An unexpected finding during a routine Pap smear

I tried to keep my voice steady, as I described what looked like an inch-long piece of cooked linguine attached to the patient's buttock.

An unexpected finding during a routine Pap smear
An unexpected finding during a routine Pap smear

I was practicing women's health in a New England health maintenance organization, catering largely to working families. Although I knew I was under some stress, I was quite confident in my professional competency, until I had the occasion to see a patient whom I will refer to as "Susan."

Susan was a pleasant, middle-aged woman in no acute distress who presented for her routine Pap smear and pelvic exam. She appeared to be well nourished and well educated. After a brief history in which she offered no complaints, I performed a breast exam and then sat at the foot of the table as Susan scooted into the lithotomy position.

That was when I saw it. Something that looked like an inch-long piece of cooked linguine was attached to the skin of her buttock, a few inches lateral to the anus. And it was waving in the air. It was sucked right onto her skin, writhing in space.

I didn't think my mental status had deteriorated to the point of visual hallucinations, but I was having a hard time believing my eyes. I blinked three times to clear my vision. It was still there. Afraid that I would alarm the patient, I tried to keep my voice steady, as I attempted to describe what I was seeing.

"Susan, I see here what appears to be a little squirming piece of pasta," I stuttered.

"Oh, one of those. I find them in my bed all the time," she replied.

I almost gasped at her calm reaction. Using the Pap spatula, I gently removed the specimen from her buttock and placed it in a sterile urine container. Excusing myself, I brought it down to the laboratory. The technicians' eyes grew large, but they just shook their heads and shrugged. They didn't know what it was either. We arranged to send the unusual organism off to the state lab for identification, and I completed Susan's otherwise unremarkable pelvic exam.

About a week later, I received a call from an excited state lab physician. "This is a proglottid, a segment of a tapeworm," he exclaimed. "It could be from a fish. I never get these nowadays!"

After feeling impressed with my unusual find, I began to fill with dread. How would I tell Susan of her distasteful diagnosis? Hoping that I wouldn't betray my own excitement or my squeamishness, I dialed her number and swallowed hard.

I expected her to be upset. As a child growing up in New York, I had heard the urban legends of 6-foot tapeworms lured out of children's stomachs through their mouths using hamburger as bait! Even if the remedy for Susan's condition was mundane by comparison, she might find the news a bit unsettling.

"Hi Susan, this is Jeanne Holtzman," I began. "The state lab just called to tell me that they identified your specimen." I paused for a second. "It is part of a tapeworm."

"Oh," she said evenly, completely unfazed.

"It should be easy to cure," I added quickly. "You'll just need to take some pills."

"Okay, fine," she said.

Susan and I could not uncover any particular risk factors that could explain her tapeworm acquisition other than that she had lived in the Netherlands for a few years. I referred her to a gastroenterologist for treatment, and she never again found wiggling linguine in her bed.

Jeanne Holtzman is a physician assistant from Massachusetts.



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