# Presentation: 447623

## DPDx Parasitology Telediagnosis Assistance: 

***What is it and what can it do for me?***

## D  P  D   +   Dx   =

- DPDx is a project developed by investigators from the Division of Parasitic Diseases (DPD) at CDC.

- DPDx

**1**

## DPDx Project Purpose

- Web site: http://www.dpd.cdc.gov/dpdx

**2**

**DPDx Project Purpose**

- Provide education and training in parasitology

## Telediagnosis Process

- <date/time>

**Telediagnosis Process**

- Using a digital camera connected to a microscope and a computer with Internet access, laboratorians can transmit images to CDC via e-mail and receive diagnostic assistance in minutes to hours.

- Blaine Mathison of the Arizona State Laboratory at his telediagnosis station.

**3**

## Telediagnosis Process

- <date/time>

- If you send a request, we need the following information:
-  Your name
-  Your affiliation and address (for final reporting)
-  Telephone number (optional)
-  Specimen ID code
-  Type of specimen including date, stain used,                                               	measurement of the object, and magnification of 	the microscopic field captured
-  Presumed diagnosis
-  Any other pertinent data (e.g., pre or post treatment, 	travel history, etc.)

**Telediagnosis Process**

**4**

## Telediagnosis Process

- When a telediagnosis request comes to DPDx, it arrives in a general mailbox and is then sent out to a group of 4 team members.  Other personnel may be brought in if their expertise is needed.

**5**

**Telediagnosis Process**

## Telediagnosis Process

- <date/time>

- Telediagnosis allows laboratorians to address difficult diagnostic cases efficiently and disseminate information more rapidly.

- After there is consensus among our group, a response is sent back to the requester with either an identification or a request for more information.

**6**

**Telediagnosis Process**

## Rationale for Telediagnosis

- <date/time>

- Telediagnosis is a good screening tool.
- CDC personnel can see the suspected parasite before specimens are mailed; this allows us to

- Telediagnosis is also an efficient teaching tool.  Members of the DPDx Team can point out diagnostic features that the submitting labs may have missed

- 1)  confirm parasitic organisms or rule out the presence of these agents

- 2)  request all appropriate specimen types necessary for further testing if analysis of images cannot provide definitive diagnosis

- 3)  contact subject matter experts outside parasitology if the images indicate the presence of other classes of infectious agents

**7**

**Rationale for Telediagnosis**

## Rationale for Telediagnosis

- DPDx

**Microscopic exam (PHL)**

**Package and ship specimen**

- Approximately 1 hour
- $10.00 labor*

- 48-72 hours
- $70.00 for shipping and packaging**

**Diagnostic assistance**

- 1 specimen costs at least **$95.00** to send and evaluate.
- Minimum turnaround time of 48 hours when submitted through conventional routes.

***Traditional route for specimen submission***

- Approximately 1 hour
- $15.00 labor†

***Using DPDx for specimen identification***

**Microscopic exam (PHL)**

**Capture image and**
**send email**

- Approximately 1 hour
- $10.00 labor*

**DPDx assistance**

- Approximately 30 minutes
- $7.50 labor †

- Approximately 15 minutes
- $2.50 labor*

- 1 “specimen” (images of the specimen + patient information) costs close to
**$20.00** to send and evaluate.
- Minimum turnaround can be minutes once the image is submitted

*** Estimating labor as 10.00/hour**
**† ****Estimating labor as 15.00/hour**
**** Including labor**

**Rationale for Telediagnosis**

**8**

## If I don’t have it, how do I get it? 

**If I do have it, what if I need equipment upgrades or training?**

**9**

- Request funding through the Epidemiology and Laboratory Capacity for Infectious Disease Cooperative Agreement.
- ELC’s purpose is to improve surveillance for reportable infectious diseases by providing technical and financial assistance to state health departments.

