The Deadly Dinner Party: and Other Medical Detective Stories Read online

  The Deadly Dinner Party

  The Deadly Dinner Party & Other Medical Detective Stories

  Jonathan A. Edlow, M.D.

  yale university press

  new haven & london

  Published with assistance from the Louis Stern Memorial Fund

  Copyright © 2009 by Jonathan Edlow, M.D. All rights reserved. This book may not be reproduced, in whole or in part, including illustrations, in any form (beyond that copying permitted by Sections 107 and 108 of the U.S. Copyright Law and except by reviewers for the public press), without written permission from the publishers.

  Designed by Nancy Ovedovitz and set in Janson Oldstyle type by The Composing Room of Michigan, Inc. Printed in the United States of America.

  Library of Congress Cataloging-in-Publication Data

  Edlow, Jonathan A.

  The deadly dinner party : and other medical detective stories / Jonathan A. Edlow.

  p. cm.

  Includes bibliographical references and index.

  ISBN 978-0-300-12558-0 (alk. paper)

  1. Medicine—Case studies. I. Title.

  [DNLM: 1. Diagnosis, Differential—Case Reports. 2. Disease— etiology—Case Reports. 3. Epidemiologic Methods—Case Reports. 4. Infection—diagnosis—Case Reports. 5. Poisoning—diagnosis— Case Reports. WB 141 E23d 2009]

  RC66.E35 2009

  616.07 5—dc22 2009010830

  A catalogue record for this book is available from the British Library.

  This paper meets the requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper).

  10 987654321

  I have been blessed to find the love of my life, Pamela. She encourages my writing because she knows I love it. She edits my work to make it less obtuse. She supports me when there is a deadline—which is most of the time! But most of all, she makes waking up each day exciting and gives me peace and hope.

  Contents

  Preface ix

  Part One human meets pathogen

  1. The Deadly Dinner Party 3

  2. Everywhere That Mary Went 18

  3. The Baby and the Bathwater 34

  4. Rubbed the Wrong Way 46

  5. The Forbidden Fruit 58

  Part Two the external environment

  6. Two Ticks from Jersey 75

  7. An Airtight Case 88

  8. Monday Morning Fever 102

  9. The Case of the Wide-Eyed Boy 116

  Part Three the internal milieu

  10. A Study in Scarlet 131

  11. The Case of the Overly Hot Honeymoon 144

  12. Feeling His Oats 158

  13. The Case of the Unhealthy Health Food 170

  14. Little Luisa’s Blinding Headache 184

  15. Too Much of a Good Thing 197

  Sources 211 Index 237

  Preface

  Preface

  When I was a teenager, my mother gave me a paperback book called The Medical Detectives, by Berton Roueché. These stories had all been previously published in an occasional series in the New Yorker called the Annals of Medicine. I had never heard of the New Yorker back then, and I had no particular desire to pursue a career in medicine. But I do remember devouring these stories one after another, and being sad when each one was over and sadder still when I had finished the book.

  The volume was a collection of real-life medical mysteries—clusters of patients with odd symptoms, bizarre outbreaks of unusual diseases, and full-scale epidemics. The common thread was diagnosis, but not just any diagnosis. In each case, the solution proved tough to find. It was never a simple x-ray or routine blood test that made the final diagnosis, but doctors playing detective. Some physician or medical epidemiologist had to delve beneath the surface to find all the pieces and solve the puzzle. The first of these stories that I ever read was called “Eleven Blue Men.” As it turns out, I was not the only person who found this story fascinating; the television series House used it for its pilot episode.

  Another book that I read as a teenager was the Complete Stories of Sherlock Holmes. These yarns had the same effect on me, always making me wonder which facts would turn out to be clues and which were red herrings. I liked these stories and short novels so much that I reread the entire Sherlock Holmes canon as a college student.

