CASES; Is There a Barber in the House?
By LARRY ZAROFF, M.D. and JONATHAN ZAROFF, M.D.
Published: December 19, 2006
Attention is paid to hair.
In our culture the hair industry is huge -- shampoos, conditioners, coloring, cutting, shaping, styling. For ''hair-loss treatment'' alone, Google conjures up 749,000 references. Some people undergo surgical procedures, sometimes uncomfortable and expensive, to implant hair.
Total hair loss is often an unfortunate and undesirable complication of the agents used to treat and cure cancer. Yet baldness -- the hairless look -- can for some represent spirituality and religion, or for others may suggest that they are athletic, smart, cool, reeking of testosterone.
Depending on where you are in your life, what you are doing, your age and sex, baldness is loved or hated -- or just accepted. Baldness can be bought and bought off. But it is not a medical treatment, at least not since shaving the head for lice was stopped.
In one patient, however, shaving the head was life saving.
A 50-year-old woman was admitted to the hospital with complaints of severe weakness and difficulty breathing. She had been quite healthy until the afternoon of the admission, with no history of serious illnesses.
The doctors at the university hospital where she became a patient are known for using their brains. They also use their stethoscopes wisely, and observe closely how a patient looks.
On examination this one was sweaty and had pinpoint pupils, and her lungs were wheezy. But unlike physicians of centuries ago, doctors today do not regularly use their noses. (In the 18th century, doctors could make diagnoses of kidney failure, diabetes and liver disease by smelling a patient.) For this woman, the diagnosis remained obscure for the next hour as her breathing got more labored and she became comatose.
A tube was placed in her windpipe and she was attached to a breathing machine. Then an experienced nurse, with good sense and a good sense of smell, came to the rescue. The nurse noted that the patient had a peculiar odor, resembling garlic, most prominently from her hair. The unusual odor raised the suspicion of insecticide poisoning with organophosphates.
The patient was immediately treated with atropine and 2-PAM to reverse the effects of the poison, while blood was sent to the lab to verify the diagnosis. Each time she received the medications she woke and improved, but then lapsed back into a coma with increasing lung problems. Her skin was washed and her hair was shampooed several times with no lasting improvement.
Since the primary contamination seemed to be in her hair, her head was shaved. After that she improved rapidly, her medicines were tapered and she regained consciousness. Soon she was able to breathe on her own.
The lab reports verified that the nurse had been correct. The patient had been poisoned with an organophosphate insecticide. Now her doctors wondered, How did her hair become impregnated with insecticide in quantities to bring her to the brink of death? This was no casual exposure. She denied a suicide attempt -- swallowing would have been more direct. Nor could it have been attempted murder -- there are easier ways to administer poisons more covertly.
The answer came from the patient when she fully awakened. She remembered exactly what she had done before becoming ill: her usual activities, except that she had gotten her hair shampooed by a neighbor.
The neighbor, when contacted, was willing to bring in the shampoo. Chagrined, she showed up shortly, bringing two containers. One held shampoo. The other, a similar jug, contained an organophosphate insecticide. Both receptacles were the same size, the labels old and blurred.
I must have used the wrong one, she said, when told that her friend was just recovering from insecticide poisoning.
Organophosphates have a bad reputation, and quite correctly. They are extremely dangerous, even in small amounts, and are easily absorbed through the skin as well as the lungs. They poison an important enzyme, acetylcholine esterase, without which acetylcholine accumulates in the body, disabling muscles and nerves and important centers in the brain.
Organophosphates are frequently used in agriculture as an insecticide. Studies suggest that each year, there are 18 cases of pesticide-caused illness for every 100,000 American workers. In gaseous forms, like tabun and sarin, they can also be deadly biological weapons. Sarin was used by members of the Japanese cult Aum Shinrikyo in the Tokyo subway attack of 1995.
In this case, the patient recovered well, after the correct diagnosis by a nurse with a sensitive nose, proper treatment with drugs and the elimination of the insecticide by balding.
Photo (Illustration by Viktor Koen)