The Medical Detectives Volume I

by Berton Roueche

  "I honestly thought I'd never see her again. By the end of the week, I was sure I wouldn't. And then on Monday—the following Monday, May 24—the phone rang, and it was Mrs. Strong. She hated to bother me. But she wasn't any better. In fact, she was worse—much worse. The itch was driving her crazy. I was staggered. If she had called to say there was still some rash—if she had said she was only slightly improved—well, I would have been a little surprised. I'd have accepted it, though. But worse! I couldn't believe it. Except, of course, I should have known. Her husband was a doctor. That's what always happens with a damn doctor's wife. Something always goes wrong when you've got a colleague looking on. Well, I swallowed my embarrassment, and did the best I could. I told her to continue the cortisone cream, but this time cover it with Saran Wrap—with some plastic wrap—to increase absorption. I also prescribed an antihistamine—fifty milligrams of Benadryl every six hours. My hope was that that would stop the itching. Even if it didn't, it would at least give her the relief of a good night's sleep. Benadryl has about the highest incidence of sedation of any antihistamine. But I was counting on it to end the itching, and I was counting on the continued cortisone to finally wind things up. This had to be the end of the case. I couldn't imagine anything more.

  "So another week went by. Eight days, to be exact. Then, on Tuesday morning, June 1, I got a call from Dr. Strong. They had followed my instructions, but the treatment didn't seem to work. She was worse—even worse than the week before. The rash had continued to spread. It now covered every inch of her body. Every inch of her was lobster red except the palms of her hands, the soles of her feet, and her scalp. The itch was unrelenting. She was just about climbing the walls. He sounded frightened. His voice was pure anxiety. And I was frightened, too. I said he'd better bring her right over to the clinic. Or, better still, we'd get her into the hospital. But he said no to both. He said he'd rather handle it in the emergency room at St. John's. He was on that service there. He was firm on that, so I said O.K. Then we talked treatment. We settled on an injection of one cc. of betamethasone. Betamethasone is an extremely potent corticosteroid, and the usual dose is one cc. or less at intervals of six or seven days. So he took her off for treatment, and I waited another week. It was now the seventh of June. Another Monday. And Dr. Strong called. It was the same terrible story. There had seemed to be some improvement for a day or two after the betamethasone injection. But then it turned around again, and, if possible, she was worse. I said I wanted to see her. I wanted to see them both. I asked him to bring her over right away.

  "I couldn't understand it. An atopic dermatitis should have cleared up by now under this really rather heroic treatment. So I had to reconsider—I had to wonder if maybe it was a contact dermatitis after all. That presupposed the continued presence of an undetected allergen. But what? There had been nothing in her recent experience that sounded even remotely like an allergenic possibility. And I had eliminated all the obvious possibilities— cosmetics and jewelry and such. But when she and her husband arrived at my office I went back to the beginning and started all over again about anything out of the ordinary that she might have come in contact with around the middle of April, around the time of onset. Nothing. It was all completely negative. And yet I was now pretty well convinced that there was a contactant somewhere. The two conditions aren't mutually exclusive—an allergic contact dermatitis can occur in an atopic state. I've never felt so frustrated. I wondered if I should have risked a patch test at the very start. Patch testing is a means of determining sensitivity to various suspect substances, and a positive reaction is manifested by a rash. But it can be risky when the patient already has an acute and spreading rash. It isn't always accurate then, and it can also exacerbate the trouble. It's best to wait until the rash is under control. And now it was too late. Mrs. Strong was all rash. There was no place on her body to test. So I was left once more with the question of treatment. I prescribed oral corticosteroids—four tablets every other day for ten days. And a tranquillizer to try and relieve her anxiety. But it was no use. She came back to the office by prearrangement ten days later, and she was much the same, or worse. I led her back through her history again. Nothing. And I was finally at the end of my rope. I had tried every treatment I knew. I'd done everything I could. I had to start all over again. I gave her another injection of betamethasone and another potent antihistamine. She went home just about in tears. And she looked at least twice her age.

  "I had a call the following day from Dr. Strong. There was, of course, no encouraging news. He was calling because he was getting a little frantic. He was finishing up his interneship in a couple of weeks, and then he would be moving to Dallas for his residency. Could I refer him to a dermatologist there? Should we have another consultation? Was there absolutely nothing more I could do? He didn't mean it as a challenge, but it was challenging. It was threatening. I began grabbing at straws. I dug into their life as deep as I could. I began throwing out questions just on a chance. One of them was, What did they do for birth control. He said she had an IUD—an intrauterine contraceptive device. Was that what she had always used? No—she had started on the pill, but the pill had made her sick. So she had been fitted with an IUD around the middle of April. The middle of April! A bell began to ring. I wondered if there was any metal in her IUD—any copper. There is sometimes metal in an IUD, and when there is it is almost always copper, because copper has a certain anti-spermatozoon action. And copper is a known allergen. It's not common, but it happens. But Dr. Strong said he had no idea. I'd have to ask the gynecologist who inserted it. He turned out to be one of my friends, and I called him about two minutes later. He said yes. The device was one that contained a small amount of copper. I told him what I had in mind, and asked him to pull it out. He thought I was crazy. But, as I said, he's a friend, and I sent Mrs. Strong down to his office the next morning, and he took it out. That was on Friday, June 18. I saw her four days later, on Tuesday. It was fantastic. It was unbelievable. It was the most dramatic clearing of a dermatitis that I've almost ever seen. But, of course, I had to make sure. I waited a couple of days for the last of the rash to subside, and then called her into the office for a patch test. I tested her for copper, for nickel, for potassium, for cobalt, and for mercury. There was one positive reaction—to copper. It gave her a beautiful, definitive, four-plus flare."