  Part of the appeal in both sets of stories was their length—not too short and not too long. As an adult, my attention span is not much longer than it was when I was a teenager, and I liked being able to read these tales in a single sitting. The second element they had in common was the simple pull of any detective story: figuring out “whodunit” and following, at least in retrospect, how the hero, whether an epidemiologist or Sherlock Holmes himself, solved the puzzle. Last, each of these miniature mysteries had all the elements of any good story—plot, character, and setting. The writing placed the reader in the midst of the investigation, just like Dr. Watson, the sidekick to Holmes.

  Part of every doctor’s and epidemiologist’s job is to solve mysteries. Many are not so challenging. A patient consults a doctor because of fever and bloody diarrhea after eating undercooked hamburger. The doctor sends a stool culture and E. coli grows out. Case closed. Or a patient shovels heavy wet snow, develops chest pains, and comes to an emergency department. An electrocardiogram shows a heart attack. Another patient seeks medical advice in June for a low-grade fever and a large, unusual red rash over the abdomen at the site of a tick bite. It doesn’t take a Sherlock Holmes to diagnose Lyme disease.

  But sometimes, patients present problems that can be far more challenging. The clues lead to dead ends. The x-rays, blood tests, and CT scans are normal. Even smart doctors are unable to make a diagnosis. Or sometimes, they make a presumptive diagnosis, but the treatment fails. In these cases, the doctor becomes detective and the diagnosis can be as elusive as any criminal. Clues may not be so easy to find, sometimes because they are hiding out in the open, just as in Edgar Allan Poe’s “The Purloined Letter.” Sometimes doctors may call in the local public health epidemiologists to help with the problem. In other situations, if the scope of the outbreak overwhelms local resources, the Epidemiology Intelligence Service of the Centers for Disease Control and Prevention will be called in. Dr. Alexander Langmuir created this service in about 1950 when he began training a cadre of young physicians to become the country’s medical sleuths.

  The young men and women who work for this program today are available on a moment’s notice, suitcases prepacked, to respond to any outbreak of disease or epidemic in the United States. They are famous for what Langmuir called “shoe-leather epidemiology.” They solve cases the old-fashioned way, like the detectives in any good mystery story— by knocking on doors, interrogating witnesses, coming up with hypotheses, and then testing them.

  With this in mind, as an adult I began collecting my own medical mysteries and was fortunate enough to have Boston magazine and Ladies’ Home Journal publish some of them. I thank all the many individuals who made time to share parts of these stories with me.

  People necessarily have an anthropocentric view of the world, but even though we may be at the top of the food chain, that doesn’t mean we have dominion over the world or our environment. As Friedrich Nietzsche put it, “The human is by no means the crown of creation; every living kind stands beside it on the same level of perfection.” In fact, we share our planet with an uncountable number of other species, each one scratching out its own ecological niche.

  When humans fall ill to some virus or bacterium, it is simply the interplay between competitors in the same environment, each procreating and fulfilling its own bi
ological destiny. Several of the stories here may be classified as “human meets pathogen.” In “The Deadly Dinner Party,” a notorious bug makes its mark and turns a suburban meal into a disaster that almost claims its host. This case shows how a microorganism can strike, not through a direct assault on human beings, but by a toxin that it elaborates. A tale like this provides an extraordinary lesson about the history of the relationship between humans and our cohabitants on the planet.

  “Everywhere That Mary Went” exemplifies our struggle with another bacterium that has evolved such that Homo sapiens provides its only natural reservoir—hitchhiking, as it were, with our species. This is a story not only of an interesting outbreak of disease in the Catskills, but one about a malady that has had a major impact on human activities over centuries. “The Baby and the Bathwater,” another case of infection, is a detective story par excellence. It shows how epidemiologists think and how shoe-leather epidemiology (not to mention hunches and an occasional bit of luck) plays into the solution of a mystery.

  “Rubbed the Wrong Way” is a prime example of how the most mundane of human activities—personal hygiene—can lead to troublesome problems. Our microcosm becomes a bacteria’s macrocosm, where several square feet of our body surface is their entire universe. Rounding out the first part of the book, “The Forbidden Fruit” illustrates not only the connection between bacteria and humans but the considerably more complex interplay of other animals, microorganisms, and people, sometimes with catastrophic results.

