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 (Scheuermanns 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 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 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. B. Cestodes was 20 per minute. The blood pressure was 138/82. 1. Roundworm 1. Taenia A mild tenderness in the epigastric region was 2. Threadworms 2. Hydatid disease noticed upon palpation. The liver was enlarged to 3. Muscle worm C. Trematodes 4. Hookworm 1. approximately 2 cm. below the right costal mar- 5. Whipworm gin; however, this was difficult to evaluate because 6. of the patient's obesity. The remainder of the phys-

JOURNAL A.O.A., VOL. 63, MARCH 1964 647/63 ical examination was unremarkable. associated with Loa loa, and 'either cystic disease Her admission laboratory data included an eryth- or abscess of the liver. Although Entamoeba his- rocyte count of 5,000,000; hemoglobin of 15.2 tolytica was never identified, it was definitely felt grams; hematocrit reading of 49.5; and a leukocyte that she also had amebic abscess of the liver. count of 11,800, with a differential of 2 per cent Inquiries were made of the United States Public nonsegmented neutrophils, 57 per cent segmented Health Service, and of physicians who had served neutrophils, 19 per cent eosinophils, 5 per cent in Nigeria. They stated that amebic abscess of the monocytes, and 17 per cent lymphocytes. The sedi- liver was quite common in this particular area of mentation rate was 15 mm. per hour. The SCOT Nigeria. They advised against operation to drain was 1,500 units, and SGPT was 1,320 units. Serum the abscess. It was thought that a liver biopsy iron was 232 mcg. per 100 cc. No urobilinogen was might be dangerous; so this was not attempted. found in the urine, but the urine was positive for The patient was sent home with Hetrazan and high bile. Serum bilirubin by the direct method was potency B vitamins. Careful follow-up care was 16.0 mg., and by the indirect method was 8.20 stressed to the patient, and she agreed to cooperate mg. Cephalin flocculation was 4 plus in 24 hours because she was anxious to get back to her work and 48 hours. Alkaline phosphatase was normal. in Nigeria. She has now been observed for approxi- Thick and thin smears for plasmodium were nega- mately 4 months, and 'has remained in apparent tive. Heterophil agglutination was normal. The good health. stool upon occasion was 3 plus guaiac positive. No ova or parasites were observed. The electrocardio- grams were within normal limits. Treatment The patient was considered to have acute hepa- titis, etiology unknown. She was placed at bed Drugs effective against microfilariae may not in- rest and on a high carbohydrate diet with intra- fluence the adult worms, which will continue to venous glucose and vitamins, and she responded reproduce for years. An effective agent against the to therapy. Because of the hepatomegalia and eosin- adult worm is thiacetarsamide given intravenously ophilia, a liver scanning test was done, using in a dosage of 1.0 mg. per kilogram of body weight Au198; results were abnormal, demonstrating two for 15 days.3 Diarrhea is a frequent accompani- large masses which could have been either abscess ment of the administration of this drug. Micro- formations or cysts. These occupied approximately filariae may be demonstrable in blood smears after 75 per cent of the liver. a course of this medication, but they soon disappear Repeated stool examinations were negative for and relapse is rare. Diethylcarbamazine (Hetrazan) ova and parasites. Complement-fixation studies for in an oral dosage of 2.0 mg. per kilogram of body granulosus were reported as nega- weight, three times daily for 4 weeks, is an effec- tive, as well as studies for leptospirosis. These tive microfilaricide.3 The initiation of treatment studies were done at the State of Michigan Labo- with this drug may be followed by a bout of ratories. filarial fever which usually subsides within 72 As previously stated, the patient seemed to re- hours. Further experience with Hetrazan indicates that it probably injures the adult worm also, and spond well. However, on March 29, 1963, while rubbing her eye, she noted something floating impairs its ability to reproduce, resulting in per- across the eye. She stated that it felt as if it were manent clearing of microfilaria from the blood in crawling. Later that same day she extracted a small many patients. At present Hetrazan would appear threadlike worm from the eye. The pathologist re- to be the drug of choice, with thiacetarsamide to be ported this as Loa loa. used for cases of relapse or failure of response.3 The patient was then started on diethylcarbama- Pressure bandages and surgery sometimes benefit zine (Hetrazan) which was followed by a drop in elephantiasis when it occurs as a complication. The the eosinophil count. This also caused a skin re- prognosis for life is excellent, particularly if the action with a resulting welt on her thigh from affected individuals leave epidemic areas, or other- wise avoid reinfections.3 which additional worms were extracted. Additional worms were later recovered from her eye. A sin- gle microfilariae form of Loa loa was recovered on Summary an evening blood smear. The patient progressed very well, and was discharged on the forty-eighth A case of loaiasis has been presented and treatment hospital day, with a SCOT of 88 units and SGPT outlined. Re-education to this type of illness is now of 50 units. Her serum bilirubin was 4.64 mg. total necessary since Americans are serving in all areas and 3.06 mg. direct. There was only a trace of of this small world. Although we realize this is a. icterus to be seen in the sclerae. rare condition in the United States, recognition can It was felt that this patient had acute only come to the alerted physician.

