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.

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

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.