Ascaris lumbricoides? (Letters to the Editor).

To the Editor: We thank Dr. Ash (1) for his observations and comments about our article. (2) Succinctly, the case report described a 39-year-old man who brought a live worm to the emergency department that he claimed to have voided recently through his urethra. Urinalysis revealed 5-10 WBC count, red blood cells too numerous to count, and many bacteria. A urine culture was ordered. The laboratory identified the worm as Ascaris lumbricoides. A urology consultation was arranged. On the basis of the laboratory's identification, the patient was treated with mebendazole. In subsequent urologic follow-up, the urine culture failed to grow any bacteria. Stool cultures were negative for ova and parasites. Three intravenous pyelograms and one CT scan of the urinary system failed to detect any residual or retained A. lumbricoides but did identify two kidney stones in the inferior pole of the right kidney. Dr. Ash (1) expressed concerns about the appearance and true identification of the worm in question, as well as the validity of the reported source of the worm. We would like to respond to Dr. Ash's critique.

First, Dr. Ash commented that the worm specimen in the photograph is dark in color instead of off-white, which is the customary coloration of an adult Ascaris. We agree with his comment and offer the explanation that the case occurred in approximately 1997, but the Ascaris was photographed at the time of manuscript preparation in October 2000. Oxidation while the specimen was in formalin, especially if air was present in the specimen bottle, may account for the discoloration. In accordance with this journal's manuscript submission policy, the original photographs submitted for publication were destroyed after being retained for 1 year after the publication of the manuscript. If the original photographs had been available, we would have been delighted to provide them to Dr. Ash to review.

Second, Dr. Ash opined that the worm looks not like an Ascaris but rather like a common earthworm. As we mentioned in the article, we treated the worm as a surgical specimen and delivered it to our laboratory for identification and classification on the date of the patient's visit. The laboratory report identified the specimen as A. lumbricoides.

Third, Dr. Ash further states, "Patients do funny things and often bring in strange objects that were supposedly voided, passed in feces, or recovered from lesions" (p 102). (1) He further states, "Since the patient brought the worm to the emergency department and no one witnessed the actual voiding of the worm, I wrote to the authors early in June 2001, questioning the validity of this case report" (pp 101-102). (1) Dr. Ash concludes his letter thus: "It is a little surprising that the authors apparently did not question the source of the worm" (p 102). (1) In response, we simply state that we reported the facts as the patient reported them to us and attempted to corroborate the accuracy of the presentation by cogent questioning of the patient according to standard clinical practice in physician encounters with patients. In this circumstance, we also point to the fact that we corroborated the patient's history on three different occasions: the first emergency department visit, a follow-up examination in the urology clinic 4 days later, and a telephone call to the patient's residence at the time of manuscript preparation approximately 3 years after the initial incident. We inquired of his travel history and any other possible exposure to A. lumbricoides at the initial emergency department encounter. Last, we point Out that access to a living specimen of A. lumbricoides is somewhat limited in the United States.

In the 3 years between his initial presentation and the time of our manuscript's preparation, the patient experienced no further encounters with A. lumbricoides and reported no further medical problems of any sort except treatment for hypertension. The patient certainly did not evidence bizarre behavior or attempt to perpetrate a medical hoax, as far as we can ascertain. He was still employed at the same automobile repair shop where the voiding event had occurred.

Dr. Ash remarked that he attempted to reach Dr. Quick by letter, and the editor's note at the end of Dr. Ash's letter stated that the editor attempted to contact us so that we would have a chance to respond. Dr. Ash states that he desired to offer assistance in identifying the worm and asked Southern Medical Journal to publish a correction of our publication or to reexamine the case if the specimen proved to be an earthworm. Dr. Hamdy's editor's note states, "Attempts to send this letter to the original authors were unsuccessful. If the authors wish to respond, we will publish their comments" (p 102). (1)

We respond that all authors left the University of Oklahoma in 1998, but both Drs. Quick and Walker still reside at the same street addresses, answer to the same home telephone numbers, and maintain the same email addresses as we did at the time of publication of our case report. We are responding now because we happened to see Dr. Ash's letter to the editor and thought that our responses certainly were indicated. We thank Dr. Ash for raising these issues and have addressed them as accurately and completely as possible within the confines of the author response format.

Gary Quick, MD

James S. Walker, DO

Oklahoma Heart Hospital

Oklahoma City, OK

Reference

(1.) Ash LR. Ascaris lumbricoides South Med J 2003;96:101-102 (letter).

(2.) Quick G, Sheikho SH, Walker JS Urinary ascaniasis in a man with hematuria. South Med J 2001;94:454-455.