Posts Tagged ‘lead poisoning’

Neuropathy, lead, mercury, and a breakfast colloquium

May 27, 2015

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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Slightly outside the parking lot medicine

September 14, 2010

When a child has deficient attention

This is my diagnostic contention:

     The least sufficiency

     Would be to test for deficiency

Of iron and vitamins that I’ll mention

This evening I went to another town outside my thirty-mile non-compete limit with a friend who teaches Tae Kwon Do. 

I could write a great deal about martial arts, and in fact I made Tae Kwon Do the subject of a novel (not in print, I am hoping to get an agent).  In brief, martial arts communities have an important place in our cities and towns.

I sat next to the mother of two of the students, a male age eight and a female age ten.  She gave me permission to write about the following information.

The eight year old had a medically complicated first two weeks, and since then he’s been a behavioral problem at home, but not in school.

I asked if he were on medication; the mother told me no.  I told her that a medication list with nothing on it is a good start.

Then I said that I never give the diagnosis of ADD or ADHD until I have the following normal lab work:  complete blood count, erythrocyte sedimentation rate, thyroid stimulating hormone, 25 hydroxy vitamin D, lead level, chemistry 14 panel, ferritin, vitamin B12, and folic acid.

I have never once seen lead poisoning, and I’ve been looking hard for thirty years.  But I’ve seen a lot of behavioral problems from iron deficiency, which has much biochemistry in common with lead poisoning, hangovers, and porphyria (a very rare blood disease).

I’ve also seen ADHD get a lot better with vitamin B12 replacement; my youngest B12 deficient patient was eleven years old.  Some of my ADHD patients improved when the vitamin D deficiency resolved.

The few children I’ve seen with underactive thyroids all had behavioral problems, which either improved greatly or disappeared when they had adequate thyroid supplementation.

I’m not a big fan of medication for ADHD.  The disease runs a spectrum from not so bad to disabling, and at every level treatment involves varying combinations of coping strategies or medications.  Pills alone won’t help nearly as much as pills and skills.  A combination of an alarm watch that goes off every fifteen minutes, a continuously updated list, and a Palm or other PDA can go a long way to obviating a pharmacologic strategy.

If easy distractibility makes the diagnosis of ADD, then I have the disease.  I suppose in comparison to other people my age I’m hyperactive.  I have made a lifelong habit of avoiding cross talk and multiple conversations, and I will be the first to admit that I don’t multitask well.

I’m a Family Practitioner from Sioux City, Iowa.  In the year that my 30-mile non-compete clause ticks out I’m having a lot of adventures.  If you want to comment on a post, click on the title.

The easy, the hard, the self-made

July 23, 2010

My clinical experience was linking

 A case that set me to thinking,

     It wasn’t the lead

    But porphyria instead

And it was aggravated by drinking.

Morning conference included a discussion of a patient with psychiatric problems, severe recurrent abdominal pain, constipation, and neurologic problems including diffuse whole body pain.  We threw ideas back and forth across the table.  I really didn’t have much to add.  I’m a front line doc, I’m not a specialist and if my colleagues have looked at a patient I can offer a different point of view and not much else.  But it was fun to be in the discussion.

Half the morning patients didn’t arrive.  In the time freed up by the no-shows I called patients about abnormal lab results and made arrangements for follow-ups of other problems. 

One of the morning patients, when asked if I could write about him, said “My life is an open book, write what you want.”  He had a problem with anger, he said, and before he moved to Barrow he spent fifteen years in prison.  Twenty years ago he left Anchorage for a two-week vacation in Barrow.  He quit drinking and spent his own money for three years of counseling.  He is a hard-working family man, a solid citizen.  In many ways he has become the person he chose to be.

We talked about how many people in Barrow have quit drinking.  Some have used the church, some have used AA, and some have just quit. 

I brought lunch, shepherd’s pie, back to the apartment.  Bethany and I shared generous portions and did improvisational comedy.  We marveled at how bright and clear the air was, and made frivolous speculation about what the red and white Canadian Coast Guard cutter was doing, anchored 800 yards outside our window.

After lunch I sought out an exit interview with the acting Clinical Director.  Most of what I talked about was the healthy part of the medical subculture in Barrow and why I’d had such a great time.  I had a few constructive suggestions.

Afternoon walk-in clinic brought the parade of the human condition, drama and irony, the diamonds in the grit.  At one point, responding to yet another patient’s request to refill all of the other prescriptions, I didn’t say, “Make an appointment, this is too much for one visit.”  I said, “Sure.  It’s my last day,” and I grinned.  But I gently asked that the patient be kind to other doctors in the future.

I don’t have many publications to my credit, but one of them was entitled Looking For The Lead, and it was published in The Hudson Monitor.  A patient who should have had lead poisoning didn’t; he had porphyria.

The porphyrias are a group of rare disorders in the synthesis of heme (the red stuff in hemoglobin).  I have seen about three dozen cases; the very long story of why I would even look involves a friendship with a thoughtful surgeon and a unique sequence of patients. 

It was porphyria that drove George III of England mad, leading directly to the formation of the United States and weakening the monarchy of Great Britain.  The symptoms of the disease include psychiatric problems, severe recurrent abdominal pain, constipation, and neurologic problems including diffuse whole body pain.

Thus, when the luck of the draw brought me the last patient of the day with that symptom complex, I thought of porphyria.  I had to scurry around to the lab to get the right twenty-four hour urine test ordered.

Treatment will be more about avoiding drugs, especially alcohol, than about taking them.

I won’t be here when the lab results are back.