  The Strongs moved down to Dallas at the end of June. The dermatologist there to whom Mrs. Strong had been referred reported back to Dr. Barranco that she was now entirely recovered. Dr. Barranco enjoyed his diagnostic triumph. It was also, he came to realize, a most provocative one. This realization led him to the library, and his sense of triumph increased. His experience, he found, had been a rare one—almost disconcertingly rare. He was able to find on medical record only six other cases of allergic contact dermatitis involving copper. In three of these, the exposure to copper had occurred in a New England industrial setting. One, reported by a French physician, involved exposure in a chemical-products warehouse, and another, reported from the Netherlands, involved a telephone lineman. The sixth involved an American woman for whom the contactant was copper jewelry. What disconcerted him was the discovery that his was the only case in which the exposure to copper was internal rather than external. There was, however, he was relieved to learn, a considerable record of eczematous dermatitis resulting from internal exposure to metals other than copper. That was reassurance enough. His experience with Mrs. Strong had been rare—notably rare—but not beyond belief. What he wanted now was an audience.

  "I knew I had something worthwhile to report," Dr. Barranco says. "I got all my notes together—my clinical notes and my review of the literature—and began to draft a little paper. I thought I might get it published somewhere. Maybe in the Southern Medical Journal. Or maybe even in the Archives of Dermatology. But first of all I wanted to tell Buzz Solomon about it. Buzz is Dr. Herman Solomon. He's in a small dermatological group practice up in Wichita that's very much like ou
rs, and he is also my best friend. We roomed together at medical school, at Mississippi, and I was best man at his Jewish wedding and he was best man at my Catholic wedding. Buzz and I go to all the same meetings—we take our wives and have a big reunion—and the next meeting on the schedule was a dermal- pathology course in Houston in August. We met as planned, and the first chance we got we sat down and I told him all about Mrs. Strong. He was fascinated. One thing I didn't know—one thing I couldn't precisely explain—was just how her sensitivity to copper originally came about, and we talked that over. Our best guess was that the sensitizing exposure was probably to a piece of costume jewelry. It might have been a copper bracelet— one of those arthritis amulets—or something made of brass. It could have happened weeks ago, or months, or even years. Well, as I say, Buzz was fascinated—really fascinated—by Mrs. Strong, and when I finished he told me why. He had a case that sounded a whole lot like it.

  "His patient was a young woman, too. I'll call her Janet Walker. She was now twenty years old, but Buzz had seen her for the first time a little over a year earlier, when she was referred to him by a colleague. She was suffering from a generalized eczematous dermatitis, which the referring doctor had diagnosed as pityriasis rosea. That's an eczema that some people think may be caused by a virus. She told Buzz that her rash had been coming on little by little for a couple of months. He treated her with topical cortisone, and set up an appointment for two weeks later. When he saw her then, she was worse. He hadn't expected that—just like me and Mrs. Strong. So he reconsidered the diagnosis. Her history was a little bit suggestive. Her father was an asthmatic of long standing. That at least hinted at the possibility of allergy. So did the fact that her ears had been pierced for earrings about two years before. A pierced ear provides a very good setting for a sensitization to metal. He suggested the possibility of allergy to Janet, and told her to take her earrings off and keep them off, to wear no jewelry of any kind for the next two weeks, and then come in and he would see how things looked. I gathered that she wasn't much impressed by the allergy idea. For some reason or other, she seemed to resist it. But she said O.K., and Buzz sent her off with an injection of cortisone.

  "But she didn't show up for that next appointment. She simply disappeared, the way some patients do. A year went by. Apparently, she had been wandering from doctor to doctor, and nobody had done her much good. And now he had seen her again. Buzz thought she looked pretty bad. He was now convinced that her trouble was an allergic eczematous contact dermatitis. And although he hadn't been able to test it out, he thought the allergen was most likely nickel. Nickel is by far the most common metal allergen. She admitted that she had gone back to wearing jewelry, and there was a very pronounced dermatitis on her earlobes and around her ring fingers. The trouble was, Buzz said, he hadn't been able to help her. He had even had her in the hospital. No kind of treatment helped. He was still convinced that it was a nickel dermatitis, but he couldn't find the nickel. He had eliminated every conceivable source. And that is no small job. The sources of nickel allergen—particularly for women—are everywhere. Hairpins. Hair curlers. Bobby pins. Eyelash curlers. Earrings, of course, and rings. Spectacle frames —particularly those metal granny glasses. Coins. Medallions. Dental instruments. Necklace clasps. Zippers. I.D. tags. The wire in bras. Garter clasps. Handbag handles. Thimbles. Pens. Scissors. Needles. Watchbands. Lipstick cases. The metallic eyelets on boots and shoes. As a matter of fact, nickel turns up as an element in a whole range of alloys, including sterling silver and fourteen-carat gold. Well, I was beginning to see why Buzz had been so fascinated by my Mrs. Strong. He had separated Janet Walker from every possible source of nickel—every external source. He hadn't considered the possibility of an internal source. He didn't know if it was a possibility. But he went back to Wichita with that little glimmer of hope.

