Robert J. Littman

Hellenic Holocaust: A historical clinico-pathologic conference

The traditional clinico-pathologic conference (CPC) begins with a case presentation. Next, a clinician analyzes the clinical information, illustrating the diagnostic process and proposing one “best-fit” diagnosis for the anonymous (and often dead) patient. Finally, a pathologist presents the actual autopsy or histologic findings, either validating or rejecting the clinician’s diagnosis. This “historical” CPC differs from the traditional CPC in two ways: first, we have no all-knowing pathologist to deliver a final answer, and second, we are challenged to name the patient. CASE PRESENTATION Fever, headache, sore throat, and vomiting developed in a 65-year-old man. He had been in excellent health until approximately 1 week earlier, when he had sudden onset of headache, ocular erythema, and halitosis. On the third day of illness, he began to sneeze and cough, and noted bilateral pleuritic chest pain. On the sixth day, he developed projectile vomiting of dark, bilious fluid. At this time, he complained of fever so intense that he would not allow himself to be covered with even the lightest clothing. He also complained repeatedly of intense thirst. Although he drank copious amounts of water, his thirst persisted, worsened by frequent vomiting. The patient had no history of major illnesses. He drank wine in moderation and did not use tobacco. He was taking no medications and had no known allergies. The patient was a resident of Athens, where he had lived his entire life, except for brief excursions throughout the eastern Mediterranean. He spent his early years in military service. In recent years, he had devoted himself to politics. He was married and both of his children by this marriage, sons aged 30 and 25 years, had died recently of illnesses similar to his own. Another son (by his mistress), aged 10 years, was alive and well. The patient’s father had died in battle at age 47 years; his mother’s history is not known. His sister had recently died while in her mid sixties of an illness similar to that of the patient. The condition of his brother, who was approximately 60 years of age, is not known. A similar illness simultaneously afflicted many of the patient’s fellow Athenians. The epidemic began about a year earlier, 1 year after the outbreak of hostilities with a neighboring city. Although enemy forces had besieged Athens continuously during this period, their troops do not appear to have been affected by the illness. Refugees entering the city from the surrounding countryside, however, were quickly affected. The disease attacked all age groups and socioeconomic strata, with the highest incidence among physicians and other caregivers. The illness, which was reported to have originated in subSaharan Africa, had not been seen in Athens before the current epidemic. It was believed to have entered Athens through Piraeus, the city’s port. Much of the eastern Mediterranean was also afflicted with the disease. The epidemic had waxed and waned since its appearance, with no apparent seasonality. Of those who contracted the disease, approximately one quarter died. Persons who recovered were immune to further attacks of the

AIDS and AAA in Egypt

7. Miller RL, Armelagos GJ, Ikram S, de Jonge N, Krijger FW, Deelder AM. Paleoepidemiology of Schistosoma infection in mummies. Br Med J 1992;304:555-6. 8. Capron A, Dessaint JP, Capron M, Ouma JH, Butterworth AE. Immunity to schistosomes: Progress toward a vaccine. Science 1987;238:1065-72. 9. Gryseels B, Stelma FF, Talla I, van Dam GJ, Polman K, Sow S, et al. Epidemiology, immunology and chemotherapy of Schistosoma mansoni infections in a recently exposed community in Senegal. Trop Geogr Med 1994;46:209-19. 10. El Alamy MA, Cline BL. Prevalence and intensity of Schistosoma haematobium and S. mansoni infection in Qalyub, Egypt. Am J Trop Med Hyg 1977;26:470-2.