS and RNOS production.4 Anti-idiotype antibodies produced in chronic infection may also down-regulate both specific and non-specific immune responses.5

This case is an unusual presentation in the US in that viable ova are typically not seen, and S. mansoni is more likely to involve the distal colon and liver rather than the small bowel. There is a known association between S. mansoni infection and HCC, and there are sporadic reports of association with tumors of the prostate, ovary, uterus, and cervix.5,6 To our knowledge however, there are no other reported cases of duodenal adenocarcinoma with concurrent schistosomiasis.

References

  1. Chai J and Jung B. Epidemiology of Trematode Infections: An Update. 2019. Adv Exp Med Biol. 1154:359-409.
  2. Barsoum RS, et al. Human Schistosomiasis: Clinical Perspective: Review. 2013. Journal of Advanced Research. 4:433-44.
  3. Hussaarts L, et al. Chronic helminth infection and helminth-derived antigens promote adipose tissue M2 macrophages and improve insulin sensitivity in obese mice. 2015. FASEB J. 29(7):3027-39.
  4. El-Tonsy MM, et al. Schistosoma mansoni infection: Is it a risk factor for development of hepatocellular carcinoma? 2013. Acta Trop. 128(3):542-7.
  5. Palumbo E. Association Between Schistosomiasis and Cancer. 2007. Infectious Diseases in Clinical Practice. 15(3):145-8.
  6. Peterson MR and Weidner N. Gastrointestinal neoplasia associated with bowel parasitosis: real or imaginary? 2011. J Trop Med. 2011:234254.

-Daniel Welder, MD is a second year Clinical Pathology resident at UT Southwestern Medical Center in Dallas, Texas. He has interests in Hematopathology, Transfusion Medicine and dabbles in Microbiology.

-Dominick Cavuoti, DO is a Professor at UT Southwestern in the Department of Pathology. He is multifaceted and splits his time as the Medical Director of the Parkland Hospital Clinical Microbiology Laboratory and Parkland Cytology attending among other administrative and educational activities.

-Clare McCormick-Baw, MD, PhD is an Assistant Professor of Clinical Microbiology at UT Southwestern in Dallas, Texas. She has a passion for teaching about laboratory medicine in general and the best uses of the microbiology lab in particular.

An Asymptomatic 52 Year Old Female with a Surprise Finding on Colonoscopy

Case Presentation

A 52-year-old female with no significant past medical history is seen for a routine annual examination and is scheduled for a colonoscopy due to her age being over 50 years. The colonoscopy was performed and an isolated single worm was found within the cecum (Images 1-2). The worm was removed with cold forceps and subsequently placed in paraffin and sectioned (Images 3-5).

Image 1. The worm is depicted within the cecum attached to the mucosal wall by its anterior end.
Image 2. The worm is captured using cold forceps.
Image 3. Hematoxylin and eosin stained section of the worm.
Image 4. Higher power magnification, showing eggs with distinctive characteristic bilateral polar plugs and barrel shape.
Image 5. Higher power magnification, showing eggs with distinctive characteristic bilateral polar plugs and barrel shape.

Discussion

The worm was identified as Trichuris trichiura. The common name for this organism is the whipworm. It belongs to the Nematode classification of parasites, which are commonly referred to as roundworms. Adults measure up to 5 cm in length and have a tapered or whip-like anterior end. The eggs measure 50 x 25 µm, and have brownish thick shells on stool smear. The eggs also have a barrel shape and distinctive protruding polar plugs at each end. These morphologic characteristics of the egg are diagnostic of Trichuris trichiura. The lack of a tissue migration phase and a relative lack of symptoms characterize whipworm infection, with only those with a heavy parasite burden becoming symptomatic. If these symptoms do arise, they are usually mild, ranging from loose stools with minimal blood loss and nocturnal stools, to iron deficiency anemia and vitamin deficiency. As parasite burden increases, however, symptoms can progress to dysentery, colitis, or rectal prolapse. Prolapse is more frequent in the Pediatric population, but has been described in adults as well.

