Unusual case teaches derm to expect the unexpected

February 1, 2007

National report - A bizarre case involving an apparent cyst will always hold a couple of lessons for William Philip Werschler, M.D.

Years ago Dr. Werschler, who is currently assistant clinical professor of medicine/dermatology at the University of Washington School of Medicine, was referred a patient with what had been diagnosed as a cyst on his temple. The referring doctor's orders to Dr. Werschler were to excise the cyst.

"This was a college professor who'd been dealing with this for weeks - it just wouldn't heal, even after taking all kinds of antibiotics," Dr. Werschler says. "The man said it was keeping him awake at night, and I replied that it wasn't unusual for cysts to be painful. 'It doesn't hurt,' the patient said. 'It makes a noise. That's what's keeping me awake.' Very odd, I thought to myself, not quite knowing what to think, but I went ahead to start the excision."

Just as he made the first incision, Dr. Werschler says, "out pops what looks like a white worm - and it's moving!"

Dr. Werschler finished the excision successfully; the wrongly diagnosed cyst never reappeared. But that's not the end of the story - nor of the lessons it teaches.

It turns out that the college professor/patient had gone on a tour of the Amazon River shortly before the "cyst" appeared on his temple. After some research, Dr. Werschler determined that the patient had been bitten by a tropical species of fly, which managed to deposit larvae at the site of the bite. That growing larva was what was making the noises that kept the patient awake at night as it moved inside the swollen bite area. What Dr. Werschler saw as he made the initial incision was the tail end of the larva.

"They stick that up to get air," he says.

Lesson one

"I learned two good lessons from that case," Dr. Werschler says. "First, never assume anything. I assumed that the primary care doctor had correctly diagnosed the problem as a cyst, and in this case it really didn't make much difference because excision would have been called for either way. But the lesson still stands - don't assume anything, and always treat patients as though you're the first doctor to see them."

Lesson two

The second lesson is that in today's world, where supersonic jets can transport travelers - and diseases - around the world in less than a day, doctors should always expect the unexpected.

"Gone are the days when you can treat patients regionally or geographically," Dr. Werschler says. "Any kind of disease can be transported quickly, and thinking that because you practice in the Pacific Northwest you don't have to know about tropical diseases, for instance . . . well, that's a mistake. We live in an increasingly small world."

Small, comic world

Speaking of a small world, Dr. Werschler tells another story about two patients whose common affliction, though not serious or even unusual, still draws some chuckles when he tells colleagues about it.