- http://www.cdc.gov/ncidod/osr/site/epi_lab/index.htm

## Cameras

- <date/time>

**Cameras**

- Diagnostic Instruments
- SPOT-RT camera
- $9,000-$12,000

**10**

## Cameras

- <date/time>

**Cameras**

- Olympus, DP70
- $8,000

- Magnafire
- $9,000-$17,000

**11**

- Micropublisher
- $6,000-8,000

## Computer Specifications

- <date/time>

**Computer Specifications**

- Monitor:
- A 19” or 21” color monitor is recommended with at 1600 x 1200 pixel resolution at 32 bit color and a refresh rate 85 Hz or better.
- Computer:
- Pentium IV, 2.0 GHz, 512 MB RAM or higher, over 40 GB hard drive
- Video Card:
- A card that supports 32 bit, true color at the
- desired resolution with a refresh rate 85 Hz (any NVIDIA 64MB card)
- One available PCI slot
- Database image file storage options:
- Zip drive or CD recordable/rewritable drive
- Operating System:  Windows 2000 or higher.

**12**

## 14

**14**

## 15

**15**

## Telediagnosis -- malaria

- <date/time>

**16**

**Telediagnosis -- malaria**

- I want confirmation on a malaria specimen I received.  The patient is a young adult who traveled to Ghana and stayed there for a approximately 17 days. I received slides and a vial of blood.  It looks like *Plasmodium falciparum*.  The infected red cells are the same size as uninfected. All I have seen are ring forms, there are numerous multiply infected cells, as well as applique forms. Your confirmation would be appreciated.  *specimen number was given

- B

- A

## Telediagnosis -- malaria

- <date/time>

**17**

**Telediagnosis -- malaria**

- D

- C

## Telediagnosis -- malaria

- <date/time>

**18**

**Telediagnosis -- malaria**

- E

- F

## Telediagnosis -- malaria

- <date/time>

**19**

**Telediagnosis -- malaria**

- A

- B

## Telediagnosis -- malaria

- <date/time>

**20**

**Telediagnosis -- malaria**

- C

- D

## Telediagnosis -- malaria

- <date/time>

**21**

**Telediagnosis -- malaria**

- E

- F

## Telediagnosis -- malaria

- <date/time>

**22**

- Based on the images, 3 DPDx team members reviewed and agreed on the identification of *Plasmodium falciparum*.

- The images were cropped slightly for this presentation, but the requester did the following correctly:
- Provided all case history that they had, including travel, and a presumptive diagnosis
- Sent multiple images taken from various fields of the slide, although only from the thin smear
- Included uninfected red blood cells in the images for size comparison with infected cells

**Telediagnosis -- malaria**

## Telediagnosis – tissue section

- <date/time>

**23**

**Telediagnosis – tissue section**

- I sent a photo of an H&E slide to your web site diagnostic center. I am unsure if you received the photo as I have not heard anything yet. The patient is a young adult who recently moved to the area from Africa. The patient discovered an inguinal mass, which was thought to be a lymph node. A biopsy demonstrated a 'ball of worms'. We are unable to identify the worm based on morphology and would like your help!

## Telediagnosis – tissue section

- <date/time>

**24**

- Problems with this telediagnosis request:
- Requester sent only one image
- No magnification given
- No specific location in Africa given

**Telediagnosis – tissue section**

## Telediagnosis – tissue section

- <date/time>

**25**

**Telediagnosis – tissue section**

- After input from one of the DPDx team members, and consultation with our resident nematode expert, we were able to provide an identification of *Onchocerca volvulus*.

## Telediagnosis – possible helminth

- <date/time>

**26**

**Telediagnosis – possible helminth**

- I’m sending some pictures of a ”parasite” they found in a feces sample in a hospital, they are strange looking formations.  *Strongyloides stercoralis*??

- A

- B

- C

## Telediagnosis – possible helminth

- <date/time>

**27**

**Telediagnosis – possible helminth**

- E

- D

## Telediagnosis – possible helminth

- <date/time>

**28**

- Problems with this telediagnosis request:
- No magnification given
- No size measurements on the objects
- No patient history

- But our DPDx team members were able to provide an identification of *no parasites found*.  Probably plant material.

**Telediagnosis – possible helminth**

## Telediagnosis – possible malaria

- <date/time>

**29**

- Unable to provide an identification, larger images necessary.

