52. McDougall, A., Glasgow Royal Infirmary, 84 Castle St., Glas- surgical treatment and complications. Am. Surgeon 24:908-918, Deb. gow C 4, Scotland. Personal communication, Feb. 5, 1960. 1958. 53. Wahren, IL: Herniated nucleus pulposus in child of twelve 59. King, A. G.: Surgical removal of ruptured intervertebral disc years. Acta orthop. scandinay. 18:40-42, 1945. in early childhood. J. Pediat. 55:57-62, July 1959. 54. Lannin, D. R.: Intervertebral disc lesions in teenage group. 80. Hansen, H. J., and Olsson, S. E.: The effect of Minnesota Med. 37:136-137, • Feb. 1954. single violent trauma on spine of dog. Acta orthop. scandina y. 24:1-7, 1954. 55. Bjelkhagen, I., and Gladnikoff, H.: Case reports; calcified disc protrusion in children. Acta radiol. 48:151-155, Aug. 1957. 61. Hirsch, C., and Schajowicz, F.: Studies on structural changes 56. Van Landingham, J. H.: Herniation of thoracic intervertebral in lumbar annulus fibrosus. Acta orthop. scandinay. 22:184-231, 1953. discs with spinal cord compression in kyphosis dorsalis juvenilis 62. Hendry, N. G.: Hydration of nucleus pulposus and its relation (Scheuermann s disease); case report. J. Neurosurg. 11:327-329, to intervertebral disc derangement. J. Bone Joint Surg. 40-B:132- May 1954. 144, Feb. 1958. 57. Kemp, A.: Two cases of protruded intervertebral disc in chil- 63. Horton, W. G.: Further observations on elastic mechanism of dren with dysrhaphic features. Folia Psychiat. Need. 61:560-571, intervertebral disc. J. Bone Joint Surg. 40-B:552-557, Aug. 1958. 1958. 64. Ho, R. W. H.: Testing intervertebral joint movement. J. Am. 58. Bradford, F. K.: Lumbar intervertebral disc rupture; diagnosis, Osteop. A. 61:635-839, April 1961.
Loa loa: Report of case of infection
SYDNEY F. ELLIAS, D.O., F.A.C.O.I.,° Detroit, which have become a challenge to the physicians Michigan, JOHN V. DIMANIN, D.O., Dearborn, of this country. Medical school training, extensive Michigan, SHELDON N. KAFTAN, D.O., Detroit, and thorough as it is, must limit its teaching con- Michigan, and TREVOR H. PHILLIPS, D.O., De- cerning these entities. troit, Michigan The resistance accumulated through the years by the natives of an area may nullify the acute exacer- bations, while the stranger is more seriously af- The desire to be of assistance to all mankind is fected, often in subtler ways. Occasionally this may something which lies quiescent in the hearts and make various manifestations of the disease condi- minds of most of the human race. The citizens of tions appear unrelated. the United States have been most liberal and en- thusiastic in offering knowledge, technology, and We feel that a greater emphasis must be placed upon tropical medicine which pertains to the coun- material goods to the peoples of all lands. How- tries where Americans are now serving. The case ever, the missionaries, military personnel, and presented involves a missionary who was sent to Peace Corps recruits who have been sent to all Africa where she contracted loaiasis. points of the globe have been attacked by infec- tions to which they had little or no inherent resist- The first authentic record of the worm Loa loa ance. was provided in 1770 by Mongin. He reported the Because Americans are not acclimated, they have extraction of a female specimen from the front of been subject to serious and often disabling diseases the eye of a Negress in St. Domingo, West Indies.1 The endemic zone of loaiasis is limited to western Dr. Elias is chairman of the Department of Internal Medicine, Dr. Dimanin and Dr. Kaftan are residents in the Department of In- and central Africa, where the infection is widely ternal Medicine, and Dr. Phillips is a resident in the Department of distributed. The distribution of the Loa loa corre- Pathology, Art Centre Hospital (Osteopathic), Detroit, Michigan. sponds to that of mango flies (Chrysops dimidiata °Address, 2069 W. Grand Blvd. and Chrysops silacea). They breed in relatively
446/62 clear, flowing streams in high-canopied rain forests Infected mosquito and come out to nearby clearings to bite man. In (Chrysops dimidiata or Chrysops silacea) this way, they pick up the microfilariae from hu- man carriers and later, after a period of incubation, inoculate other persons with the infective-stage Injects infective-stage larvae. Blood (human with micro- larvae into human filariae in blood stream The adults inhabit the subcutaneous tissues, bitten by mosquito) through which the worms are continually migrat- ing. They are threadlike, whitish, with a bossed t Larvae penetrate skin cuticle, and they taper gradually toward both ends. Migrate to the head, thence The male measures 30 to 34 mm. in length by 0.35 across corneal conjunctival to 0.43 mm. in diameter. The female measures 50 to tissue 12-month incubation in human 70 mm. in length by 0.5 mm. in diameter.1 The microfilariae of Loa loa exhibit diurnal pe- riodicity in peripheral blood, displaying stiff but Females become adults rapid movements among the erythrocytes. These and migrate through microfilariae are relatively large, measuring 250 to subcutaneous tissues of 300 microns in length and 6.0 to 8.5 microns in body mid-diameter.2 They have a core of nucleated cells Fig. Life cycle of Loa loci. which extends without interruption into the tip of the tail. with filaria antigen will almost always provide a When the microfilariae of Loa loa are ingested positive reaction. by the day-biting mango fly, they migrate down to the tip of the fly's proboscis, ready to be transferred Case report to the next human host about the tenth day after the infective meal. This is the case of a 40-year-old white obese fe- After entering the human host, not much is male, admitted to Art Centre Hospital (Osteopathic) known about the filariae. They may take 12 months on March 20, 1963. The patient complained of hav- to incubate. During this period and after maturity ing "an icky feeling," nausea, chills, anorexia, and the females migrate through the subcutaneous tis- diarrhea. She stated that she had experienced these sues of the body and periodically reach the head, complaints for 3% weeks. Ten days prior to admis- crossing in front of the eye under the corneal con- sion she had noted jaundice which was increasing junctiva during each excursion. The adult worms and was associated with excessive flatulence. The have been estimated to have a longevity of ap- patient stated that she had been in good health proximately 17 years. prior to this period. In the migrations through the various parts of The family history was noncontributory. The the body, the adult worms can be demonstrated in social history revealed that the patient was a reli- the extremities, trunk, and head. The worms are gious woman who had served as a missionary in more of a nuisance than a cause of severe local Africa for 2 years and had returned to this country tissue reaction. However, there is almost always on December 15, 1962. She had been stationed in a temporary inflamed tract (Calabar swelling) in Nigeria and had traveled extensively in that coun- the wake of each worm.2 try. At the end of the biologic incubation period Past medical history revealed that she had had the microfilariae of Loa loa can be found in day- the usual childhood diseases. She had undergone time blood except in cases in which the worm fails operation for an appendectomy and hysterectomy to mature. Blood smears (thick) stained with Giemsa in 1958; no malignancy had been found. There was stain demonstrate them well. In cases where the no history of smoking or drinking of alcoholic bev- organism is not demonstrable but the patient had erages. a history of being exposed, the intradermal testing Physical examination revealed a 5 foot 5% inch female, weighing 239 pounds, obviously jaundiced. Her oral temperature upon admission was 100° F., TABLE I—CLASSIFICATION OF DISEASES DUE TO WORMS pulse rate was 80 per minute, and respiratory rate A. Nematodes