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April 26, 2023
5 min read
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Worm recovered from young girl

What’s your diagnosis?

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James Brien

A 6-year-old girl is urgently brought into the Weed Army Community Hospital’s pediatric clinic at Fort Irwin, California, after the mother removed a long worm from the toilet bowl right after the child had a bowel movement (Figure 1).

IDC0423WYD_Figure1_1200X630
Figure 1. The worm was removed from the toilet bowl after the child defecated. Image: James H. Brien, DO.

The child is otherwise a normal, although somewhat frightened, healthy and active 6-year-old girl. The family history is initially unremarkable. However, it was found on further questioning that the family recently moved to the United States from Kingston, Jamaica, after the father got into the U.S. Army about 4 months earlier. When pressed for a family history for worms, the mother did recall that the child had been treated for a similar problem twice before when she was several years younger in Jamaica. About 4 years earlier, the mother was treated for coughing up a very small worm. However, she was not ill and did not recall any other “worm history.”

Examination of the child revealed a normal-appearing 6-year-old girl with normal vital signs, normal growth and development, normal abdominal exam, normal rectal exam and clear breath sounds; essentially, no abnormalities were found. No lab tests or radiographs were obtained.

What’s your diagnosis?

A. Ancylostoma duodenale

B. Ascaris lumbricoides

C. Enterobius vermicularis

D. Trichuris trichiura

Answer and discussion:

The answer is B, Ascaris lumbricoides, the largest nematode (roundworm), and is found worldwide, especially in tropical or temperate climates, especially where sanitation is poor. As seen in Figure 1, the worm is tan color and can reach a length of over 35 cm. If the worm is seen, no testing need be done. It is a true visual diagnosis, as long as it can be tied to the patient (not literally, although it may be long enough). The history is also supported with the mother having been treated several years earlier for coughing up a small worm, which was highly likely to be Ascaris larvae in the pulmonary migratory phase. In the right setting, these problems tend to be recurrent.