Cautionary Tales for the Physician

By Peter Drew M.D.

This book provides in verse an A-Z of unusual cases which have challenged the author over a period of more than 40 years. Some are exotic, some tragic, some embarrassing, some triumphant, but all are recorded as they happened.

This book presents each case in verse with anecdotes, often amusing, to explain what really happened. The explanations which follow, in prose, will enable the reader to learn about some very rare cases and thereby share the learning experience.

Above all, this book is meant to convey the joy of medical practice, with new challenges just around the corner ready to test the unwary.

• Language: English
• Publisher: Troubador Publishing Ltd
• Release date: Jul 28, 2023
• ISBN: 9781805145950

Peter Drew M.D.

Peter Drew qualified in medicine in 1977. In 1986, he was appointed consultant renal physician in Wrexham, North Wales, where he worked for 31 years. After retirement in 2017 he worked for several years in rural New Zealand as a general physician and now continues working part-time in Wrexham supporting the local renal service.

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Copyright © 2023 Peter Drew M.D.

The moral right of the author has been asserted.

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.

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To Bob C,¹ and the two Franks,²,³

In memoriam, and with my thanks.

REFERENCES AND NOTES

1 Robert Donald Cohen (1933–2014), professor of medicine, the London Hospital Medical College.

2 Francis Patrick Marsh (1936–2011), consultant physician and nephrologist, the London Hospital.

3 Frank John Goodwin (1938–1987), consultant physician and nephrologist, the London Hospital.

He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.

Sir William Osler

Let me give you this advice:

Examine once, examine twice,

Examine from the head to toes

Before you dare to diagnose.

More harm is done because you do not look,

Than from not knowing what is in the book.

Zeta

(Sir Zachary Cope, an earlier proponent

of the use of verse in medical instruction)

INTRODUCTION

This book is meant to be read for fun but I hope that those who persevere will find profit as well as pleasure.

There are twenty-six chapters arranged in alphabetical order. Each chapter contains some verse, followed by an explanation, perhaps some additional, and often quirky, information, and some lessons learned. The chapters detail unusual cases, most of which came under my care over a period of more than forty years. I have tried to report the cases accurately, and to avoid the historian’s supernatural talent of changing what has already happened. I have, however, changed the names of the patients and sometimes their occupations, to preserve anonymity.

No doubt some of my peer group will guffaw at the delayed diagnoses, the missed diagnoses, the wrong diagnoses, and the firm assist I needed from my registrar to make another diagnosis, as well as the gaps in my basic knowledge, but each case that I present has taught me a lesson (or two) and I hope others might learn from my experiences.

Nearly all the cases in this book were presented by me at learned meetings, or published in peer-reviewed journals over the years, and I have had recourse to my original PowerPoint presentations and acetate slides to check on detail. This has been useful, as in the rare case where I have wanted to check some fact in the original notes I have either had to trawl through endless pages of microfilm, or worse still find that a deceased patient’s notes have been culled with no remains, or even worse, that my notes have been culled and endless fluid balance charts have been retained!

I took to presenting cases in rhyme over thirty years ago. I had a great case to present (Alf) and was wondering how best to develop a quite complex clinical story without losing the attention of the audience. At the time, I was attending a national meeting listening to a talk on an immunological subject and I am ashamed to say that my mind had wandered, and I lost the thread of the talk (which was not difficult). I started jotting down bits of doggerel about Alf and then took the subject seriously and wrote the case up in rhyme, memorised it, and delivered it in verse without notes. I found the process an excellent way of getting to grips with a topic. A lot of reading was required to put the subject in verse but, once memorised, and especially after the adrenaline of a delivery without notes, the detail stuck. The process also gave me a lot of enjoyment and I have increased my interest in poetry along the way. I hope that shows in the later poems, where I have paid more attention to iambic pentameter and other styles. In fact, some of the lines are very good but many of you will realise that I have lifted these from the masters like Shakespeare, Belloc, Pope, Tennyson, Browning, Kipling, Keats, Yeats, Hayes and above all, Byron, with little change and scant recognition.

I mention that most cases were under my care. There are two exceptions. Surekat was dead when I first saw him, of that there was no doubt. But the manner of his demise taught me a lesson that has stayed with me for nearly forty years and one that I remember every time I prescribe steroids. ‘Bread of Heaven’ is a poem about a condition that I suspect is common on the world stage but I have never seen (knowingly).

