As a freshman biology/pre-med major at Wesleyan University (just 30 minutes from

Question

As a freshman biology/pre-med major at Wesleyan University (just 30 minutes from her family home), Shana was so excited for her first spring break. It would be quite an adventure as it was her first chance to travel, independently. Instead of fun in the sun at a beach with hundreds of other college students, Shana chose to travel to an impoverished Brazilian village with other volunteers from the university’s chapel program. They were scheduled to help the villagers for one week with a building project and provide brief educational programs regarding agriculture and health/hygiene measures to improve their overall quality of life.

After an exhilarating flight and a cramped donkey cart ride, Shana and her friends finally arrived at the village. She was delighted to learn she had been assigned to assist the doctor and nurse in the village clinic. “This will be a great experience for a future doctor,” Shana thought. But her enthusiasm for her assignment quickly turned to concern as she observed the steady stream of patients coming to the clinic. In addition to the specific ailment that brought the patient to the clinic, Shana noted varying degrees of malnutrition in almost everyone. She talked with Dr. Pac about the situation that evening as together they cleaned the exam rooms and restocked supplies. “Good observation,” Dr. Pac remarked. “You’re already on your way to becoming a great doctor. Why do you think so many of our patients here suffer from this problem?” Shana decided this was a trick question since she had already observed many villagers eating an appropriate amount of high quality foods such as meat, fish, and fresh produce. Dr. Pac smiled at Shana as she tried to reason through her observations to a diagnosis. “Stay with me tomorrow as I examine patients and see if any clues become obvious.”

Intrigued by the challenge, Shana paid close attention to Dr. Pac’s actions the following day. While a variety of health concerns brought villagers to the clinic, Shana noticed quite a few patients demonstrated mild diarrhea, abdominal cramps, lethargy, and a red, vesicular, itchy rash on their feet. For these patients, Dr. Pac consistently ordered a CBC and asked them to bring in a stool sample the next day. By mid-afternoon Nyah, who was about 8 months pregnant, came to the clinic with the same symptoms but her fatigue was extreme and she had some shortness of breath. Again, Dr. Pac ordered the CBC and stool specimen but he also immediately gave Nyah Mebendazole and reminded her to continue taking her prenatal vitamins.

That evening after dinner, Dr. Pac and his nurse, Elaine, taught Shana how to perform several simple laboratory tests on the specimens they had collected from their patients earlier. Shana beamed with pride when she quickly learned how to count red blood cells (RBCs) and analyze blood smears. She noted that the malnourished patients with diarrhea, malaise, and rash all suffered from anemia and had an elevated eosinophil count. The next evening Shana realized medicine was not always glamorous as Elaine taught her how to examine fecal specimens under the microscope. With Elaine’s guidance, Shana was able to detect ovoid structures ~40 x 60 m. “What is that?” Shana queried. “That is the reason these poor people are having such problems,” Elaine explained. “So, what do you think we’re dealing with here?” asked Dr. Pac as he entered the room. Together they reviewed the symptoms and the results of the blood work before deciding the stool specimens contained the eggs of a gastrointestinal parasite. “Do you remember what medication I prescribed for Nyah? That will give you a hint as to the causative agent,” Dr. Pac said.

1. What kind of infection is treated with Mebendazole?

2. Based upon the symptoms, laboratory results, prescribed medication, and geographic location, what causative agent do you suspect?

“It’s hard to believe something so small can have such a large impact on so many people,” Shana said. “I only have one day left before I must return to college. You’ve taught me so much in a short time, but I still have a lot of questions. In fact, I’m even questioning the type of medicine I want to practice. Someday I think it would be very rewarding to use my medical training like you have, helping people living in desperate conditions. I wish I could stay longer and learn more.” “You are welcome to help in my clinic any time,” Dr. Pac responded. “I hope you’ll consider coming back for your next spring break.” Shana eagerly agreed to return the following year. “Good!” said Dr. Pac. “Now I have a deal for you. You want more answers and I’m in a position to help you learn about some interesting medical conditions. Let’s write out a list of your questions about this current medical case. When you get back to school, I want you to start researching the answers. Get on-line, talk with your professors, and read. This will be good practice for analyzing case studies in your later course work. When you think you’ve got the answers, send me a letter. I’ll write back with a new case from the village patients so you can see if this is truly the type of medicine you might want to practice.” Shana couldn’t believe her good fortune to have Dr. Pac volunteer to be her mentor. As soon as she retired to her quarters, Shana wrote down her list of questions:

3. Diagram and explain the life cycle of this parasite? How does the life cycle relate to the patient symptoms?

4. How is this microorganism transmitted? How can infection and reinfection be prevented?
5. Are there any other symptoms associated with this infection?
6. What factors influence the severity of symptoms?
7. How does Mebendazole work? Are there any other treatments commonly used with these patients? 8. Which individuals are at greatest risk of infection?

9. Why did Dr. Pac immediately prescribe medication for his pregnant patient without waiting to confirm her infection via laboratory tests?

10. Are there complications associated with this infection?
11. What diagnostic tests are available for identifying this infection?

12. Is this problem widespread?

Explanation / Answer

Answer

1. Mebendazole (MBZ) is a medication used to treat parasitic worm infestations. It is highly antihelmintic indicated for the treatment of nematode infestations including roundworm, hookworm, whipworm, threadworm, pinworm, and intestinal form of trichinosis prior to its spread into the tissues beyond digestive system.

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