At the Focal Point

eases, National Institutes of Health, Bethesda, Maryland,
Yvonne R. Shea, MD, Microbiology Section, National Insti-
tutes of Health, Bethesda, Maryland, David E. Kleiner, MD,
Laboratory of Pathology, National Cancer Institute, National
Institutes of Health, Bethesda, Maryland, Steven M. Holland,
MD, Immunopathogenesis Section, National Institute of Al-
lergy and Infectious Diseases, National Institutes of Health,
Bethesda, Maryland, Theo Heller, MD, National Institute of Di-
abetes and Digestive and Kidney Diseases, National Institutes of
Health, Bethesda, Maryland, USA
doi:10.1016/j.gie.2011.04.021

Commentary
Atypical mycobacterial infection was described in the mid-1950s, although it was the AIDS epidemic that brought these
nontuberculous mycobacteria to the familiarity of most clinicians. In 1959, the botanist Ernest Runyon grouped these organ-
isms into 4 groups: photochromogens, which develop pigments in or after being exposed to light (eg, Mycobacterium kansa-
sii); scotochromogens, which become pigmented in darkness (eg, Mycobacterium scrofulaceum); nonchromogens, a group of
prevalent opportunistic pathogens that includes Mycobacterium avium complex (MAC) as well as M genavense; and finally, the
rapid growers (eg, Mycobacterium fortuitim). M genavense, described by Bottger et al in 1992, is a fastidious organism that has
a slow growth rate in liquid media, requiring 3 to 12 weeks to be identified. Although it can grow on solid media, it does not
grow on standard solid media like Lowenstein-Jensen. M genavense infections occur only rarely in persons other than AIDS
patients, although all patients infected with this organism are immunocompromised. M genavense resembles MAC in its
clinical infection patterns and is a good organism to keep in mind when faced with an AIDS patient who has diarrhea, fever, and
lymphadenopathy. Interestingly, M genavense is common in birds, especially passerines (which include songbirds and spar-
rows) and psittacines (which include parrots and parakeets). We must wage war against M genavense, the name of which
derives from Geneva, the source of the first isolate. But must we respect the conventions also named after the same city in this
battle? There are 4 Geneva conventions (and 3 protocols), which set the standards for humanitarian treatment of the victims
of war and were conceived by Henri Dunant after his witnessing the horrors of war at the Battle of Solferino in 1859. I would
treat the patient as humanely and kindly as possible and bring all force to bear to annihilate the invader. John F. Kennedy said
“Mankind must put an end to war before war puts an end to mankind.” In this case, a battle won will enable man’s sur-
vival . . . and we can then deal with the immunocompromise that allowed the invasion to occur.
Lawrence J. Brandt, MD
Associate Editor for Focal Points

A case of beef tapeworm (Taenia saginata) infection observed by

using video capsule endoscopy and radiography (with videos)
A 50-year-old Japanese man was referred for treatment
of cestodiasis. He was asymptomatic, and all laboratory
study results were normal, including hemoglobin, albu-
min, liver biochemical profile, and basic metabolic panel.
The patient first noticed excretion of proglottids in his
stool while living in Indonesia 3 years earlier, at which
time he was treated with an anti-helminthic agent. One
month later he again noticed proglottids in his stool. Two
years later, he was diagnosed as having a GI stromal tumor
and had a partial gastrectomy. After mentioning to his
surgeon that he passed proglottids in his stool he was
referred for evaluation. A small bowel series was per-
formed with water soluble radiopaque contrast medium,
and meandering tapeworm movement was observed (A;
Video 1, available online at www.giejournal.org). An
excreted proglottid was captured, and counting of its
uterine branches under the microscope, it was deter-
mined to be Taenia saginata; excretion of the scolex
was not confirmed. Videocapsule endoscopy (Endo
capsule EC-1; Olympus Medical Systems, Tokyo, Japan)
was performed to determine whether there were any
residual parasites. Indeed, residual tapeworm in the
video capsule endoscopy (B; Video 2, available online
at www.giejournal.org) and appeared similar to that
seen on the radiologic study.
DISCLOSURE
All authors disclosed no financial relationships relevant
to this publication.
Naoki Hosoe, MD, PhD, Hiroyuki Imaeda, MD, PhD, Center
for Diagnostic and Therapeutic Endoscopy, Susumu Oka-
moto, MD, PhD, Rieko Bessho, MD, Riko Saito, MD, Yo-
suke Ida, MD, Division of Gastroenterology and Hepatology,
Department of Internal Medicine, Seiki Kobayashi, PhD, De-

690 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 3 : 2011 www.giejournal.org

 At the Focal Point

partment of Tropical Medicine and Parasitology, Takanori Ka- agnostic and Therapeutic Endoscopy, School of Medicine, Keio
nai, MD, PhD, Division of Gastroenterology and Hepatology, University, Tokyo, Japan.
Department of Internal Medicine, Toshifumi Hibi, MD, PhD,
doi:10.1016/j.gie.2011.05.011
Division of Gastroenterology and Hepatology, Department of
Internal Medicine, Haruhiko Ogata, MD, PhD, Center for Di-

Commentary
Here we have a worm, the size, appearance, and location of which enable rough identification without sophisticated testing.
In fact, just the history of passing proglottids mandates the phylum Platyhelminthes, class Cestoda. The body of this worm
consisted of a series of proglottids, which, in the aggregate, form a strobila that resembles a strip of tape; hence the common
name “tapeworm.” The Greek word tainia, which also means band or ribbon, provides origin to the worm’s family and genus
names. Its life cycle begins with either eggs or the gravid proglottids being passed in the feces and then being ingested by
cattle or pigs. Oncospheres hatch in the small intestine, invade its wall, travel to the striated muscles of the animal, and develop
into cysticerci, which then are ingested by us—the definitive host— upon consuming contaminated raw beef or pork. In-
gested cysticerci develop into adults, attach to the small intestine by their scolices, and therein can live for up to 25 years.
Taenia saginata are about 1000 to 2000 proglottids long (rarely can reach up to 25 meters in length), with each gravid
proglottid containing 100,000 eggs, whereas Taenia solium contain about 1000 proglottids, with each gravid proglottid
containing 50,000 eggs. Each mature proglottid contains all the reproductive organs including, among others, the uterus,
ovary, and testes, but it does not have a digestive tract. In the gravid proglottid, the uterus is branched and is filled with eggs.
Is it important to determine whether T solium or T saginata is infecting the patient? The answer clearly is yes, because only T
solium produces cysticercosis, whereas T saginata usually produces no symptoms or mild, nonspecific abdominal discomfort
in patients with high worm burdens. Polymerase chain reaction detection of the ribosomal 5.8S gene is definitive but takes the
fun out of looking at the stool under a microscope. The eggs of Taenia species are indistinguishable from each other, but
looking at the scolex (not retrieved in this patient) or the gravid proglottids can help. The scolex of T saginata has 4 suckers but
no hooklets, whereas the scolex of T solium is armed with hooklets. When the uterus in the proglottid is injected with India ink,
its branches become visible. T saginata uteri have 12 or more branches on each side, whereas T solium has only 5 to 10. Mark
Twain said that only kings, presidents, editors, and people with tapeworms have the right to use the editorial “we.” A dose of
praziquantel should enable this patient to transition nicely from first person plural to first person singular.
Lawrence J. Brandt, MD
Associate Editor for Focal Points

www.giejournal.org Volume 74, No. 3 : 2011 GASTROINTESTINAL ENDOSCOPY 691