- Speaker #0
This is Case Encounters, a journey to the true medical mysteries solved by pathologists, like Carlos Morales, who gave a first-year resident a lesson she'll have nightmares about for some time.
- Speaker #1
Carlos?
- Speaker #2
Carlos? 9-1-1, what's the emergency? Hi, um... Carlos Morales was 36, a husband, brother, son, a hard-working man with family roots in Guatemala. He'd overcome addiction and survived a car accident years ago that left him with lingering seizures from a head injury. He loved his wife and their new home. It was an ordinary evening. Carlos stood tidying the kitchen one moment and suddenly fell to the floor the next. And in the space between, his wife's world collapsed too. By the time they got him to the hospital, sadly, Carlos was gone. His story ended that night, but ours is just beginning.
- Speaker #3
Time of death, 9.14 p.m. Damn it. Let's go talk to Mrs. Morales.
- Speaker #2
Carlos Morales' death certificate would list seizure disorder, a phrase that on the surface looks like an explanation. He'd had an ethanol addiction and had suffered a traumatic head injury in a car accident. This diagnosis made sense. Sometimes, the most obvious explanation really is the best one. But sometimes it's not. Carlos's brain was removed and preserved in fixative solution. A long month went by before his case was passed into the hands of Dr. Daniel Zhang, a pathologist, not a fixer of symptoms, but a finder of causes and a solver of mysteries. His lab is pristine. The autopsy suite, aka the morgue. His patients are... always silent, but they tell the most intricate stories. On this case, Zhang was joined by first-year resident Dr. Rachel Hayes.
- Speaker #4
Good morning, Dr. Hayes. Glad to see you on this rotation today. Who do we have here?
- Speaker #5
Mr. Carlos Morales, male, 36. History of alcohol use, suffered from seizures after a head injury sustained in a car accident years ago. Found unresponsive at home. Declared dead in the ER. Looks like the seizures finally caught up with him.
- Speaker #4
Hmm. Well, sometimes the obvious answer isn't always the right one. Let's remember to read the body, not just the chart.
- Speaker #2
For the living, a seizure might look like a symptom. For Dr. Zhang, it looked more like a cipher. A code demanding a translation.
- Speaker #4
Multiple nodules along the derma, encapsulated, each about a centimeter, into parenchymal lesions too. Can you tell me what that means, Hayes?
- Speaker #5
Small lumps on the brain surface and deeper inside too. Not bleeding, not trauma. They almost look organized, like pearls strung through the tissue.
- Speaker #4
Fibrotic cyst walls, chronic inflammation, multinucleated giant cells. Explain it to me like I'm 12, Hayes.
- Speaker #5
So, this isn't the result of a trauma, and also not the result of alcohol use. It looks like scar tissue has built up around a little pocket in his brain, and there are large clusters of immune cells fused together surrounding it. The inflammation has been there for quite some time.
- Speaker #2
To the untrained eye, it could pass for scar tissue. To Zeng and Hayes, it looked more like evidence than evidence. of a siege. Morales's body had been fighting something before he fell that night. But what takes root like this and then strikes with one final silent blow?
- Speaker #4
Let's have a closer look. Tell me what you see.
- Speaker #5
Cyst with fibrotic wall and degenerating parasite. The fragments look like parts of a worm.
- Speaker #4
What are we looking at here, Hayes? What's the differential?
- Speaker #5
Toxoplasmosis can mimic this, but usually makes abscesses. Malaria or amoebas would look more destructive. Paragonimus, a fluke, can wander to the brain. And Neurocysticercosis, tapworm larvae, makes cysts like these.
- Speaker #4
Let's have a closer look at the detail of the cells and cyst walls and any inflammatory changes.
- Speaker #5
The cyst wall is scarred. There's chronic inflammation. Giant fused immune cells, like crystals. from tissue breaking down.
- Speaker #2
The suspects are narrowing. What was once a crowded stage is down to one bad actor beneath the interrogation room spotlight.
- Speaker #5
Wait. There are no eggs here. None of the features of a fluke.
- Speaker #4
Go on. What does that leave you with?
- Speaker #5
Then it has to be tapeworm. The larvae, neurocysticercosis.
- Speaker #4
Yes, look at that. The cyst walls, the chronic inflammation, the fragments of a scolex, all classic for tapeworm.
- Speaker #2
Not a bruise from an old brain injury, not the effects of substance use, and not the fall.
- Speaker #5
Tapeworms in the brain. I've read about it, but I've never actually seen it.
- Speaker #2
And so our culprit emerges. A parasite. A microscopic creature that infiltrated Carlos' brain and had no choice but to settle in for an extended terminal stay.
- Speaker #4
Cause of death, Dr. Hayes?
- Speaker #5
Complications of neurocysticercosis. I'm going to have nightmares about this one tonight, for sure.
- Speaker #2
Hickam's dictum. The world is often more complicated. than an obvious single cause. It would have been easy to close Carlos Morales' case with the cause of death cited on his death certificate, seizure disorder. That's why we learned to read the body, not just the chart.
- Speaker #6
Mrs. Morales, I'm Marion, a social worker here at the hospital. I know waiting can be so hard. Thank you for coming in. I want to share what we found.
- Speaker #7
Was it from the car accident? He's had seizures more frequently.
- Speaker #6
No, no. What we found was something quite different. Carlos had a tapeworm in his brain.
- Speaker #7
Tapeworm? In his brain?
- Speaker #6
Yes. The larva, the eggs, can get into the body through contaminated food or water. It could have happened years ago when he was still living in Guatemala. And they were likely the cause of his seizures, including the one he had that night at home. I know it's unsettling. You should know, nothing you could have done would have stopped it. It wasn't your fault or Carlos's.
- Speaker #2
We don't all get to choose our journeys. Sometimes we end up at our destination by accident. These parasitic hitchhikers were swept onto a path they didn't choose and shouldn't have been on, trapped with no way out, with Carlos Morales as their unsuspecting host for years.
- Speaker #0
You've been listening to Case Encounters. This story is inspired by a true medical mystery solved through collaboration, curiosity, and a pathologist. Names and locations are fictitious. Until next time, stay curious. The voices you just heard are those of real pathologists. people who work long days and even longer weeks to solve medical mysteries big and small. To learn more about the work pathologists do for patients, visit yourpathologist.org. For a full list of the pathologists featured in this episode, and those who advise the creation of this story, please visit the show notes. Case Encounters is a production of the College of American Pathologists. Creative support from Studio North. Produced and directed by Natalie Gregory. Sound design, editing, and original music by Jake Sorgan. Written by Paige Freeborn for Studio Nord.
