Triumph by Treachery

By Tony Dajer|Friday, July 01, 1994
RELATED TAGS: INFECTIOUS DISEASES
Ay, me duele, doctor. Por favor, ya no. It hurts, doctor. Please, no more.

My right hand recoiled instinctively, but I had to be sure. It sank carefully--again--into the soft right lower part of my patient’s belly. Again the 57-year-old Puerto Rican woman cried out.

No doubt about it. This was classic appendicitis. I put my left hand--the innocent one--on her shoulder.

Señora, it’s very possible, I began, in Spanish, that you have appendicitis. You may need an operation. In a little while the surgeons will come down to see if I am right. Until then--and you must forgive me-- we can’t give you anything for the pain. If we did, it would make it very difficult to arrive at the correct diagnosis.

Ay, doctor, she moaned, not very comforted by my clinical imperatives. Por favor, haga algo. Do something, doctor.

I squeezed her shoulder and mumbled, As soon as I possibly can.

At the nurses’ station I picked up her chart to make sure I had all my ducks in a row. Her temperature was 101.8. Her white blood cell count--a reliable sign of infection--was 19,000, far above the normal range of 4,300 to 10,800. Her abdomen was tender right over McBurney’s point, the spot about midway between the navel and the corner of the pelvis that people commonly call the hipbone. But the clincher was that Mrs. Velez complained of pain even when I tapped gently over her McBurney’s point. This response, called rebound tenderness, is triggered when the outer covering of an inflamed appendix rubs against the nerve-rich wall of the belly. My patient needed to be in the operating room.

The surgeons answered my page right away.

I think I’ve got a hot one for you, I said, rattling off Mrs. Velez’s symptoms of fever, high white blood cell count, and tender belly.

Yep, sounds like the real McCoy, the chief resident drawled. We’ll be right down.

A throng of blue-pajamaed residents materialized in the emergency room.

Over there, I said, nodding toward Mrs. Velez’s cubicle.

I watched them troop in, expecting an instant verdict and a swift decampment to the operating room. Instead they just stood inside, conferring, reexamining, milling about like a football huddle during a time-out. Finally the chief emerged.

You know, I agree she’s tender, but she doesn’t need an operation, he said, almost apologetically. I’d guess her exam has changed since you saw her. To me, she’s more tender on the left--and higher up. And she says she’s been having a lot of diarrhea. I think she’s got enteritis.

Enteritis means inflammation of the intestine, but it’s far from an exact diagnosis. It’s a bit like saying headache to explain pain above the neck.

Enteritis? I squinted dubiously.

Yeah. I can’t give you a better answer than that. She definitely needs to be admitted--the high white count worries me--but I also know she doesn’t need an operation.

Sheepishly, I went back to Mrs. Velez. Sure enough, her belly was now tender on the left. From certainty to bafflement in 30 minutes. Seven years of training just to be confused, I muttered to myself. And eight years’ experience, piped another little voice in my head. Nothing to do but start asking more questions.

Mrs. Velez, it appears you may not have appendicitis, I began. That’s the good thing. The bad thing is that now we’re not sure what you have. Do you think you could answer a few more questions?

Mrs. Velez pressed gingerly on her abdomen. Well, it seems less painful. So maybe I’ll remember better this time.

Very good, I said. Let’s see, the only medicines you take are for asthma, right?

Yes. The Proventil inhaler and, when I need them, steroid pills.

Inhalers, the standard treatment for asthma, relieve wheezing by delivering an agent that dilates the bronchioles, the tiny airways that constrict during an attack. The pills, which contain steroid hormones, suppress the migration of white blood cells and hinder the release of the inflammation-causing substances that clog the airways and ignite asthma flare-ups. Because long-term steroid use damps the immune response, doctors reserve steroid pills for severe asthma attacks. Mrs. Velez had averaged three or four courses of steroids a year. She had finished the last one three weeks before.

And that’s it? I asked.

Mrs. Velez folded her hands over her stomach. Well, two weeks ago I finished a series of antibiotics. The doctor said I had bronchitis.

Oh really? Which antibiotic?