**Telediagnosis – possible malaria**

- Attached are slides of a presumptive *Plasmodium* species. Patient is a young adult.  Geimsa stained smears were prepared on [date given by requester].  The magnification used is 100x.  Patient has a recent travel history to West Africa.  * specimen id was sent

## A

- <date/time>

**30**

**Telediagnosis -- *****Babesia***

- Elderly patient
- no history of tick bite/exposure or transfusions until current admission
- hospitalized several months previously; babesiosis diagnosed by blood smear
- developed recurrent symptoms ~ 2 weeks ago
- had spleen removed several years ago
- Is infected with *Babesia* but what species?

## Telediagnosis -- Babesia

- <date/time>

**31**

**Telediagnosis -- *****Babesia***

- B

## Telediagnosis -- Babesia

- <date/time>

**32**

**Telediagnosis -- *****Babesia***

- C

## Telediagnosis -- Babesia

- <date/time>

**33**

**Telediagnosis -- *****Babesia***

- D

## Telediagnosis -- Babesia

- <date/time>

**34**

**Telediagnosis -- *****Babesia***

- E

## Telediagnosis -- Babesia

- <date/time>

**35**

**Telediagnosis -- *****Babesia***

- F

## Telediagnosis -- Babesia

- <date/time>

**36**

- Serology performed at CDC’s parasitology diagnostic serology lab was negative for *B. microti.*
- Serology then performed for *Babesia* spp.  Result: positive.

- PCR performed at CDC’s parasitology diagnostic molecular lab was positive for *Babesia* MO-1.

- Could not make an species identification based on images or by microscopic examination.

**Telediagnosis -- *****Babesia***

## Telediagnosis -- helminth 

- <date/time>

**37**

**Telediagnosis -- helminth **

- I trust that you received the serum, stool, and BAL fluid we submitted.  We received digital photographs of the parasite recovered from this patient taken by microbiology staff at the location this patient is currently being treated.  I'm hopeful that these photographs may be helpful to you in making a confirmatory identification of this parasite.

- A

## B

- <date/time>

**38**

**Telediagnosis -- helminth **

- C

## Telediagnosis -- helminth 

- <date/time>

**39**

**Telediagnosis -- helminth **

- D

##                Size.

- <date/time>

**40**

- Based on the images, we agreed that this looked like *Strongyloides **stercoralis*.
- What did the requester leave out that was important?
-                Size.

**Telediagnosis -- helminth **

## Telediagnosis -- helminth 

- <date/time>

**41**

- Microscopy: *Strongyloides stercoralis*
- Serology: + for strongyloidiasis

**Telediagnosis -- helminth **

## Telediagnosis -- malaria

- <date/time>

**42**

**Telediagnosis -- malaria**

- The patient is a middle aged.  He grew up in Nigeria and recently visited there.  He is not aware of having had malaria in the past.  His children returned from Nigeria with malaria, I was not told the type.  He is now suffering from fevers and body aches.  The patient is being treated with chloroquine.  The people the hospital found banana shaped gametocytes (though I haven't yet) and so have determined he has *P. falciparum*.  But they also found schizonts, enlarged infected red blood cells, amoeboid trophozoites and I am sending you images of these.  They are suggestive of* P. vivax* which the hospital also suspects.

- A

- B

## C

- <date/time>

**43**

- D

- E

**Telediagnosis -- malaria**

- F

## G

- <date/time>

**44**

- H

- I

- J

**Telediagnosis -- malaria**

## We responded to this telediagnosis, by asking for smears and blood and making an identification of Plasmodium sp. vivax vs. ovale.

- <date/time>

**45**

- We responded to this telediagnosis, by asking for smears and blood and making an identification of *Plasmodium* sp. *vivax* vs. *ovale*.

- The following week, we received a follow-up telediagnosis.

**Telediagnosis -- malaria**

## Wanted you to confirm. In my initial examination of the thin smears sent with this case I did not find any. 

- <date/time>

**46**

- I decided to look at one of the thick smears associated the case I sent you last week to confirm the presence of *P. vivax*.  I found what look like the banana shaped gametocytes of *P. falciparum*.
- Wanted you to confirm. In my initial examination of the thin smears sent with this case I did not find any.

