A 19-year-old woman comes to the office due to intermittent nausea, abdominal discomfort, and diarrhea. She has also had a diminished appetite and feels that her abdomen is swollen. Her parents immigrated to the United States from Guatemala when she was an infant, and she recently went there for 3 weeks to meet her cousins. The patient had a mild cough for a few days during the trip but no diarrhea or abdominal pain. She is a college freshman and does not use tobacco, alcohol, or illicit drugs. She does not take any medications. Vital signs are within normal limits. The lungs are clear to auscultation and heart sounds are normal. The abdomen is soft, mildly distended, and nontender with increased bowel sounds. There is no rebound tenderness or hepatosplenomegaly. Fecal occult blood is positive. Laboratory results are as follows: This patient is most likely to improve with which of the following medications?

Question

A 19-year-old woman comes to the office due to intermittent nausea, abdominal discomfort, and diarrhea.  She has also had a diminished appetite and feels that her abdomen is swollen.  Her parents immigrated to the United States from Guatemala when she was an infant, and she recently went there for 3 weeks to meet her cousins.  The patient had a mild cough for a few days during the trip but no diarrhea or abdominal pain.  She is a college freshman and does not use tobacco, alcohol, or illicit drugs.  She does not take any medications.  Vital signs are within normal limits.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft, mildly distended, and nontender with increased bowel sounds.  There is no rebound tenderness or hepatosplenomegaly.  Fecal occult blood is positive.  Laboratory results are as follows:  This patient is most likely to improve with which of the following medications?

Quizplus · Accepted Answer

Explanation: This patient who recently visited Guatemala has gastrointestinal symptoms, positive occult fecal blood, and significant peripheral eosinophilia, suggesting intestinal helminths. Intestinal helminths are largely a disease of the developing world where water and sewage sanitation is poor. In these regions, more than a billion people are infected with the most common helminths including Ascaris lumbricoides (roundworm), Trichuris trichiura (whipworm), and Ancylostoma duodenale (hookworm). In the United States, most cases arise in travelers returning from a developing region or in recent immigrants. Clinical manifestations typically reflect the life cycle of the infecting helminth with early, transient pulmonary symptoms (eg, dry cough, dyspnea) followed by long-term gastrointestinal symptoms (eg, nausea, vomiting, abdominal discomfort, diarrhea). Peripheral eosinophilia is a defining feature, and patients often have positive fecal occult blood. Diagnosis is usually made with stool ova and parasite testing. Treatment with oral albendazole is typically curative (mebendazole is slightly better for whipworm). (Choices B and C) Ciprofloxacin is commonly used to treat bacterial travelers' diarrhea, which usually manifests with acute gastrointestinal symptoms (eg, diarrhea, abdominal pain, vomiting). Metronidazole may be used for protozoal forms of travelers' diarrhea, including Giardia lamblia and Entamoeba histolytica, which may present with longer (>2 weeks) incubation periods. This patient with gastrointestinal symptoms and significant peripheral eosinophilia after recent travel to a developing region is more likely to have intestinal helminths. (Choice D) Eosinophilic gastroenteritis is an inflammatory condition of the gastrointestinal tract that may be treated with prednisone. Manifestations include abdominal pain, nausea, diarrhea, and peripheral eosinophilia. Intestinal helminths are far more likely in this patient with recent travel to Guatemala. (Choice E) Trimethoprim-sulfamethoxazole can be used to treat travelers' diarrhea due to enterotoxigenic Escherichia coli, which usually manifests with acute watery diarrhea. Peripheral eosinophilia would be atypical. Educational objective: Intestinal helminths are endemic to developing regions where water and sewage sanitation is poor. Manifestations reflect the life cycle of the worm with transient pulmonary symptoms followed by long-term gastrointestinal symptoms. Patients often have peripheral eosinophilia and positive fecal occult blood. Diagnosis is made with stool ova and parasite testing, and treatment with albendazole is typically curative. References: Human intestinal parasites. (http://www.ncbi.nlm.nih.gov/pubmed/18402180)

A 19-Year-Old Woman Comes to the Office Due to Intermittent