However, I have seen a lot of bizarre cases over the years, in London, Essex, North Wales and New Zealand, and some of them are presented here. I hope you find the alphabet entertaining. I hope they also convey the amazing variety and constant surprises that come with medicine, which has made it such a fabulous career.

I have of course worked with some fantastic colleagues in the management of these patients, some of whom have done the heavy lifting, and some of whom have dug me out of deep holes of my own making. I am grateful to them all, and to those who have read and corrected proofs of this book. These groups include Dr John Barnes FRCP, Dr David Levine FRCP, Professor John Monson FRCP, Professor Terry Feest FRCP, Professor Sir John Cunningham FRCP, Dr Paul Altmann FRCP, Mr Alan de Bolla FRCS, Dr Eleri Edwards FFARCS, Dr Jenny Jamieson FFARCS, Dr Les Gemmell FFARCS, Dr Andy Campbell FFARCS, Dr Campbell Edmonson FFARCS, Dr Sam Sandow FFARCS, Dr Chris Littler FFARCS, Dr David Southern FFARCS, Dr Victoria Scott-Knight FFARCS, Mr Nilesh Makwana FRCS, Mrs Linda de Cossart FRCS, the late Mr Gwyn Evans FRCS, Dr Peter Humphrey FRCP, Dr Mark Doran FRCP, Dr Clive Williams FRCPath, Dr Gareth Davies FRCPath, Dr Chris Rincon FFARCS, Dr David Watson FRCPath, Dr Lally de Soysa FRCP FRCPath, Dr Brian Rodgers FRCPath, the late Dr Peter Needham FRCPath, the late Dr Tony Caslin FRCPath, Dr Mared Owen-Casey FRCPath, Mr Chris Roseblade FRCOG, Dr Vaughan Jones FRCR, Dr David Parker MRCP FRCR, Mr Bill Taylor FRCOG, Dr Sally Meecham-Jones FRCR, Dr Richard Cowell FRCP, Dr Syed Hussain FRCP, Dr Ibrahim Fahal FRCP, Dr Julia Platts FRCP, Dr Lim Hooi Leng MRCP, Professor Stephen Riley FRCP, Dr Bhanu Prasad FRCPC, Dr Aled Lewis FRCP, Dr Judith Welham MRCP, Dr Ines Held MRCP, Dr Stuart Robertson FRCP, Dr David Glover FRCP, Dr Ben Thomas FRCP, Dr Vijaya Ramasamay FRCP, the late Dr Frederick Lees FRCP, Professor Peter Lepping FRCPsych, Dr David Child FRCP, Dr Chris Duffy FRACP, Dr Graham Wilson FRANZCO, Dr Stuart Mossman FRACP, the late Dr Chris Cefai FRCPath, the late Dr Martin Wood FRCP, the late Mr Ali Bakran FRCS, Professor Robert Sells FRCS, Dr Steve Waldek FRCP, the late Dr Lindsay Morrison FRCP, Mr Ajaib Soorae FRCS, Dr Ian Casson FRCP, Dr Ros Quinliven FRCP, Dr Helen Hughes FRCP, Dr Khalid Khan FRCP, Professor Rod Stables FRCP, Dr Geraint Owens FRCP, Dr Phillip Minchom FRCP, Dr Elizabeth Silverstone MRCP FRCR, Professor Mike Dillon FRCP, Professor Isky Gordon FRCR, Mr Mick Crumplin FRCS, Dr Olwen Williams FRCP, Professor John Harvey FRCP, Dr Jecko Thachil FRCPath, Dr Robin Davies MRCP MRCGP, Dr Richard Moore FRCP FRACP, Dr Iain Keeping FRCP and the late Dr Mark Chaput de Saintonge FRCP.

I am grateful to BMJ Publications, Elsevier, and the Massachusetts Medical Society for allowing me to use copyright material, and to the estate of Victor Noel Petty for permitting me to reproduce ‘Lord Tennyson’s Revenge’ in Chapter R, and ‘Aida’ in Chapter Z. The other poems I have included are, I believe, in the public domain.

The passage of time means that many of the patients included in this book have sought second opinions from a higher authority, but those who survive, and who I have been able to trace, have given their approval for publication.

The Alphabet

A

Apopleptic Alf

A Super Case of Acute Renal Failure

Let’s start with Alf, a man near sixty years,

Urgently referred by one of my peers,

With renal failure that was quite severe.

