Close encounters of the first kind
I cannot help but compare director Steven Spielberg’s Close Encounters of the Third Kind to treating a case for the first time and wondering what it really is, where it came from, how did it appear and why it happened.
This movie by Spielberg is ultimately an inspiring, optimistic story with themes of perseverance and humility, but it has many scary, spooky moments before the aliens' exact nature is revealed.
Similarly, a new and difficult case in one’s practice is always uplifting and can stimulate one’s brain, encourage one to read more, do research and persevere until one ends up with a precise diagnosis.
In Close Encounters, a mother, Jillian, is horrified when her toddler son Barry disappears, becoming the captive of unknown entities. This is just like the long process of observing a patient and prescribing medications but when all seem to fail, the physician undergoes the horror of realizing that he or she is dealing with the unknown.
Recently, a doctor was referred to me for diagnosis and management. Her uncle was a luminary in the field of surgery, so I was compelled to find a cure for whatever was ailing her. A year before her admission she had an episode of severe urticaria after taking azithromycin, but it went away. Then, a day before she was admitted, she was taken to the emergency room and had another episode of severe urticarial rash, this time with fever, was given a steroid intravenously but shifted to an oral steroid, together with an antihistamine and another oral medication (a leukotriene receptor antagonist — LTRA — Montelukast).
Her urticaria, however, still evolved, increasing in number and even causing swelling of the eyelids. So I decided to put her back on intravenous steroid injections; this time another antihistamine was added. I also noted the hoarsening of her voice and coughing, so I suggested a referral to an ENT or infectious specialist for further evaluation, as her complete blood count was abnormal, too. I hesitated to do a skin biopsy as I thought it was a simple case of urticaria.
So, lesson learned: do not hesitate to do tests, no matter if you think of the diagnosis as simple, because just in case your management does not work, you will always have a fallback.
At the time she was admitted I was considering neutrophilic urticarial, which is really difficult to manage because this particular urticaria does not respond to antihistamines or steroids and usually a biological — which is not yet available in this country — is what is needed. But I did not rule out that she was also probably having a reaction to the drug Montelukast, whose common side effects include the following: swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, hoarseness, itching, rash, hives, fever, flu-like symptoms, pins and needles or numbness in the arms or legs, pain and swelling of the sinuses.
Luckily after two days she was better and she was eventually discharged (prayers really work). The case is closed as of this writing and I’m hoping that her skin rash does not return.
The second case is JD, a diagnosed case of tuberculoid leprosy from Pangasinan, which is endemic for such a disease. He was treated with anti-leprotic drugs but unfortunately developed a reaction after taking them for 10 days, and so was told to stop. After the rashes faded he was asked to take them again, but when a similar rash reappeared, he was told to discontinue his medicines.
At the time of the reaction his lesions was described as few reddish itchy patches bizarrely shaped and distributed throughout his body. I gave him medicines to address his relapse and on follow-up the rashes eventually abated except for a reddish nodule on his left arm, which became bigger. Histopathology results revealed leukocytoclastic vasculitis — probably drug-induced.
There was no evidence of leprosy but I still did another test to further rule it out, which turned out to be negative as well. I also gave a topical cream that would eventually flatten the nodule on his left arm but if it does not flatten then I have no option but to do another test. But clinically speaking, I think the patient does not really have leprosy.
The third case is AH, a demure, 55-year-old lady who was sporting what seemed to be a scarf wrapped around her head. She had been to several dermatologists and for three years her hair failed to grow fully. She has a scalp that is almost without hair except for a few strands left on her hairline and some in the middle. According to her she is so depressed because she used to have a head full of dark-colored hair and hair loss was never really a problem.
She refused to do a biopsy to rule out whatever was really her problem, so I went ahead and treated her. Clinically her problem seemed to be alopecia areata (poknat in layman’s terms) and also maybe menopausal thinning or female-pattern hair loss. Since the management is almost the same, I went ahead with the procedure. After four months her hair was back with a vengeance and the smile on her face was beyond words. She was so happy that she referred another patient but with the more difficult problem of frontal fibrosing alopecia (FFA), which requires a maintenance treatment for it not to progress. But this friend of hers is also okay now except that compared to AH, her hair grew but not as thickly, because FFA is really a more complex and obstinate entity to treat.
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