Big white pills.

How many times a day?

Twice.

Do you remember if they were called Bactrim, by any chance?

Her hands flew up in confirmation. Yes. That’s what they were called.

And your diarrhea started when?

Yesterday. But ay, doctor, today it’s very bad.

Watery or bloody?

Watery. Lots and lots of water.

A light went on in my head. But I still had a few more questions.

And you’ve never been sick from anything else?

No.

No recent travel?

No.

And you’re from Puerto Rico, right? I continued.

Pues claro, of course, she grinned. From Utuado. The mountains. And from your accent, doctorcito, it sounds like you’re from the coast.

I confess, I smiled back. I grew up in San Juan.

But you know, I’m really from here. From New York. I came when I was 15, she corrected, then gave me a nudge. I’ve probably been living here since before you were born, right?

Right again, Mrs. Velez.

Pues, mijo, what are you going to do about my problem belly?

I think I may have just the trick, I winked.

Feeling like a doctor again, I sauntered over to the surgery resident.

Did she tell you about that Bactrim two weeks ago? I asked him.

He looked up from the note he was writing. You know, I was thinking the same thing.

You were? So you’ve thought of pseudomembranous?

Yup, he nodded. Definitely a possibility.

Pseudomembranous colitis is one of the terrible reasons that antibiotics should not be prescribed without good cause. Common antibiotics like ampicillin and Keflex (and, less commonly, Bactrim) can wipe out the colon’s normal bacteria and allow a nasty bug called Clostridium difficile to run rampant--even up to six weeks after the antibiotics are finished. In severe cases, the two toxins secreted by C. difficile can cause the lining of the gut to slough, creating a pseudomembrane that can be seen when the colon is examined with a fiber-optic scope. Ironically, ridding the colon of C. difficile requires another antibiotic--Flagyl or vancomycin.

I told the admitting team about my now-not-so-original idea and ordered a full series of stool tests for Mrs. Velez. I then stopped in to say good night to her. I left expecting to find a much happier patient the next morning.

It was not to be. The first person I met in the hospital the next day was Mrs. Velez’s son.

Doctor, he pleaded, she hasn’t slept all night. She’s been up every ten minutes with the diarrhea. It never stops.

My heart sank. Mrs. Velez should have improved a little by now. And to make matters worse, she was still in the ER holding area, waiting for a more comfortable bed upstairs.

Ay, doctorcito, she complained, I’m like an open faucet. You must do something.

I reviewed her orders. Flagyl, the antibiotic that kills C. difficile, had been given by vein instead of by mouth. This was not a mistake, but, I reasoned with the residents now caring for Mrs. Velez, better to put it directly into the intestine, where it was needed.

Sure, Dr. Dajer, they nodded.

And try to relieve her symptoms, I added. You know, try Kaopectate, Imodium, that sort of thing. The stool tests would take another day. Treating symptoms without a firm diagnosis is the stuff of medical nightmares, but we had no choice.

The next morning I found that Mrs. Velez had been moved to a bed upstairs. When I checked in on her, she said the diarrhea had eased a bit. But despite lots of IV fluids, she looked haggard.

I still haven’t slept a wink, she said with a sigh. Last night I felt like I was going to spend the rest of my life on the toilet!

Out of fresh ideas, I offered a few words of consolation, then hurried on to the lab.

Dr. Dajer! one of the technicians greeted me. We have a great slide for you!

Really? What? I brightened. At least someone had made a diagnosis.

Strongyloides. Tons of them. I’ve never seen so many on one slide.

Huh, I bent down and fiddled with the knob on the microscope. Who’s the patient?

Velez.

You’re kidding, right?

No joke. The technician, normally a serious man, displayed a rare, brilliant smile.

Under the scope, dozens of larvae, coiled like tiny, translucent eels, zoomed into focus. They were a lucky find: stool specimens turn up the parasite in only about one-quarter of all Strongyloides cases. Sometimes the worm can only be detected through blood tests, biopsies, or probes of the intestine.

