Fillers A patient who changed my practice

Fifteen years before looking at job

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7313.628 (Published 15 September 2001) Cite this as: BMJ 2001;323:628
  1. Piero Stratta, clinician,
  2. Caterina Canavese, clinician
  1. Nephrology, Dialysis, and Transplantation, University of Torino, Italy

    When we recently looked at a survey on chronic uraemia that included patients for whom there was no occupational history, we felt that not enough attention was paid to this factor. We went back to the story of a 38 year old man who was admitted to our hospital in September 1976 complaining of severe abdominal pain. His clinical history was unremarkable up to 1961, when he first experienced abdominal pain and was admitted to another hospital. As laboratory tests showed no abnormalities and his clinical picture spontaneously improved, he was discharged, but he relapsed with colic-like severe abdominal pain and hypertension, and he was admitted to the same hospital once a year for the next 15 years. Diagnostic hypotheses were pancreatitis, liver disease, diverticulitis, and pancreatic cancer, without any confirmation.

    On his admission to our hospital, a suspicion of plumbism was formed. Body lead burden on EDTA mobilisation tests was 1650 µg (normal value 150 µg, toxic levels >1000 µg). He had been working since 1952 in a ceramic industry, making hand prepared enamel. When somebody asked him why he never talked about his job, he said: “I did, but the physicians told me I have not ‘black tooth,’ so I could not be lead intoxicated, and I was most probably suffering from psychosomatic symptoms or was even a drug addict.” A renal biopsy showed ischaemic glomeruli and arteriolosclerosis compatible with lead-nephropathy. Chelation therapy was done for 20 years (body lead burden was still >600 µg in 1992) and halted only in 1998, as normal lead excretion was obtained. There was no relapse of abdominal pain, and he is now enjoying good general health, with normal renal function and good blood pressure control.

    This case illustrates two important points: (a) only if doctors ask their patients about exposure may a causal association be established; and (b) only if doctors know the potential risk implications of an occupation on health may a correlation between symptoms and exposure be recognised.

    Although some doctors think occupational diseases are a thing of the past, occupational risks do still exist, as do environmental and lifestyle exposure risks (from pollution, hobbies, habits) such as lead toxicity in children and elderly people. Occupational diseases lack “glamour” for potential clinical investigators, but they are important because they can be prevented. They also serve as models (few workers exposed to high concentrations of toxins over short periods) that help in the understanding of environmental diseases (large populations exposed to low concentrations over long periods).

    So, please ask patients about job experience and other possible occupational or environmental exposure, as we have done routinely since looking after this patient.

    Footnotes

    • 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.

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