A Dr. Woo Sup Chung is on the line for you, my secretary called to me. He’d like you to see one of his patients.
In my specialty, calls from unions, companies, and individuals are common; calls from private doctors are not. Many doctors don’t even know that my specialty--occupational and environmental medicine--exists.
Dr. Markowitz, I am an internist in private practice in Queens, Dr. Chung began, and I have a patient, Mr. Kim, who’s been quite a mystery to me. He’s a 45-year-old Korean immigrant who came to me about a month ago complaining that his stomach hurt and that he had been vomiting a lot.
He added that Mr. Kim had emphysema, an enlargement--and progressive destruction--of the tiny air sacs in the lungs. Mr. Kim had been taking medications to treat his shortness of breath, but his stomach symptoms were entirely new.
When I saw him, he was obviously losing weight, Dr. Chung explained. And he sometimes doubled over with belly pain. Though I couldn’t find anything wrong, I was worried. The first blood tests weren’t much help. All I could tell was that he was mildly anemic, and his liver tests were abnormal.
Hepatitis, I thought. When a virus invades liver cells, the cells respond by spilling their contents into the bloodstream. Infection with viral hepatitis is nearly universal in parts of Asia, and the infection sometimes causes chronic disease.
So I admitted him to the hospital, continued Dr. Chung. He was so dehydrated from the vomiting that he needed intravenous fluids. Also his belly pain was so bad I had to give him an injection of pain medication. But his test for hepatitis turned up negative, so I started a gastrointestinal workup.
What Dr. Chung described was quite a workup: a CT scan of Mr. Kim’s abdomen, an abdominal sonogram, and colonoscopy, in which a tube is inserted into the large intestine to inspect its walls. Mr. Kim had also endured a barium enema, which made his colon visible on X-rays. Every test was normal. Meanwhile the mysterious abdominal pain--though less intense-- persisted.
Then a resident suggested that Mr. Kim had porphyria, continued Dr. Chung. I didn’t think it likely, but we had nothing to lose by testing him.
Acute intermittent porphyria is a rare disease that causes bouts of puzzling illness. The disorder, which tends to run in families, is caused by a defect in a gene that encodes an enzyme that helps red blood cells make heme. Heme is the oxygen-binding part of hemoglobin, the folded protein that ferries oxygen from the lungs to the rest of the body. Ultimately, that enzyme deficiency causes anemia and the accumulation of heme precursors. The most common symptoms of this form of porphyria are mental disturbances and excruciating abdominal pain that mysteriously comes and goes. One way to detect the disease is to test for high levels of heme precursors in the urine. Although the disease cannot be cured, it can be treated by eating a restricted diet and avoiding certain medications.
Mr. Kim didn’t have any mental symptoms, Dr. Chung continued, but he did have anemia, and I had previously seen a porphyria case with just the abdominal symptoms. We sent a urine test for heme precursors, and sure enough, they were elevated. The resident was thrilled. Mr Kim was also beginning to feel better, and he was keeping down fluids. We explained how he could cope with the disorder and discharged him about ten days ago.
I am not a geneticist, and I do not treat genetic disorders. Yet from Dr. Chung’s description I now suspected that a very different problem was causing Mr. Kim’s pain. Although intense, unexplained belly pain and high levels of heme precursors are consistent with porphyria, that constellation of symptoms is also a classic profile of a much more common disorder. But I let Dr. Chung continue.
While Mr. Kim was still in the hospital we took a blood test for lead. Yesterday we got the result--76 micrograms of lead per deciliter of whole blood. I don’t know how he’s getting exposed to lead, and I know your unit has a lot of experience with treating lead poisoning. Can you see him?
Mr. Kim’s blood lead level was about 20 times the average value among American adults. I agreed to see him the next day.
How can disorders so different in origin--one genetic and the other environmental--cause such similar symptoms and test results? The answer is simple: both disorders interfere with hemoglobin formation, but each disrupts a different step in that process. The overall result, however, is the same. Fortunately for Mr. Kim, there is one important distinction: unlike porphyria, lead poisoning is easily remedied if it is caught early.
The following morning Mr. Kim came to my office. He was polite, serious, and as thin as a rail. And he was clearly in pain. As we talked, he bent over, groaning and clutching his belly. But he said the pain was not as bad as when he was hospitalized.
The first step was to figure out how Mr. Kim was being exposed to lead. Among adults, about 90 percent of lead poisoning cases occur at work- -while smelting lead or removing lead paint during construction work. If someone is not exposed at work, he or she may be exposed at home while stripping lead paint or using lead to make stained glass.
What kind of work have you done during the past few years? I began.
I used to teach at a school in Korea before I immigrated to the United States in 1981, he replied. Then I worked for ten years as a bookkeeper. Now I own a shoe repair shop.