  This last case introduces the importance of the world around us. Our relationship to nonliving parts of the environment is another category of exposure to illness. As fans of this genre will recognize, the title of the next story, “Two Ticks from Jersey,” pays homage to Berton Roueché, whose “A Pig from Jersey,” about trichinosis contracted from eating undercooked pork, was included in his original collection. In the tick story, we again see the ramifications of our life on a planet that we share with other creatures. Ticks have become increasingly important as vectors for a variety of diseases, mostly infectious. In this story, the lives of two little girls were in peril.

  A large part of our lives is work, and work can sometimes be dangerous. In “An Airtight Case,” a young executive was diagnosed with lung cancer. The odd thing was that his tumors seemed to wax and wane, and he was otherwise the picture of health. His physician was the detective who solved a mystery that baffled other doctors. “Monday Morning Fever” shows how a manufacturing process was central to the solution of a mini-epidemic in a small New England mill. This story is a classic example of how doctors see trees while epidemiologists see forests. Sometimes examining the commonalities in a group of cases helps to establish the diagnosis in an individual patient.

  But we do not even need to leave the house for the environment to invade our space; it’s everywhere. In “The Case of the Wide-Eyed Boy,” we see how even a ten-year-old can be the victim, and how an emergency physician’s sixth sense alerted him to the presence of an unusual problem that cracked the case.

  We must also remember that there are really two “environments”— the internal and the external. The famous French physiologist Claude Bernard first introduced the term “internal milieu” to the scientific lexicon in 1865, when he wrote that the internal environment, in this case the inside of a cell, must be maintained within certain constant parameters for the cell to survive. But whether we mean an individual cell or an individual organism, this principle remains true. The interplay between internal and external environments is yet another category for diseases in humans.

  In “A Study in Scarlet” (this time a nod to Sir Arthur Conan Doyle’s story of the same title), an alert infectious diseases specialist at a medical conference suspects an unusual cause behind an outbreak of disease in a quaint New Hampshire hotel: once again, an epidemiologist’s hunch plays a role in solving a colorful case. In another story, “The Case of the Overly Hot Honeymoon,” the patient’s brother (then a medical student) helped to unravel the mystery of why his sister could eat her footballplaying husband under the table without gaining weight. This is a classic case of the internal milieu gone haywire.

  In this day and age of food additives, irradiated fruits, genetic manipulation of crops, and fast food, eating healthily has become a near obsession for some. In “Feeling His Oats,” a former advertising executive from Connecticut starts a health-food diet and almost eats himself to death by following the instructions in a best-selling diet book. “The Case of the Unhealthy Health Food” presents a similar theme. A suburban housewife suspected of having cancer undergoes numerous invasive tests and surgical procedures, but her diagnosis proves elusive. A curious medical student with time on his hands finds that the problem is not a cancer but, paradoxically, comes from a product that the patient is taking to feel better.

  In “Little Luisa’s Blinding Headache,” a young girl nearly loses her vision from a health potion her grandmother had given to her with the best of intentions. The concoction contained substances that may be helpful at one dose but toxic at another. Finally, in “Too Much of a Good Thing,” children in the Boston area get sick from something that belongs to a rite of childhood. When adults in the area also become ill, doctors begin to put the pieces of the puzzle together at a local educational conference.