K of 7, disproportionate urea,

For what was a modest elevation in

The serum phosphate and creatinine.

Figure 1: Blood results at the time of referral.

But first, let me tell you more of the history,

Which explains why this case was such a mystery!

This man presented back in May

That’s almost six months to the day

Before this renal indiscretion.

His problem then was left chest pain,

And the diagnosis was quite plain,

Either pulmonary infarction or infection.

A V/Q scan was promptly done,

Mismatch seen where there should be none,

And that clinched the diagnosis.

Heparin and warfarin were provided,

The pleuritic pain then subsided,

And there was no further thrombosis.

The only point left for debate,

Was how long to anticoagulate,

In the absence of risk factors.

Some said three months, some said more,

Six months was agreed, just to be sure.

That seemed like safe practice.

He was seen again at the end of time,

And all was well, and he felt fine,

And he had a normal urinalysis.

His U&Es were good,

And as things then stood,

Who’d think he’d soon need dialysis?

Well, he stopped the warfarin by request,

And for some five days retained his zest,

Before this next admission.

With sudden onset of left chest pain,

Pleuritic, just the same,

Except in a slightly lower position.

Well the admitting team knew the score:

One clot proved and now some more,

And they started heparin by infusion.

The left chest pain started to subside,

Then lightning struck on the other side,

Just to add to the confusion.

Well, the only thing left to do,

Was perhaps to repeat the V/Q,

Knowing that as things stood,

If repeat clot was proved,

Temporary treatments were eschewed.

It was anticoagulants for good.

Proof seemed quite elusive!

The scan was inconclusive,

Venography excluded calf vein clot.

And all the while the patient

Took on looks quite ancient,

Improvement like the last time there was not!

As poor Alf got gradually sicker,

His blood was found to be stickier,

But there were no signs of a monoclonal band.

Then urinalysis was repeated,

Blood and protein found secreted,

And the answer looked quite close at hand.

Figure 2: Gross elevation of plasma viscosity but negative screening tests for myeloma and vasculitis.

This looked like a nephritis.

Systemic features argued vasculitis,

And treatment was started straight away.

Steroids, saline and resonium,

The latter given per rectum,

He seemed a good deal better the next day.

Alas, he remained oliguric,

And for a short time was anuric,

And the potassium continued in its rise.

Bladder drainage seemed complete,

By now he was salt and water replete,

But urine microscopy really gave surprise.

You see, there were simply fistfuls

Of uric acid crystals.

Figure 3: Uric acid crystals in the urine can have various shapes, such as the rhomboids in the left frame above, barrel shapes, or rosettes of the needle shapes seen on the right in the ‘fields of corn’ aspirated from the thumb of an elderly lady with acute tophaceous gout.

This proved a real mystifier,

And I had to turn to Gottschalk and Schrier.

Figure 4: Diseases of the Kidney, edited by Carl Gottschalk and Robert Schrier.

It seems that radiocontrast causes uricosuria,

And urate with contrast in tubules leads to oliguria,

And three days before Alf had bilateral venography

And the exact diagnosis was shown on plain radiography.

Figure 5: The plain abdominal X-ray (left panel) suggested delayed excretion of contrast, which was confirmed by a CT cut that same day (right panel). Nowadays a full CT scan would have been done.

The films showed persistent contrast,

And what should have been removed fast

Has stayed in the nephrogram phase.

The radiologist, doubtful (and fearing litigation),

Took a CT cut and to his consternation,

Proved the Hounsfield count was raised.

But let me tell you this,

As you ponder the likely twist,

If his thoughts had not been so low,

We would not have been so slow,

To make the eventual diagnosis!

Two dialysis spins were needed,

And they rapidly succeeded

In reducing the potassium down to 4.

Alf promptly diuresed,

Of that we were quite pleased,

But then we did not know what we had in store.

The steroids we maintained,

Having not adequately explained

The improvement that was produced

Before dialysis was introduced.

This action proved to be wise.

Have you guessed the surprise?

With dialysis needed no longer,

His general condition grew stronger,

But just when our job seemed completed,

He became salt and water depleted.

Infusions were given with effect,

To remedy this homeostatic defect,

But when the saline was stopped,

His standing systolic pressure dropped.

This sequence left me quite vexed

About what tests to do next.

A former boss gave this advice

About conditions you seldom see twice.

