Man With the Mustache

Channeling Sherlock Holmes, an attending physician unravels a hairy situation.

By Louis F. Janeira|Thursday, July 28, 2016

It was my first day as an attending physician. Nervousness and excitement competed for the most prominent emotion inside me.

I was assigned a medical ward full of patients, each an enigma, each a challenge. I introduced myself to the students, interns and residents as I entered the conference room where we would begin hospital rounds. Jane, the senior medical resident, began her report on the toughest case on our rounds.

“Mr. Peterson is a previously healthy 61-year-old man who presented two weeks ago to his primary care physician complaining of protracted vomiting and diarrhea. All outpatient testing was normal.” Jane paused to retrieve the patient’s chart. “Every test known to man was normal.”

“There are always more tests!” I said, smiling. “So why is he in the hospital?”

“Dehydration,” said Jane. “Every few hours he begins to throw up, then has massive diarrhea. And all for no apparent reason.” Jane bit her lower lip. “We really hope you can help us shed some light on this case.”

“Does this poor guy have these symptoms all day and all night?” I asked.

“No, it all quits when he’s asleep.”

“Once you’ve eliminated the usual causes, whatever’s left, however improbable, must indeed be the correct diagnosis.”

Intrigued, I held out my hand to receive the patient’s chart. Slowly, I leafed through his test results. Jane was right, I thought as I studied the test results. Everything was normal. Blood work, liver and kidney function, radiologic tests, ultrasound, CT scans — normal. Cultures from blood, urine, stool — unremarkable. There were no signs of infection. “What do the GI consultants say?” I asked Jane as I began to read the lengthy report from the gastrointestinal doctors who reviewed the case.

“GI is as perplexed as we are,” said Jane. “Scoping of the stomach and lower intestines shows non-specific signs of inflammation with mild redness and swelling, but nothing diagnostic or even remotely helpful.”

“OK,” I began, unsure of what to say but desperately searching for something important to add. “We’ve ruled out the usual. Now we need to think of the weird things.” I smiled, remembering the words of the famous detective Sherlock Holmes. I declared, with a deliberate professorial English tone in my paraphrasing, “Once you’ve eliminated the usual causes, whatever’s left, however improbable, must indeed be the correct diagnosis.”

“Like what?” asked Lauren, one of the medical students, obviously unimpressed by my words of wisdom.

“Let’s go see the patient first. Then let’s research for unusual causes of his symptoms,” I said. “Jane, please lead the way to Mr. Peterson’s room.”

As the group sauntered down the hall, I silently reviewed the causes of diarrhea, not wanting to miss something by overlooking the obvious. Food poisoning occurs when one ingests foods that have toxins produced by infectious agents such as Staphylococcus aureus and Escherichia coli. But Staph and E. coli were ruled out. He had not been traveling in an area where he might have contracted traveler’s diarrhea, which can be due to infectious organisms such as Shigella, Salmonella, Giardia or Campylobacter, among others. Tests for all these were negative. Pseudomembranous colitis? This is a condition caused by an overgrowth of a normal colonic bacteria, Clostridium difficile, typically after taking a course of antibiotics. I looked in the chart. Yep, it was ruled out already! What else? Viral gastroenteritis, an infection of the walls of the stomach and intestine, was ruled out. So was lactose intolerance.

Then he would bite the hair. I tried to imagine what that must feel like. 

I probed deeper into my memory, trying to recall all the potential unusual causes for our patient’s symptoms. There are some exceptionally rare instances when vomiting and diarrhea can be caused by histamine- or serotonin-producing tumors, the so-called carcinoid syndrome and mastocytomas. Produced in normal amounts, histamine and serotonin are crucial in the regulation of gut movement. But when the body produces too much, massive diarrhea can ensue. Syndromes like these are incredibly unusual. What were the chances that my first patient ever as a medical attending would have one of these? I took a deep breath as I re-entered my contemplative state. I could see a few hours in the medical library in my near future, relearning these conditions.

A Striking Sight

We reached the patient’s room. The first thing I noticed was the man’s impressive and handsomely full mustache. Even more striking than its bulk was how jet-black his mustache was. The same went for his hair color. I sat down at his bedside and tried to ignore my mustache envy.

I began explaining what I’m sure Mr. Peterson already knew and probably was tired of hearing over and over again. “All the tests we’ve done so far have been negative. We still don’t know why you continue to have vomiting and diarrhea.”

I was happy when Jane decided to chime in, “We’ll continue to study your case until we have something to go by.”

I noticed that as we spoke, the patient would occasionally run his tongue along his mustachio. Left to right, then right to left. Up and down. Then he would bite the hair. I tried to imagine what that must feel like.

And then it occurred to me.

“Don’t you worry, Mr. Peterson,” Jane was saying, “we’ll figure you out yet and . . .”

“How long have you had that mustache?” I interrupted. Jane and the others looked at me like I had just lost my mind.

“Almost a month,” he said proudly, temporarily halting his mustache sucking and sweeping.

“And how is it that you keep it so black?” I said. “I’m amazed a man your age doesn’t have some grays.”

“Oh, I do. I use hair color.”

It looked like I wasn’t going to spend overtime in the medical library after all. “We need to see your hair color product,” I said. “I believe your vomiting and diarrhea are caused by your ingestion of the chemicals as you . . .” I pointed at his tongue, which, as I spoke, was making a pass through his thick upper lip hair. “I believe if you shave your mustache, your vomiting and diarrhea will go away.”

I explained that hair coloring involves the use of oxidation dyes, typically benzene- or toluene-type chemicals. Over the years, concerns about the cancer-causing potential of these agents have been brought forth, but studies remain inconclusive. What is known is that these chemicals can be toxic. At the very least, they can cause skin irritation — a standard warning you’ll find in the instructions of most hair-coloring products. Certainly, they should never be ingested. Chronic intake of these chemicals may lead to serious health consequences such as liver and kidney toxicity and failure, and even death. In that light, my magnificently mustachioed patient was lucky that gastrointestinal symptoms were the worst of his problems.

Thankfully, even those became a thing of the past for the patient. My hunch turned out to be correct: He shaved off the offending facial hair and remained free from his disabling symptoms.

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