Dangers of Afghan food

BMJ 1995; 310 doi: (Published 08 April 1995) Cite this as: BMJ 1995;310:945
  1. George Dunea

    Have you ever played geography games? Can you name the strait that lies between Sicily and Sardinia? Do you know what countries bound Lake Titicaca? Our father used to play these games with us when we were little to teach us geography. Since then I have added to my repertoire such gems as “Can you name three towns in Afghanistan?”

    This brings me to my friend, an internist, who so far has shown little interest in such games. He knows the Strait of Messina but refuses to venture further north. He can no more locate Lake Titicaca than expound on the rainfall in Ougadougou (is there any?). He cares little about Afghanistan, an indifference that can have serious consequences.

    For on a wintry night in a suburb of the Windy City—so named for its beastly weather or long winded politicians—his neighbour, a highly strung fashionable young woman, knocked at his door. She was pale, sweating, doubled up with abdominal pain, and had diarrhoea. Though she was not his patient, he took her to the local hospital and gave her intravenous fluids. She recovered promptly and then told him that she had eaten at an Afghan restaurant, and that the same thing had happened before. Perhaps she was allergic to the spices they put in their curries. My friend, not to be fooled by Afghan red herrings, sent stools for culture, occult blood, ova, and parasites—all normal—but nevertheless prescribed metronidazole empirically.

    A few weeks later she called again, this time for postprandial epigastric pain, but said she had been under stress. As she by now seemed to have become his patient, he ordered some ranitidine; but living in a litigious and invasive climate he also arranged for a gastroscopy—which Dr Pappworth, who coached hundreds of MRCP candidates, would have called “diagnostic greed,” and which was normal anyway. Again her symptoms subsided.

    Then a month later she called to say that she had seen large drops of blood on the surface of her stool. This time he recommended a colonoscopy. She said she wanted her own gastroenterologist to do this, because he had wanted to do it some time before. It showed a fungating carcinoma of the caecum with liver metastases.

    My friend was devastated by this whole affair, especially as the young woman's family suggested that somehow he had missed the diagnosis. Yet there was nothing in the history, he protested, nor in the physical examination or laboratory tests to even vaguely suggest cancer of the colon, let alone metastases. Yes, he had done a rectal exam, no there were no masses, no occult blood in the stool, and, yes, the alkaline phosphatase was normal. Why did she already have her own gastroenterologist? Because apparently she loved eating ethnic food, but said it often made her sick.

    So we had to conclude that medical practice, like geography questions, can turn out to be quite tricky, and often unfair. Indeed, on the basis of the available information, he would no more have been expected to diagnose this poor woman's cancer than be able to list all the towns in the remotest of remote countries. I did none the less advise him to henceforth beware of women who come in the night, especially if they like Afghan food.—GEORGE DUNEA, attending physician, Cook County Hospital, Chicago, USA

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