Fillers A lesson learnt

The virus and the hookworm

BMJ 1999; 318 doi: (Published 19 June 1999) Cite this as: BMJ 1999;318:1693
  1. Sundaram V Ramanan, associate professor of clinical medicine, University of Connecticut School of Medicine

    Hookworm infestation with the nematode Necator americanusis endemic in the highlands of Sri Lanka. Patients present profoundly anaemic with a characteristic facial appearance that often lends itself to a “spot diagnosis.” Indeed, it was common for an intern to tell a colleague in passing, “I see you've got another hookworm coming in.”

    Hepatitis A, or infectious hepatitis as it was known a few decades ago (to distinguish it from hepatitis B or serum hepatitis), was also a common infection. At any time, the medicine ward would include three or four patients so afflicted. As inspection of the urine was a better index of jaundice than examination of the eyes, clear glass jars containing a morning specimen of urine could be seen by each patient's bedside. Then, as now, the treatment was largely supportive. As managed care was a phrase yet to come, patients remained in bed for about three weeks, and when it was deemed that the patient had convalesced enough, plans for discharge were initiated.

    When I was an intern, it was such a patient who taught me a lesson that I shall never forget. Examination of the stools for parasitic ova and cysts was routine for all inpatients, regardless of the reason for admission. Helminthiasis was so prevalent that eradication of asymptomatic infestation was the usual practice. The patient's stool had yielded hookworm ova, and on the day before discharge I ordered the standard dose of trichlorethylene (TCE). This was the treatment of the day, and, although not as effective as the drugs now available, it had a high success rate in eliminating the parasite.

    Of course, a recurrence of illness was the rule rather than the exception, and there was no way you could tell whether the recurrence was because of incomplete eradication or reinfection. Nor did it matter. On the morning of discharge the patient was drowsy, and I rather naively attributed his somnolence to a poor night's sleep. The consultant was more impressed by the patient's appearance than by my explanation. He reached for the chart and studied it. “I see that you have prescribed TCE for this patient,” he said, and misinterpreting this as a compliment I responded, “Yes, because his stools contained hookworm ova, and I thought it best to treat him before he left hospital.” “Do you know the formula for trichlorethylene?” he asked, and with increasing pride I replied, “Yes Sir: C2HCl3.” “And what,” he asked, “are the agents used for the experimental induction of hepatic necrosis?”

    I still suspected nothing. Remembering an old mnemonic from pathology, P for phosphorus that causes peripheral necrosis, and C for carbon tetrachloride that results in centrilobular necrosis, I answered with some satisfaction, “Phosphorus and carbon tetrachloride.” “And what,” continued the consultant, “is the formula of carbon tetrachloride?” And that was when the penny dropped, as did my heart. As I responded, “CCl4,” I knew what was coming next. “I hope you realise,” he said, “that you have administered a highly hepatotoxic drug to a patient whose liver is recovering from hepatitis; a drug that is different by but two atoms from a powerful toxin.” I said nothing; what could I say? And then he used the same phrase that has been used before, “Never again.”

    Results of the thymol flocculation and zinc turbidity—liver function tests used at the time—confirmed what we already knew; there was a marked deterioration. Fortunately, a few more days of tender loving care resulted in complete recovery. As I saw the patient walk out of the ward, I said to myself, “Never again.”

    We welcome articles up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake,or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.

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