Visual Diagnosis: Stool Passage of a White Ribbonlike Object in an Adventurous Eater

Abstract

1. Nurul I. Hariadi, MD* 2. Nava Yeganeh, MD† 3. Jennifer Dien Bard, PhD‡ 4. Natascha Ching, MD§ 1. *Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, MI. 2. †Department of Pediatrics, Division of Pediatric Infectious Diseases, UCLA Medical Center, Los Angeles, CA. 3. ‡Department of Pathology and Molecular Medicine, Queen's University School of Medicine, Kingston, Ontario, Canada. 4. §Pediatric Infectious Diseases, ‘Specially For Children, Dell Children's Medical Center of Central Texas, Austin, TX. A previously healthy 5-year old boy passes white ribbonlike objects in a bowel movement that are removed in multiple segments (Fig. 1). The specimens are sent to the microbiology laboratory, and the patient is seen in the pediatric infectious diseases clinic. Before the episode, he had normal appetite with no abdominal pain, diarrhea, constipation, flatulence, cough, or any other constitutional symptoms. He complains of intermittent periumbilical pain after the episode but has no other symptoms. Figure 1. Multiple white ribbonlike segments measuring approximately to 3 to 10 in. Further questioning of the patient and family reveals sophisticated and adventurous eating habits. He has been eating raw fish for 1 year before presentation, including salmon and tuna sushi and sashimi. He eats rare beef and lamb and tries delicacies such as cooked crickets, ants, and scorpions. He has three cats with fleas and feeds Koi fish in a pond but has no contact with other animals. During recent travel to Sierra, California, he swam in a cave pond but did not drink its water. He also visited Kauai, Hawaii, 2 months ago but did not consume sushi, sashimi, or Hawaiian delicacies of raw fish there. Findings on his physical examination are normal, his weight is at the 25th percentile, and his height is between the 10th and 25th percentiles. Complete blood cell count reveals no evidence of anemia. The white blood cell count is 9.6×103/μL (9.6×109/L) with a normal differential count, hemoglobin is 13.0 g/dL (130 g/L), hematocrit is 38.2% (0.38), and platelet count is 258×103/μL (258×109/L). Mean corpuscular volume is 84.1 …