COTW: Ergotism, or A Little Progress on the Enduring Mysteries

(from Eric McLaughlin)


First off is her age.  She was "elderly".  In the rural villages of Africa, exact age is hard to come by in the geriatric population.  But this was ridiculous to the point of funny.  When the intern called me to admit her, she was 102.  The next day we discovered she was 70.  A beautiful 70 with a joyful disposition.

Second is that she was actually admitted for pneumonia with reactive bronchospasm or COPD (usually in the elderly from a lifetime of living in a house with cook-fire smoke).  She looked pretty comfortable, but we couldn't check her oxygen level, because that requires placing a little monitor on your finger, and her fingers had a problem.

They were black.  And cold.  And they had been for several weeks, and they were getting worse, spreading up from the tips.  And her feet had a similar problem.

Wow.  This was strange.  We put our heads together.  We hypothesized.  We ran some tests. (For the medical types, her WBC was 20 after steroids, and her ESR was 17.)  We took some photos and emailed some specialists in the US.  

She was put on antibiotics and steroids for her lungs, which improved greatly.  And almost everything we could think of for this hand problem should have also gotten better with steroids.  But it didn't.  Her hands and feet were turning gangrenous before our eyes.  You can see the wasting of her fingertips in this close-up picture.

We all admitted we were stumped.  The surgeons had seen a similar case once a few months prior; a teenage girl with just the feet involved.  She had them amputated as a last resort.  The family for this lady wasn't interested in that direction, and she was eventually discharged home on hospice.

***

One of the lesser-recognized challenges of working in medicine in Africa is the mystery.  Patients have problems and you just don't know what it is.  That's hard enough, but I find myself wishing that at the end of every month I would get to see the answer key.  See what I got right, what I got wrong.  Not for my own knowledge, but so that next time, when I saw a similar patient, I would know better what to do.  And this is a perfect example.  The young girl with the feet.  Now the elderly lady with the same problem, and we still don't know.

***

Fast forward to last week.  I'm sitting in a big air-conditioned classroom at Johns Hopkins University, on the last day of my four weeks of tropical medicine school.  It couldn't be a more different setting.  The very last lecture is entitled "Unusual Tropical Diseases", meant to be a sort of relaxing show-and-tell prior to the final exam (I know, doctors have strange forms of relaxation).  Five cases into the list, the professor throws up a picture.  A young Ethiopian boy with unexplained gangrene.  Wasting.  Something clicks in my brain.  I've seen this before.  What is this?

Well, this case was called Ergotism.  It's caused by ingesting toxins from a fungus that grows with cereal crops.  In some cases, it causes convulsive or psychotic symptoms (and is interestingly theorized to be the cause of the bizarre behavior that spawned the Salem Witch Trials.  Again, doctors and their odd hobbies.)  But the other cases are gangrene, compatible with our two patients, who had the right environment for an exposure to this fungus.  There is a non-surgical treatment option, namely vasodilator therapy.

A little mystery made a little more clear, and we'll see if it comes to pass again.  The reality of these puzzles will continue to play a big role in our hospital development choices, especially as we are working with an educational system, where the benefit of a solid diagnosis not only may help the patient in front of you, but provides an educational foundation for each young doctor, who will likely see these problems again.

"It is the glory of God to conceal a matter; to search out a matter is the glory of kings." -Proverbs 25:2