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Imaging Diagnosis

The live guinea worm will not be identified radiologically except in those rare instances where iodinated contrast medium is injected into the body of the worm, as it lies near the skin surface, in order to delineate its full extent. After its death, however, the guinea worm may undergo calcification in several forms, especially if it has become entombed in the deeper subcutaneous tissues or muscle planes without being fertilized or releasing its larvae. In its typical location in the limbs, especially the lower extremities, the female Dracunculus medinensis appears as a long, string-like, serpiginous or curvilinear calcification which may extend at times for as much as 1 meter (several feet) (Fig. 27.11). Frequently, the calcification is segmented and beaded because muscle movement breaks up the necrotic worm (Figs. 27.11-27.14).

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Fig. 27.11 A,B. Guinea worm calcifications in a patient from Saudi Arabia. There are several calcified worms in the calf and thigh. The longest of these extended from the mid-thigh to the ankle (B). These worms are elongated, nodular, beaded and fragmented due to muscular action breaking up the worm in several areas, particularly in the calf. This is the classic type of calcification seen in guinea worms in the extremities. (Courtesy of J. M. Abukhalil, Fairhope).

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Fig. 27.12 A-E Guinea worm calcifications in four different patients. A Convoluted, serpiginous calcification in a necrotic adult guinea worm in the soft tissues of the foot. A squamous cell carcinoma of the skin is adjacent to the base of the fifth metatarsal. (Courtesy of Dr. A. Khajavi: Clin Radiol, 1968) B Extended, linear calcification with slight beading and fragmentation in the subcutaneous tissues of the posterior calf of a Saudi Arabian. The distal portion of the worm is somewhat convoluted upon itself. (Courtesy of J. M. Abukhalil, Fairhope) C, D Several calcified guinea worms are present in the thigh posterior to the distal femur in a patient from a hyperendemic area in western India. There are both linear thread-like calcifications and dystrophic, oval calcifications, suggesting there was some inflammatory reaction around portions of the decaying worms.E Another patient with a coiled, calcified guinea worm posterior to the knee.

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Fig. 27.13 A-D. Calcified guinea worms in the upper extremities of three different patients. A,B Convoluted, serpiginous calcification of a guinea worm in the soft tissues over the volar aspect of the distal forearm near the wrist. C Linear, elongate calcification of a dead D. medinensis in the soft tissues of the thumb. (Courtesy of Dr. Douglas Sheft, San Francisco, California.) D Linear, serpiginous and beaded calcification in a dead guinea worm in the axilla of another patient.

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Fig. 27.14 A-D. Calcified guinea worms in the pelvis, scrotum, and thighs of four different patients. A AP view of the pelvis and hips of a Saudi Arabian man with numerous calcified guinea worms in the soft tissues of the hips, thighs, and scrotum. Several of these worms have an elongated, linear configuration; others caused a localized inflammatory reaction upon their death, resulting in oval, dense, dystrophic calcifications. (Courtesy of J. M. Abukhalil, Fairhope, Alabama.) B Similar findings in another patient. Note the dense, oval, amorphous calcification in the scrotum as well as the classical serpiginous, beaded calcification of another dead guinea worm in the soft tissues of the left thigh lateral to the femur. Several linear streaks of calcification are seen about the medial aspects of both thighs and above the left hip, representing partial calcification of several other dead worms. C The serpiginous calcified outlines of dead guinea worms are seen in the soft tissues overlying the right side of the pelvis, pubis, and left ilium, as well as a dense dystrophic calcification caused by inflammatiory reaction around another dead worm overlying the right upper pelvis in a Nigerian. D Serpiginous, beaded calcification in a dead guinea worm in the soft tissues of the pelvis overlying the bladder in a patient from India. This appearance can occasionally be mistaken for calcification in the vas deferens or in a vessel. (Courtesy of Dr. A. Chandrahasan Johnson, Tulsa, Oklahoma).

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