Neuropathy, lead, mercury, and a breakfast colloquium


We like to eat breakfast out

So we know what we’re talking about

The information we share

The learning, the care,

Helps to alleviate doubt.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. In the meantime, I’ve done a couple of assignments in rural Iowa, and one in western Alaska.

I breakfasted early with a friend and colleague. We worked together for a while. We kept up occasional morning meals for quite a time afterwards.

Our colloquia touch on economics, game theory, reality testing, clinical medicine, puzzling patients, family, medical politics and religion. (For why I don’t write about a couple of those topics, see my post https://walkaboutdoc.wordpress.com/2010/09/13/why-i-dont-write-about-religion-politics-or-sex/.) Much of our clinical discussion centered on neurology.

Syphilis remains the great imitator; but HIV runs a close second. Anytime a doc does a blood test on anyone, he or she has to keep in mind the chances of a false positive or a false negative test, and what can happen from either. The usual test for syphilis, the RPR or VDRL, reaches maximum usefulness 6 months after infection when the accuracy hits 95%. The false negative percentage mounts with time until 20 years later when it bottoms out at 50% (the accuracy of a coin flip). Thus I always get the confirmatory test, the TPPA (treponema palladium plasma antigen) which replaced the FTA (free treponemal antigen) early this century.

I only have that information because of a series of cases that happened before the growth of the internet.

My work up for any neuropathy (disease of the nervous system) includes B12, folate, lead, CBC, a Lyme panel, and VDRL/TPPA.

“Lead?” my friend asked, “Why lead?”

I had to admit I had never seen a case of lead poisoning, and I talked about a patient I’d attended last century (I won’t say where) who should have had lead poisoning. He’d worked with lead paint for fifty years and had all the symptoms. Every test we did to show lead poisoning, including bone biopsy, came out negative, but we didn’t get the diagnosis till he’d been in the hospital a few days and his urine turned the color of port wine.

“Porphyria?” my friend asked, and I nodded. Supposedly rare, I’ve seen three dozen cases in that family of hereditary disorders of hemoglobin synthesis.

“And no symptoms till age 73.”

I got to brag about finding several cases of B12 deficiency, each in a unique individual whose diagnosis brought drama and irony to a personal narrative and social context.

I forgot to mention a conversation I had years ago with a doc who found mercury poisoning in a patient who ate too much northern pike; the presentation had looked like dementia but included too many neuropathy symptoms.

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