Mr. Kim’s answers offered no clues. I pursued other possibilities: Did he have any hobbies? No. Was he doing any home repair? No. Did he have any dishware that might contain lead? No. As far as I could tell, nothing Mr. Kim did put him at risk for lead poisoning. Moreover, no one else in his family was ill. So he clearly wasn’t getting sick from lead leaching out of old water pipes.
I was stumped. Then Mr. Kim volunteered one last piece of information.
You know, Doctor, he said, about two months ago, before I got sick, I started drinking a tea I made from an herbal mixture--two cups a day. A Chinese herbal doctor gave it to me for my breathing. It hasn’t helped it much, but now my stomach hurts too much for me to pay attention to my breathing.
Can you brew some for me? And are you still drinking the tea?
I can bring some in, he replied, but I haven’t taken any tea since I went into the hospital.
Perhaps that explained why his pain had begun to subside. I started Mr. Kim on a five-day treatment of medication that would safely remove the lead that had accumulated in his tissues. The drug would bind to the lead as the metal was slowly released into the blood from his bone marrow and soft tissues during normal metabolism.
Mr. Kim returned the next day and made tea for me just as he would have at home. I sent the sample off to a lab at the New York State Department of Health. A week later the results came back. Mr. Kim’s brew had contained 301 milligrams of lead per liter--20,000 times the acceptable level of lead in drinking water. Assuming that Mr. Kim drank nearly a pint of tea a day, he had probably ingested almost five grams of lead over the course of five weeks.
Now we knew where the lead came from. But how did the lead get into the herbal tea? Had other patients of that herbalist been poisoned by lead? Were other herbalists selling the same contaminated mixture?
In New York City, doctors are legally required to notify the health department whenever they suspect that someone has been sickened by an environmental contaminant. The New York City Department of Health then sends out a team to investigate whether others are at risk. The team’s first stop was Mr. Kim’s herbalist. According to the herbalist, Mr. Kim’s prescription contained 36 ingredients; none, of course, was lead. The team impounded the remaining supply of these ingredients and analyzed them. One ingredient--hai ge fen, or clamshell powder--was found to contain 22.5 percent lead.
The Department of Health team acted swiftly. First they issued a health alert to all New York City doctors regarding contaminated clamshell powder. Then they reviewed the charts of the herbalist’s 1,503 patients and identified two others who’d been prescribed hai ge fen in the past six months. They tracked down these two patients and tested their blood. Both samples were normal. Meanwhile, to prevent the spread of contaminated powder, they confiscated all clamshell powder supplies from the herbalist’s two distributors and from seven other herbal stores that carried the powder. Fortunately, none of the confiscated supplies had dangerous levels of lead.
Then two colleagues proposed another possibility. Perhaps the tea had been prepared with contaminated sea urchin powder rather than clamshell powder. If the sea urchins had clung to the bottom of a boat, they reasoned, they might have absorbed lead from the paint that protects ship hulls from barnacles. To investigate this possibility, my student Alex Li, a fluent Cantonese speaker, visited herbalists in Chinatown and consulted traditional Chinese medical texts. But he turned up no evidence that sea urchin powder--contaminated or otherwise--might have been used to make an herbal tea like the one Mr. Kim drank.
In the end, we will never know how the lead got into the clamshell powder. Most likely, the news about the poisoning spread quickly in the Chinese community, and supplies of hai ge fen were quickly discarded. Although it was possible that someone might have mixed lead into the clamshell powder to poison Mr. Kim, this seemed unlikely. The favored agent in intentional poisoning is usually arsenic, not lead.
Mr. Kim’s case is unusual, but his story is a cautionary tale. Alternative remedies are not regulated by the Food and Drug Administration, and their safety has not been established. There have been reports of chronic arsenic and mercury poisoning among patients treating themselves with some Chinese herbal remedies. And this past April a woman died after drinking Kombucha tea, a home-brewed tea that is made from a fungus. In March 1994 seven people in New York City became sick after drinking Paraguay tea, which is made from the leaves of South American holly trees. Health officials suspect that the tea became contaminated with leaves from a tree that contained poisonous belladonna alkaloids. In another recent case a Chicago woman’s liver became so inflamed that she had to have a liver transplant. The suspected cause of the inflammation was chaparral capsules, an alternative antiaging treatment derived from the creosote bush, a desert shrub.
The hazards are not likely to go away. More and more people in the United States are turning to herbal remedies. Some are simply trying to keep their health care costs down; others are emigrants from cultures with herb-based healing traditions. And some groups are pressuring the FDA to be even more relaxed in its role as regulatory watchdog. The best doctors can do is to be aware that they might not be the only health providers prescribing medicines to their patients. Public health departments must also be vigilant in detecting disease caused by environmental contaminants.
In Mr. Kim’s case, lead poisoning from an herbal tea was a one- man epidemic, easily confined and cured. After a second course of lead- removing medicine, Mr. Kim is now free of pain, though some lead lingers in his bones. He was lucky to escape without permanent harm. But not everyone sickened by unregulated remedies may be so fortunate.