  The three categories of exposure to diseases are by no means simple and binary; they frequently overlap. Our world is a complex place; the interactions between host and environment (both external and internal) and pathogen can be equally complex. The lessons learned from these stories can help us negotiate this sometimes fragile relationship. My hope is that the reader will be able to profit from these stories through both their educational as well as their entertainment value.

  part one

  Human Meets Pathogen

  1 The Deadly Dinner Party

  The get-together began as an afterthought, recalls Pam Stogess, a fortythree-year-old city legislator from Kingston, New York, a town nestled between Catskill State Park and the Hudson River. “My husband, my daughter, and I were planning to go out for Mexican food. I asked our friend Steve Gelson to join us, but he invited us to his house to eat. Steve is a marvelous chef and had hosted a party the night before and had plenty of food left over. He said, ‘nothing formal, don’t get dressed up, just come over.’ My husband and daughter were set on Mexican, but I went to Steve’s. It was a totally last-minute affair.”

  Five other guests (the names of all persons in this story have been changed) attended the dinner party on Sunday, February 19, 1989: Miles Walsh, Steve’s business partner in an ad agency; Arthur Landry, vice principal of the local high school; his wife, Barbara Landry, co-owner of their family travel agency; Janie, their thirteen-year-old daughter; and her friend Sara, also thirteen. The meal included a homemade cheese ball, salad, a pasta casserole with sausage, sweet-and-sour meatballs, garlic bread, and wine, followed by coffee and homemade fudge cake.

  It turned out to be a memorable menu in more ways than one. “I doctored up the leftover pasta dish and made garlic bread out of pita slices,” Gelson recalls. “It was a relaxing evening; we talked a lot of politics. Pam and I are active local Republicans, and Art, a Democrat, had just been told he would soon be appointed to a city commission.”

  “It was very informal,” says Pam. “Steve arranged the food on the kitchen counter, and the adults ate in there. The girls took their plates into the living room and watched videos. We had a grand time, but it was a school night, so by 10 PM, we finished our coffee and the party was over.”

  By Tuesday morning, Pam knew something was wrong. “I was working in the kitchen; I looked up at something, and my eyes wouldn’t work right. I thought maybe I’d put my contact lenses in backwards, so I wen into the bathroom, cleaned and checked them, and put them back on. But things still weren’t right; it was like I was looking at my nose crosseyed. I figured I had the flu.

  “I phoned Steve’s office, because as trustees of the Ulst
er County YWCA, we had a noon meeting. His secretary told me he was home sick, and when I called him, his speech was slurred, and he complained of nausea. He said he wouldn’t be coming to the meeting. I said that I’d speak with him at dinner time and to let me know what he wanted and that I’d make it and bring it over to him.

  “By that evening [Tuesday],” Pam continues, “my eyes were worse and my speech had also become slurred. I was having trouble talking and remember having to form the words to get them out. I called Steve again that evening and he could hardly speak. Then the idea occurred to me that Steve and I had the same bug.”

  Still, Pam isn’t the panicky type and still wasn’t particularly concerned about her own health. She assumed that she probably just had a virus that would eventually run its course.

  “Wednesday morning, I started to drive to do some errands, but as I pulled out of the driveway, the street didn’t look wide enough for the car, so my husband drove me. When I went to sign a check, I couldn’t find the right line. I was trying to hold some toothpicks but kept dropping them. It was odd. I was having perceptual problems and it gave me a whole new perspective on how handicapped people must have to deal with the world.”

  By Thursday morning, Pam felt so feeble “that it was all I could do to walk, my legs were so weak. By now I was getting nervous, and I’m not the nervous type. My husband and I own a funeral home, and the prospect of death doesn’t frighten me. I remember telling my husband, ‘I think I’ve had a stroke,’” Pam recalls. “I felt intoxicated and totally out of touch perceptually. I telephoned Steve’s house and there was no answer. I called his secretary, who told me he’d gone to Kingston Hospital. That’s when I thought, ‘My God, maybe someone else has it.’ I called Art Landry’s house.

  “Janie picked up and said her dad couldn’t come to the phone; he was sick and couldn’t speak. Janie and Barbara were fine, though. By now, I was having difficulty swallowing, chewing, or even moving my tongue. I called Dr. Mauceri, Steve’s doctor, and told him about Art and me. He said we should both come to the emergency department at Kingston City Hospital [where Steve was being evaluated] for tests.”