Saturday, May 31, 2008

Dropping the Potato Like a Hot Potato

A previously-healthy woman (will call her Amanda) comes to the hospital feeling very weak. She's kept in the ER and before any doctor can see her, Amanda becomes paralyzed and eventually stops breathing. She is placed on a breathing machine.

Unfortunately she lives alone so nobody could get a good history and tell what events could have lead to this, therefore making a diagnosis is extremely difficult. A whole bunch of illnesses can cause this.

Finally, after running a bazillion tests, a diagnosis of Botulism is made. Botulism is a disease caused by a toxin that is produced by a bacteria. This toxin and bacteria gain entry into the body somehow, through food or a wound, and once inside the body cause paralysis and often death.

Amanda was on the breathing machine. She was stable but very sick.

The question to us, the infectious disease doctor, was: where did she get it from? How did the toxin get inside her body? And how do treat this thing?
We started talking to family members separately, but nothing in what they said was suspicious. Amanda had several plastic surgeries in the past. We suspected that she had Botox done (a procedure where a very dilute toxin is injected into the face to tighten it up). However her sister who is very close to her denied that she had such procedure.

However, the sister confessed to something else. Amanda, who came form a very conservative Christian family and is single, had an abortion 2 weeks earlier and an IUD (lawlab) was placed, and she hid that from the rest of the family. The sister told us so because it might be helpful. Indeed it was. We decided to remove the IUD because it might have been the source of the toxin that was circulating in her body. We removed the IUD, tested it for the toxin, and that came back negative. Now we had to think of another source.

It turned out she had a boyfriend who wasn't visiting at the hospital. Eventually, he showed up and told us that the night before she got sick, he and Amanda bought food from a fast-food restaurant. They had exactly the same meal but because he didn't like potatoes he didn't eat them, but put the rest of the food in a bag and took it home. Being a guy he didn't throw away the food even after a week (I can relate to that!) and he was still having it by the time we were talking to him.

With help from CDC, we tested all the food he had kept from that night for the toxin, and we found that the potatoes contained exactly the same kind of paralyzing toxin that was present in Amanda's body.

Being an infectious disease physician means that you have to think of the story behind each infection, and think why did this particular healthy person get this particular infection at this particular time. Sometimes the answer is clear. In other occasions you have to dig deep and act like an investigator to try to collect every single information possible. It wasn't simple in Amanda's case. All what we saw was a paralyzed woman, with plenty of abnomral studies and abnormal lab results and abnomral X-rays and there were at least 50 explanations for each of the abnormal results that she had.

Amanda was already getting better while we were waiting for the test results to come back. One could argue that we could have left it there and not pay thousands of dollars in tests and waste all that time and effort to know where it came from. If we followed that argument we wouldn't be able to protect more than 500 daily customers of that restaurant from the food they were about to eat. In other times, it helps scientists learn more about infections, how they occur, and where do they come from, in order to help in developing new methods for prevention and treatment of these potentially fatal infections.

Last, but not least, it helps families understand why their loved one suffered from such an ailment. It answers many questions that can provide closure to many cases where the ending is not always as happy as Amanda's.

And.... you gotta do this when you still have 20 more patients to see and 2 lectures to prepare and a research you're working on, in addition to car brakes that you don't have time to fix.


kinzi said...

Sounds like House, MD, to me! Even if you did say not to believe the stuff they say, this could be an episode for next season.

How can I get you on our PPO? Thank God for you.

caroline said...

an interesting case hareega!
i really think ID is tough bec u have to know so much and remember how the MO work and how they look like and what they do,and then know all the antibiotics!I personally can't think of it as a specialty,but at least all this work pays off for you later,u will be well paid!:)lol

gjoe said...

LOL..that sounded like an episode from all those medical stuff they bring..


Everytime I watch these episodes, I wish I was a doctor to verify the BS they are telling us about medicine

lost within said...


I wanna be like you guys someday !
You are really amazing doctors ! Amanda is lucky to have you as her doctors !!

And I second Kinzi , it cud be an episode of House !

Sophia said...

You made me worried from eating Potatoes !!

What did they contain? and how were they cooked and served?

Sorry for troubling you, but I believe knowing such information can help me (and others) to avoid such dangerous infection.

Thanks in advance.

Hareega said...

kinzi, what's PPO?

caroline... you have to read a lottttt to be a good ID person, but it's really really fun at the end. IT's very rewarding but not financially, ID (and endocrine) physicians have the worse salaries among all internists, and probably the worst with general pediatrics and family practice.
About knowledge, you can always return to up to date or a good reference and read more about the case you're seeing. In Jordan they make you feel like a real idiot if you didn't know EVERYHTING but of course that's not true.

gjoe... hehe be my guest, if you go to medical school now you'll be done with residency by 2019

Lost... House is BS, BS, you'll hate him when you start your clinical rotations

Sophia, they contained botulism toxin A. There have been some reported cases of botulism with potatoes, although that's unusual. I don't recommend you start avoiding eating potatoes since this has been the only confiremd case so far. Why did it happen in that particular restaurant is something I don't know, but public health people are investigating it.
Botulism is usually anvoidable, sometimes very minor wounds serve as a port of entry of the bacteria.

YFA said...

Great work Doc!

Would you agree that it could be as easy as an employee not washing their hands after going to the restroom and then making the food? YUCK!

And all these drug resistant's getting harder and harder to defend against them.

Hani Obaid said...

So did they close down the restaurant ? Is it a well known fast food place ?

The Observer said...

I felt like I m watching grey's anatomy! Sometimes medicine can be cool! I mean getting introduced to such cases of life. Good job..

Hareega said...

yfa.... yes bacteria are more resistant to antibiotics more than any other time, this won't change since everybody takes an antibiotic for whatever reason

Hani... there will be an investigation. Not sure about the details though

Observer... it is cool!

Anonymous said...

TJ: and how come her bf didnt eat from the same potato? since when boyfriends leave anything in their plates? were the potatoes fried or boiled? hmmmmmm getting suspecious,,,maybe He has something to do with it.May be he implanted the pathogen inside the potato for revenge!hmmmm or are u trying to convince me that potatoes started taking botilisum toxins to prevent wrinkles??
seriousl hareega what drug do u think am on?
7ata el ba6a6a bidak t5awefna minha ya zalameh. da7na malnash gher el ba6a6es.

thx for the interestng story,, keep on discovering new pathogens :D :D

Hareega said...

TJ sharrafteena, ahlan wa sahlan, el marra el jaay gabel ma teeji e7ki, balki 3melnalek kaset shaay ma3batata

Sam said...

interesting...i have a friend whose sister had something like what Amanda had..i think ...well maybe not..some bacteria entered her body...killing the nerves in her limbs..all 4 limbs had to be amputated...will amanda be paralyzed forever or is it a temp thing??

Hareega said...

it's difficult to know how her outcome will be since it may take months for her to recover, but there's a chance she may have full recovery.

i doubt that what your friend had was a botulism infection. Botulism affects the nerves and causes paralysis. What your friend had was probably blood clots to the arteries in all limbs and that is usually not caused by an infection, but it might be.