Keep a book for such disease,

And learn from others’ expertise.

Watch how they have studied the data,

And these rare diseases detected.

And as you climb life’s escalator,

Watch out for the unexpected!

Well, I have kept a book

And so I took a look

And there written on page one

Was an answer to this set of clues,

The disease of Addison!

Figure 6: Keep a book of unusual and difficult cases.

Now, well should I remember this

Major diagnostic abyss,

Into which I fell before.

Because the entry here was my own,

Another patient who was known

To be sick with uraemic pallor.

With each dialysis session,

He gave the impression

That fluid he tended to booze.

But with ultrafiltration his blood pressure crashed,

And as a result each dialysis was dashed,

And his pallor he started to lose.

The increasingly pigmented look

That we clearly mistook

For under-dialysis was later discerned,

To be melanin-based,

From excess ACTH.

Thrice weekly that lesson was learned!

With memory refreshed it was quick to the phone,

Prednisolone changed to dexamethasone.

Synacthen was given,

The response was slight,

And Thomas Addison took over from Richard Bright.

Figure 7: The short Synacthen test showed very little response from the adrenals to intravenous Synacthen.

Now, what caused this condition?

That left us perplexed.

But CT scan repetition

Showed the glands apoplexed!

Figure 8: CT scan showing haemorrhage in both adrenal glands (arrows).

That’s blood and not tumour, of that we’re quite sure.

It’s haemorrhagic struma that’s swollen the core.

Fortunately the heparin we’d stopped,

Having found no lung clot,

And now we had to construe

That our failure to prove

Was because the clot

Was in an odd spot!

Well, who’d believe his next complaint

Was of right pleuritic pain and a faint

Trace of blood in the meagre spit,

And a loud pleural rub that hit

The ears as if to say,

‘Pulmonary infarction has come back to stay.’

Well, by this time we knew the ropes

And Alf found his way to isotopes,

Where the perfusion scan showed a defect wide,

And a ventilation mismatch on the same side,

And all we needed to implicate

Further clot, and a need to anticoagulate.

Now, William of Ockham¹ would decree

One diagnosis, and I’ve got three!

But if iatrogenic problems I withdrew

Then I’m only left with two.

Because I think it would be fair to say

That saline depletion led the way

To contrast-mediated renal shutdown,

And it was aldosterone lack which caused that rundown.

And it would be reasonable to imply

That saline infusion did rectify

This salt-barren state that we would expect

With Addison’s, and when oliguric, we could not detect.

But it still seemed odd to have these two

Uncommon diagnoses in a gentleman who

Until very recently was quite sound.

So, I re-read my book and on page two I found

A disease that has only recently been known:

The anti-phospholipid antibody syndrome!

Figure 9: Page two of that book supplied an answer.

Now, this disease, which fits the slot,

Is known to predispose to clot.

Recurrent thrombo-embolism is well known,

In fact it is the sine-qua-non.

And now it seems there is an association

With Addison’s disease, by direct causation.

The hallmark of this condition

Are antibodies raised by perdition

Of normal regulation agin

Phospholipid and cardiolipin.

Figure 10: The results of tests for anti-cardiolipin antibodies.

But wait, I hear you say, the adrenal diagnosis

Was haemorrhagic infarction and not thrombosis.

Now, who here would see my thesis rubbished?

Well, just wait, you toads, till you see the loads

Of cases which others have published.

Now Siu² and Yap³ and Walz⁴ and Rao,⁵

Have shown in their various papers how

The APA syndrome and Addison’s disease

Fit together with commensurate ease.

Adrenal masses are usually proved,

And in the odd case where they have been removed,

Haemorrhagic infarction may have destroyed the gland,

But adrenal venous thrombosis is close at hand.

And now the matter is up for debate

As to how the gland gets into this state.

Is haemorrhage first, after anticoagulation?

Or is back pressure, from venous thrombosis, the perturbation?

All I can say is that Alfred is well

His appetite is good, his belly is starting to swell,

His viscosity has fallen, he’s had no more chest pain,

And his adrenals have shrunk towards normal again.

Acute kidney injury due to a combination of contrast-media toxicity and volume depletion, the latter due to Addison’s disease caused by apoplexy of the adrenal glands as a result of the anti-phospholipid antibody syndrome. Recurrent pulmonary thromboembolism.

Alf was referred with acute kidney injury, oligo-anuria and life-threatening hyperkalaemia.