  "A few days after the Houston meeting, I got a telephone call from Buzz. He had a lead. He had learned from Janet that she had had some surgery done about a year before their first meeting. There was some problem with her knees. She had chronically dislocated patellar tendons. They were corrected by a Hauser procedure, and the tendons were secured in the proper position with stainless-steel screws. Buzz had talked to the orthopedist, and the screws were still there. The problem now was to persuade the orthopod to go in and remove the screws. It wasn't that Janet needed the screws. The orthopod was satisfied that they had done their job, and that the tendons were now naturally secured. But he thought Buzz was out of his head. He thought the idea was preposterous. Those screws were stainless steel. He had never heard of an allergic reaction to stainless steel. But Buzz had finally managed to persuade him. Janet was going into the hospital at the end of the week. He'd let me know. Which he did—on Saturday. The screws had been removed the day before, and there was already, he thought, some improvement. The erythema—the redness—had very definitely subsided. He would do a patch test as soon as he could. Meanwhile, he had the screws and the name of the maker, and he was writing the company for information about their composition. It was a week before I heard from Buzz again. And it was all over. Janet's dermatitis had completely cleared in just three days. Two days later, he did a patch test with a tray of six substances—pure nickel, nickel sulfate, one of the stainless- steel screws, potassium dichromate, cobalt sulfate, and mercuric chloride. The last three were negative, and the first three were all four-plus positive. Buzz said the orthopod was with him and watching but still had his doubts. So he did a test on his own. He took the screw and taped it to her back. Four hours later, she began to flare. The same generalized pruritus and erythema. And it took a couple of days to clear with topical cortisone. But by then the surgeon was doubly convinced. Buzz had heard from the manufacturer—the company that made the screws. Their stainless-steel screws were steel, all right, but the steel had a nickel content of up to fourteen per cent. That seemed to be a conventional formulation.

  "That wasn't the end of the case, however. Not quite. Buzz saw Janet Walker one more time. She came out of the hospital and disappeared from follow-up. Several months went by, and then one day she walked into his office with the same old rash. It was easy to imagine how he felt. She told him that she had gone back to school for a while and had then quit to go to work, and that she had been working about a week in a dress factory. He questioned her about her job, and the answer soon came out. She did a lot of cutting in her job, and the scissors she used had a ring of some sort that kept them hanging on her thumb. Always in contact, all day long. And, of course, all scissors contain nickel. Buzz advised her to get another job. She was much too exquisitely sensitive to even think about handling nickel. It was the same with Mrs. Strong. Her sensitivity to copper was also extraordinarily pronounced. Most dermatologists are satisfied that an atopic constitution increases sensitivity, but I wonder if an internal exposure may not further heighten sensitivity. It's an interesting thought.

  "I never saw Mrs. Strong again. But, even so, she gave me a little scare. I got a telephone call one day from her dermatologist down in Dallas. I had told him that I was planning a report on her case. His call was to tell me that I'd better slow down. Mrs. Strong had just had another bad attack. And it couldn't be related to an IUD this time. Her gynecologist had told him that her present IUD was one that contained no copper. Didn't that seem to suggest some other source of her trouble? I didn't think so. I didn't see how I could have been that wrong. But I did begin to wonder. He left me that way for about a week, and then he called me again. He had taken the precaution of having Mrs. Strong's new IUD removed, and she was much improved, but the picture was still confused. He also had been in touch with the manufacturer, and they had given him a full report on their IUD. It did contain copper. But the amount was so infinitesimal —it was thirteen ten-thousandths of one per cent. I had to admit that that wasn't much, but I thought it was enough. It had to be enough. He didn't think so. He thought it was most unlikely. But he did agree to have the IUD replaced. That was sometime
in late March or early April. I didn't hear from him again until August. This time, he wrote me a letter. I'll read you what he said:

  " 'This is a brief note to catch you up on Mrs. [Sara Strong]. I saw her again this morning for a wart on her hand, and it is interesting that she said that she had absolutely no breaking out since the last time I had seen her, but after three or four months of being clear she felt it peculiar that the IUD device would cause it, and tried it one more time, and had an almost immediate reflare on the wrists of the lichen planus-like eruption. She used her Lidex cream again, and it cleared very promptly, and she has had no difficulty since that time. I am sure that you will find this as fascinating as I did.'