Trichuris trichiura has one of the simplest of the Nematode life cycles. Eggs are unintentionally ingested, hatching in the small intestine by way of exploitation of signaling molecules from the intestinal microbiome. The larvae then burrow through the villi and continue maturing in the wall of the small intestine. They then return to the intestinal lumen, migrating to the cecum and subsequently into the large intestine, where they finish the process of maturation. Finally, the worm uses its anterior end to anchor into the bowel mucosa, where it feeds on tissue secretions and uses its posterior end for reproduction and laying eggs. Female worms can live from 1-5 years and can lay up to 20,000 eggs per day.

Whipworm infection is principally a problem in tropical Asia and, to a lesser degree, in Africa and South America. Children are most commonly infected, and can experience failure to thrive as well as cognitive and developmental defects. Transmission is by the fecal-oral route, explaining the large incidence of infection in children from developing countries, as they are far more likely to be in physical contact with soil and environmental contaminants, with subsequent placement of their fingers in their mouths. The fecal-oral route can also be facilitated by improper washing and cooking of fruits and vegetables, as well as overall poor hygiene, no matter what the geographical location. In the United States, whipworm infection is exceedingly rare. When it does happen, it is most commonly seen in the rural Southeast. Although it is rare, the incidence of infection is reported to be as high as 2.2 million individuals within the United States, with 1-2 billion cases worldwide.

Studies often reveal eosinophilia in nematode infections from ongoing tissue invasion. However, the lack of a tissue migration phase in Trichuris life cycles makes this a rare laboratory finding. Other studies such as anemia can give an indication to the presence of the worm. Characteristic egg morphology on stool smear remains the cheapest and easiest way to diagnose infection, but polymerase chain reaction using new sequencing techniques are now available in some laboratories to detect the presence of Trichuris with great sensitivity and specificity. The parasite burden can be quantified per gram of stool by the Kato-Katz technique. This procedure filters stool through mesh, with the filtered sample being placed within a template on a glass slide. The template is then removed and the remaining fecal material is removed with a piece of cellophane soaked in glycerol, leaving only eggs on the slide.

Discovery of T. trichiura in our patient was an unexpected finding, as our patient had no symptoms.  Asymptomatic detection of T. trichiura has been described in the past, so this finding is not unique. The medication of choice is mebendazole, showing a cure rate of 40-75%. The drug works well by inhibiting glucose uptake from the gastrointestinal tract of the helminth. However, this drug is very expensive, and as a result is difficult to obtain. The patient is currently receiving an alternative drug called albendazole as outpatient therapy and will be switched to mebendazole as soon as resources become available should the need remain. The patient is following up with her primary care physician and is expected to make a full recovery.

References

  1. Donkor, Kwame; Lundberg, Scott;
    https://emedicine.medscape.com/article/788570-overview. Trichuris trichiura (Whipworm) Infection (Trichuriasis).
  2. Sunkara T, Sharma SR, Ofosu A. Trichuris trichiura-An Unwelcome Surprise during Colonoscopy. Am J Trop Med Hyg. 2018 Sep;99(3):555-556. doi: 10.4269/ajtmh.18-0209. PubMed PMID: 30187847; PubMed Central PMCID: PMC6169157.

-Cory Gray, MD is a second year resident in anatomic and clinical pathology at the University of Chicago (NorthShore). His interests include hematopathology and molecular and genetic pathology, as well as medical microbiology.

-Erin McElvania, PhD, D(ABMM), is the Director of Clinical Microbiology NorthShore University Health System in Evanston, Illinois. Follow Dr. McElvania on twitter @E-McElvania. 

Is It Safe to Process Histopathology Samples from Suspected Cases of COVID19?

According to this recently-published study in the Journal of Histotechnology, ” … experts are confident that 70% ethanol and 0.1% sodium hypochlorite should inactivate the virus. Formalin fixation and heating samples to 56oC, as used in routine tissue processing, were found to inactivate several coronaviruses and it is believed that 2019-nCoV would be similarly affected.”

Read the study: https://doi.org/10.1080/01478885.2020.1734718