- A

- B

**Telediagnosis -- malaria**

## Telediagnosis -- malaria

- <date/time>

**47**

**Telediagnosis -- malaria**

- C

## Telediagnosis -- malaria

- <date/time>

**48**

- Confirmed by telediagnosis *Plasmodium* sp. and *P. falciparum*.
- Smears were read*:  P. falciparum* and *Plasmodium* sp. *vivax* vs. *ovale*
- PCR was performed: + for *falciparum* and *ovale*

**Telediagnosis -- malaria**

## Telediagnosis -- outbreaks 

- <date/time>

**49**

**Telediagnosis -- outbreaks **

- Patient 1

- Patient 2

- Patient 3

## Telediagnosis -- outbreaks 

- <date/time>

**50**

**Telediagnosis -- outbreaks **

- No size given
- Stain type not given

## Training applications

- <date/time>

**51**

- A 70-year-old man was seen by an ophthalmologist for eye pain.  Upon examination, the doctor found and removed a subconjuctival worm that was enclosed in a cyst.  The man had no recent travel outside the United States (had traveled to Central America over 5 years ago) and reported that he did have pets at home.

**A: **The cyst and the worm it contained; the worm was approximately 92 mm in length.

**Training applications**

## Training applications

- <date/time>

**52**

**Training applications**

## Training applications

- <date/time>

**53**

- A male filarial worm in the genus *Dirofilaria*,* *most likely *Dirofilaria tenuis *(based on absence of travel history and given the geographical location of the patient's residence)  The presentation of the worm in a cyst is not typical, but the morphology of the worm was consistent with the features of *Dirofilaria*.  Diagnostic features observed were:
- Size:  92 mm

**Training applications**

## Training applications

- <date/time>

**54**

- Caudal (tail) papillae shown in Image **B** (green arrow).
- Spicule (Image **B**, red arrow).  The presence of papillae and spicule indicated this was a male worm.

- 100x

**Training applications**

## Training applications

- <date/time>

**55**

- The ridging and striations of the cuticle shown in Image **A** below appear beaded, in a "corn row" effect (blue arrows), indicating that the worm belonged to the genus *Dirofilaria*.

- 200x

**Training applications**

## Training applications

- A 39-year-old female had a descending colon biopsy to determine the cause of symptoms that included chronic abdominal pain and discomfort.  No pertinent travel history was known.  Worm-like objects were detected during the biopsy, and some were recovered.  The specimens were sent to a state health department laboratory for identification.  Lab personnel at the state took digital images (Figures **A-C**) and sent them to DPDx at CDC for assistance in making an identification via telediagnosis.  What is your diagnosis?  Based on what criteria?

**A**

**B**

**C**

**56**

**Training applications**

## Training applications

- Presence of cephalic inflations on the anterior end.

**C**

**57**

**Training applications**

## Training applications

- Presence of eggs in the exposed uterus confirming that this was a female pinworm.  However diagnostic features of the eggs could not be determined by the magnification at which the images were taken.

**A**

**B**

**58**

**Training applications**

## Training applications

- The personnel promptly complied and the following image submitted of the egg below shows a typical pinworm egg based on size (50-60 by 20-32) and shape (oval with one side flattened).

**59**

**Training applications**

## Tips

- <date/time>

**Tips**

- 1)  When using lower magnification objectives (e.g., 10X - 40X) you can increase the contrast of the image by adjusting the condenser’s aperture setting according to the objective you're using.
- 2)  Always do a white balance prior to a image capturing session or when switching between differently stained slides.
- 3)  Always make a copy of your image file before using image editing software to alter the image.
- 4) You can reduce file size by saving images as .jpg files instead of as .tif files.
- Please contact us for additional instructions and tips on image capturing.

**60**

## DPDx

- <date/time>

- For more information

- Send us an e-mail at _[dpdx@cdc.gov](mailto:dpdx@cdc.gov)__ _

- Visit our Web site at _[http://www.dpd.cdc.gov/dpdx](http://www.dpd.cdc.gov/dpdx)__  _

## ForIndividual RegistrationEvaluationCEU CertificateGo to PHTN :www.phppo.cdc.gov//phtnonline Passcode = PARASITEComplete by November 19, 2005