All in the family

It was a while back. My youngest daughter, Yvonne, was finishing her undergraduate degree in Political Science. She had chosen to spend some time in Central America, seeing how cocoa was grown, how farmers farmed, etc. She had a great time, in Guatemala and Nicaragua. The day she came home, she wasn’t her usual buoyant self. “I’m not hungry, she said, and I have a sore tummy.” Do you have a fever? “No. I’m tired, and I’ve got a headache. Maybe the long flight.” I asked the usual questions, as a doc would do. This was one concerned dad. I felt her abdomen, and the liver was not only palpable but tender. I sent her the next day for lab work, and they came back with a low white count and elevated liver enzymes. Read Dr. Baillie on: My experiences of dying Oh, shit. This isn’t good. Her GP said she should consult an internist (me), and the only ID doc in town was on holiday. There is no gastroenterologist or hepatologist within a two-hour drive. I had visions of fulminant hepatic failure, something I was helpless to prevent. I needed to know more, now. I took a full history. No drug use, no potential for contaminated water, no contacts with jaundice. Yes, she had some alcohol, but nothing out of the ordinary. Everything else was negative. I called a GI doc in Vancouver, and he suggested the usual hepatitis screen, autoantibodies, etc. All negative. I asked the radiologist if he could help, and the ultrasound was pushed forward: normal. Yvonne was sleeping a lot, and not eating much. But she wasn’t jaundiced. And she didn’t have a fever, or myalgia, or any worrisome symptoms. About five days later, she comes down for lunch. “Hey, Dad, what’s for lunch?” Something had broken, she was back to normal. And true enough, her LFTs were on the mend. Her CBC had become normal. I didn’t have a diagnosis, but I was delighted with the change. Read: Dr. Baillie on: When things go wrong fast Then I got a report from the hospital lab. Someone there had recognized the need for further testing, and had come up with a diagnosis. Positive serology for Dengue solved the puzzle. Admittedly, no myalgias, but a clear (and obvious) cause of hepatitis in someone returning from an endemic area. A mosquito bite conveyed the viral agent to her liver, and the rest is history. Yvonne asked if she could drink alcohol, and I said, "No, not until your LFTs are normal." She wasn’t happy, and asked if I would find out their trajectory. Most of my lab testing was through the hospital lab, and I accessed her results through the EMR. She was happy when one day I said “Ok, but don’t drink too much.” It was a few weeks later when I was called in to speak with the hospital administrator. We talked about some political issues, and as I was leaving he said, “Did you access your daughter’s lab results on the hospital computer system?” I told him the story, with some overlay of guilt. “You can’t ever do that again, it’s against the rules.” I thought for a moment, and said to him “What would you do in the same circumstances?” He didn’t answer, but it was clear that Yvonne’s outcome was a cause for paternal concern, and justified (to me) my actions. She got an official letter in the mail, and was good enough to write a letter giving me the permission needed to check her labs, then and now. I was admonished. Read Dr. Baillie on: Home visits There is something awful that turns your stomach when one of your children is sick. Of course, children are made to get sick. My other two have had something go wrong at different times, but nothing quite as exotic. I defend them with my life. I have a colleague whose four kids have had MAJOR illnesses and trauma: It brands you with concern, and likely shortens your life. No parent should have to be in the position of being father and doctor to his adolescent child. The responsibility is huge. Fortunately, this condition was self-limited. She has to avoid a second such exposure. The most interesting aspect of this case: The wisdom of a technician, who saw her recent ports of call, and connected the dots. Something all her doctors had missed. If Yvonne had presented to a Nicaraguan health clinic, complaining of headache, anorexia and liver pain, dengue would have been at the top their list. Lesson: A travel history can make or break a diagnostic conundrum. Think of tropical illnesses in returning travellers. Yvonne made a full recovery. However, she never lost the travel bug. Note: Report written with Yvonne’s permission

Casebook of a Community Internist

All in the family

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Blog Author

Hector Baillie

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