Coughing Up Africa (or Central America) in Los Angeles

She is 62 years old, hunched over from chronic lung disease and with that anxious look of someone hoping for a little more breath than she has. As I settle into the standard ER interview protocol, "What brings you to the hospital today?" "When did it start?" etc., I sense this is not going to be a standard interview. Her condition started a year ago when she saw her doctor for "coughing up little animals." To hear her recount the story of various physician visits with varied responses, from psychiatric referral to additional pulmonary function testing, one gets a sense of her exasperation. "I even put some in a paper towel to show my doctor, but they got all dried up and you couldn't see them that well." Today, she had done one better. She had folded up these slender, white creatures into a moist towel and placed it in a plastic bag, which she proceeded to offer me.

"I think it is Ascariasis," she says. I glance at her semi-shocked, mostly-impressed. "This is how they live, they enter your stomach. The young ones crawl to your lungs and you cough them up. Then, you swallow what you coughed, and they start over." This tiny 62 year old woman with little formal education just summarized the lifecycle of Ascaris lumbricoides for me. I drop a couple of the best specimens into a jar of formalin and label it for pathology review. After about an hour I have the results of her liver function tests but am surprised to hear that our pathologists no longer review parasite slides for identification - the specimen has to go to the LA Public Health labs - that takes about a week to get results back. In any case, I'm convinced that she has a worm infestation and give her the treatment (Albendazole) and a prescription for a few additional doses to take at home.

"Will you see this often when you are in Africa?" she asks as I
explain her treatment.
"How did you know I was going to Africa?"
"That other doctor told me."
"Oh, that's Dr Jain, he's one of my favorite bosses (my word for
attending physician). And yes, I'm sure I will."