Posts Tagged ‘syphilis’

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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Syphilis and gold: finding what you look for

April 2, 2014

Across the car park I strolled
In the rain and the wind and the cold
The thing I did find
Brought hope to my mind
And turned out to be real gold.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time position with a Community Health Center. I just returned from my second locums trip to Petersburg, Alaska.

On my first Monday back from Alaska I went into the office to catch up on the miscellany that accumulated in my absence. I found 320 clinical items on my electronic desktop along with 78 administrative emails. In the quiet of the early morning, when my body clock should have screamed for sleep, I dug in and started plowing through the items one by one.

About half had to do with bad things that had happened to my patients, requiring hospitalization, while I vacationed. Every admission generated an ER note, a history and physical, progress notes, lab and x-ray reports, and a discharge summary. I could not determine the importance of each item without reading it.

I ran into some surprises.

Three patients received malignant diagnoses, and I judged each cancer gratuitous. None of them did anything to deserve their tumor.

One person’s syphilis tests came up positive. I followed the communications; saw that my partners had done the right thing through the health department notification, the lumbar puncture, and the penicillin injections. I look forward to seeing if the patient’s symptoms improve.

When my father attended medical school, his professors would lecture, “Know syphilis and know medicine,” but since then the frequency diminished to the point where we rarely think about it, and sometime we forget to look for it. Lyme disease brought a resurgence in testing because searching for one justifies testing for the other.

I left the clinic at 1230 to go home for lunch, and as I got into the car, I saw a faint gleam of yellow on the pavement. Smaller than a dime, when I picked it up I saw it had suffered from passing car tires grinding it into the gravel. But it had a milled edge, which marked it as a coin.
At age 9 I found a dollar bill in the street in front of our house, a powerful experience at the time, and even more so because of the large purchasing power it represented in 1959. I started looking for more. One finds things that one looks for.

During med school, the Michigan State school paper published a piece by a student who also found money and who kept track of it; he commented that as inflation eroded the value of money he found more and more. Perhaps because of its lower worth, and perhaps because I keep getting better at spotting it, I find a lot more money than I used to.

When I came back to the office, I stopped in at the pawn shop across the street, and asked my friends there to check the tiny item for gold content, which came, to the surprise of all, as 22 karat; I accepted the spot gold price and walked out a happier man.

I worked through till 530, when I cleared out the last of my electronic communications, thinking about how one find things that one looks for.

Blizzards, syphilis, and nosology (the study of how we know what we know)

December 12, 2010

How do we know what we know?

If the test says ‘yes’, is it so?

     False positive rates

     In some disease states

Can lead to some terrible woe.

 

Cold came to Iowa overnight, strong enough to generate national news.

I arrived to make hospital rounds yesterday, and talked with the doc on call.  We eyed the weather reports and I took over call early, allowing the other physician to get home before a blizzard hit.

Patients like to stay sheltered when the wind chill goes to double negative digits, only the much sicker come in. The forecast called for 40-50 mile per hour winds, heavy snow, and temps around zero.  After supper I packed an overnight bag and returned the half-mile to the hospital.      

I didn’t have to stay the night at the hospital; I could have waited to get called.  I wasn’t sure the blizzard would really happen, but I didn’t want to face whiteout conditions trying to get to the ER. 

I drifted to the nurses’ station first.  With a census of three, the staff outnumbered the patients.  We chatted about the cold, deer season, and the patients.  I got some surprise lab results.

Mostly we get information from laboratory tests to confirm what we think is wrong; rarely (not never) do we generate as much decision making from x-rays or blood and urine tests as we do from talking to the patient.  Sometimes the patient can’t talk, can’t remember, or won’t tell the truth.  In those cases lab and x-ray add heavily to the diagnosis.

Yes, I ask for tests “just to make sure,” and sometimes when the case perplexes me I’ll order a large number of lab tests.  Ninety percent of those results come back as expected.  Ten percent of the time they don’t.

I finished residency thirty-two years ago, when syphilis used to be called the ‘Great Pretender’ because it could mimic any other disease.  As med students we learned to order certain labs as a matter of course, especially the serologic test for syphilis, aka STS, Wasserman test, VDRL, or RPR.  Later we learned to order the confirmatory test, the free treponemal antigen (FTA) or Treponema palladium plasma antigen (TPPA). 

As rates of syphilis fell, the disease changed and enthusiasm for testing waned.  In medical school, we were taught that the infection always started with a sore.  By 1990 the sore happened occasionally.  Now we almost never find one.

I still test for syphilis despite low rates.  Since 1982 on five occasions the test came back positive and surprised us all; on one occasion, years ago in another place, the positive result startled me but not the patient.  I came away with a history lesson in riverboats and an appreciation for Midwestern life in the thirties. 

The diagnosis remains a problem in nosology.  The first test has false positives (as in Lyme disease) and false negatives (late in the illness), the second test has no false positives but cannot distinguish active disease from prior infection.  In the end, there is no substitute for clinical judgement.

Road Trip 2: Chicago

November 19, 2010

My daughter’s the third generation

She’s had enough education

     To make a diagnosis

     Infer a prognosis

And legally prescribe medication

My father did two years of medical school at University of Missouri and transferred to Harvard.  His Barnes internship gave him one day a month off.  He finished residency in Pittsburgh, and when I was six we landed in Denver for his American Heart Fellowship; he went into cardiology. 

I wrestled with my career choice for years but, unlike my father, I didn’t battle racist admissions policies. Family practice internship and residency meant a mere 100 hours per week.

My daughter, Jesse, a third generation physician, didn’t hesitate to choose medicine.  She had to learn a great deal more during her med school years than either her father or grandfather.  Halfway through residency now, in theory her work week stops at 80 hours (reality differs).

I stopped to see her in Chicago to visit her after an easy day’s drive.

She looks good; she carries herself with confidence and personal strength.  We had a great time talking about cases and patients and the meaning of medicine in the larger scheme of things. 

Nostalgia can lead one to a quagmire; in medicine it risks a journey to a swamp at a toxic waste dump.  Medical care now beats any medical care of the past.  Even if the hours look shorter, medical education get more difficult every year because every year the body of knowledge expands.

I hope but can’t prove that doctors who work sustainable hours will function as doctors more years than ones who don’t.

Society, the world, and medicine have changed since my father carried his microscope into the histology lab in 1948.  I had that microscope refurbished in 1975.  A fun toy, but microscopy skills add little to a practicing physician’s ability to take care of patients. 

We talked about cases and the front-line reality of life.  Every disease carries a human cost and the impact ripples outwards from the patient to the family and the workplace and the society.

She told me about syphilis’s resurgence in Chicago.  I told her how it always started with a chancre (a soft ulcer at the site of infection) when I began med school, but ten years later it rarely did.  She talked about her disappointment at the delivery she had attended the day before, when the breech presentation necessitated C-section.  I observed that when I started private practice in ’87 we sometimes delivered breech babies vaginally (and got some pretty beat-up babies) but by 1989 we’d stopped.

If medical office paperwork doesn’t flow functionally, it will flow dysfunctionally, I told her; this I have learned on my walkabout.  

Her ten-doctor office runs with one nurse and five Medical Assistants, which amazed me.

We went out to eat with her boyfriend (also a Family Practice resident); over Pad Thai and sashimi I got to tell stories about bring up my daughters, liberally sprinkled with observations about thyroid disease and vitamin D.  I watched vigilance exact its toll while he ate, and his OB patient labored; he kept waiting for his beeper to go off.

Doctors will always pay a price for being doctors, tradeoffs are inevitable.