648/64 Addendum and to Dominic L. DeGiusti, Ph.D., Professor of Parasitology and Biology, Wayne State University, The patient was readmitted to Art Centre Hospital for his assistance in identifying the worms. on September 28, 1963, with persistent upper ab- dominal pain. On October 9 an upper abdominal 1. Faust, E. C., and Russell, P. F.: Craig and Fausts Clinical exploratory operation was performed. The liver and parasitology. Ed. 6. Lea Febiger, Philadelphia, 1957. 2. Markell, E. K., and Vogue, M.: Diagnostic medical parasitology. spleen were both enlarged. There was no evidence W. B. Saunders Co., Philadelphia, 1958. 3. Bennett, I. L., Jr.: Filariasis, in Principles of internal medicine, of cyst, abscess, or other masses in the liver, but it edited by T. R. Harrison, et al. Ed. 4. McGraw-Hill Book Co., New appeared markedly cirrhotic. Liver biopsy showed York, 1962, pp. 1223-1225.

marked postnecrotic cirrhosis. Onchoceriasis and filariasis. Bull. World Health Organization 27: 421-643, 1962. Thomson, A. D., and Cotton, R. E.: Lecture notes on pathology: Appreciation is extended to Harriet Emerick, D.O., Classification of diseases due to worms, p. 69; Life cycle, p. 74. for referring this interesting patient, and for her F. A. Davis Co., Philadelphia, 1962. Leading Articles: Control of filarial worms. Lancet 1:589-590, assistance with post hospitalization management; March 16, 1963.

Acute infectious arthritis of the hip: Case report

DEAN R. OLSON , D .0 .,* Dayton, Ohio

A 13-year-old white boy was admitted to the hos- pital November 25, 1961, complaining of severe pain and stiffness of the right hip, shortness of breath, and pain in the chest. The patient gave a history of having fallen about 2 weeks prior to admission. The pain in the hip had begun after this fall and had become increas- ingly worse during the intervening time. The child had been brought to the outpatient department for x-ray studies shortly after the fall (Fig. 1); however, the films were negative, and the child had received no further treatment until the day of admission. The cough, chest pain, shortness of breath, and Fig. I. This first x-ray view was taken following the injury and Presented at the annual meeting of the American Osteopathic 6 days prior to admission to the hospital; it shows no apparent Academy of Orthopedics, Bal Harbour, Florida, October 29, 1962. This paper was prepared during a residency in the Department of abnormality of the right hip joint. Deformity of the left femoral Orthopedics in Grandview Hospital, Dayton, of which Dr. Donald head is noted and considered to be compatible with the history Siehl is chairman. of Legg-Perthes disease. No specific diagnosis was made, nor Address, Grandview Hospital, 405 Grand Ave. was any treatment instituted at this point.

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