Strongyloides stercoralis has a name much longer than the twentieth-of-an-inch-long worm it describes. Most of the 80 million people afflicted with Strongyloides live in the tropical Third World, but Puerto Rico and the southern United States still lie within its reach. Yet Mrs. Velez hadn’t lived in Puerto Rico for more than 40 years. And therein lies the first of the parasite’s three formidable talents: its ability to reproduce and reinfect its host without ever leaving the body.

The worm’s veritable fantastic voyage begins when filariform larvae--threadlike worms that live in the soil--burrow beneath a person’s skin. After reaching the veins, they are carried to the lungs. From there they crawl up the windpipe and, with a wheeze or a cough, are soon swallowed down the esophagus. They then pass through the stomach and finally lodge in the small intestine, where they mature and lay eggs. The eggs hatch into more larvae that are shed in feces to start a new reservoir of worms in the soil.

Lots of parasites do that: mature in the host to produce eggs or larvae that are excreted in the feces. What makes Strongyloides exceptionally cunning is that it can become an infectious larva without ever leaving the host’s gut. Once it has reached that stage, it can burrow out of the intestine into the bloodstream and begin a new cycle of infection, just as if it were penetrating the skin for the first time.

Strongyloides’ second perfidious talent is its ability to cause symptoms far from the small intestine where it lodges. As it tunnels through the lungs on its way up the windpipe and down the esophagus, Strongyloides provokes an inflammatory response that mimics asthma.

But here’s the coup de grâce: when disease or malnutrition weakens a host’s immune system, many more larvae can make their way out of the intestine and up through the lungs. They eventually settle back in the intestine, dramatically boosting a patient’s worm load. The results are fever, severe abdominal pain, and diarrhea--the very symptoms that brought Mrs. Velez to the ER.

And perversely, nothing allows the worms to flourish better than the steroids used to control the asthmatic symptoms that Strongyloides triggers. By hampering normal immune function, Mrs. Velez’s repeated courses of steroids over two decades had slowly allowed Strongyloides to reach a critical mass in her intestine.

Strongyloides was likely to be the true foe in Mrs. Velez’s long battle with asthmatic wheezing and bronchitis. But we wouldn’t know for sure until we rid her of the parasite. Luckily, there is strong medicine-- thiabendazole--for the worm. Wily though it is, Strongyloides, too, would fall before the armamentarium of modern American medicine. The next day I expected to find a grateful patient well on her way to health. Instead, Mrs. Velez seemed about to leave tire treads on my shirt.

I want to leave! Now! That little resident told me I was dirty! Here he is, a Chinese, telling me, a New Yorker, I must have come from a poor, dirty country to get this disease. And then they shut me in! As if I were contaminated. I’m leaving. Get me the papers!

I coaxed her back into an armchair.

But what happened? I stammered.

Apparently, Mrs. Velez’s doctors had approached her with all the finesse of a search-and-destroy mission. True, the same larvae that can reinfect the patient within the intestine can, if strict hygiene is not observed, be spread from feces to hands or sheets and then to other people. But the team of residents didn’t bother to explain this to Mrs. Velez. Instead, they had simply clapped her in isolation and refused to touch her without gown and gloves.

Doñita, I pleaded, they’re only interns. . . . This was a half-lie. They thought they were doing the right thing. But what’s most important is that you stay for another day. The treatment takes two days. If you don’t, you will only get sick again.

After much cajoling, she agreed to stay. But Strongyloides is a stubborn adversary. Because the eggs and larvae can survive treatment that kills the mature worms, many patients are not cured after just one course of thiabendazole. To be sure the parasite was eradicated, Mrs. Velez needed to come back for more stool tests and possibly more medicine.

She never did.

Strongyloides had triumphed again by triggering precisely the wrong response in its foes. By provoking too vigorous an immune response in the lungs, the parasite causes asthmalike symptoms. When doctors attack the asthma with steroids, the wily worm runs rampant. So, too, in Mrs. Velez’s case, the presence of Strongyloides set off a prejudice in her doctors’ minds that she came from a poor, dirty country. By treating her as if she were somehow unclean, her modern doctors drove Mrs. Velez away and gave Strongyloides another lease on life.
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