title: [Intractable vomiting, convulsions and megaloblastic anemia: anamnesis, key to diagnosis].
abstract: In July 1996 a 43-year-old illiterate Hispanic woman presented with uncontrollable vomiting, palpitations and confusion. In 1994, despite several hospitalisations in other medical centres where a cerebral CT-scan, oesogastroduodenoscopy, colonoscopy and abdominal ultrasound were performed, no satisfactory diagnosis could be found. A psychiatric origin was finally considered. On admission, the laboratory findings showed severe metabolic alkalosis with associated hypokalaemia, confirmatory evidence of vomiting. The ECG showed tremendous P waves (5 mV) in the standard derivations, which can be explained by the hypokalaemia, with multiple supraventricular extrasystoles. Echocardiography and pulmonary scintigraphy ruled out pulmonary hypertension and a pulmonary embolus. After additional discussion with her daughter we discovered that the patient had been treating chronic headaches for years with 4-5 Cafergot-PB suppositories per day. This drug contains 2 mg ergotamine tartrate, 100 mg butalbital, 100 mg caffeine and 0.25 mg belladona alkaloids. As is known, vomiting is a classical symptom of ergotamine intoxication. After rehydration we discovered a megaloblastic anaemia with a folate deficiency compatible with chronic barbiturate intoxication. Folate and iron supplementation allowed a rapid normalisation of the haemoglobin values. Five months after having stopped the Cafergot-PB, the patient was well and did not vomit anymore. The headaches were treated with chlorpromazine with a good result. Despite sophisticated technical means, the diagnosis could only be established after a thorough history taking. This message should be heard in times when high tech medicine tends to obscure the place of a good history taking!
authors.affiliation: Département de Médecine Interne, Hôpital Communal, La Chaux-de-Fonds.
authors.forename: M
authors.initials: M
authors.lastname: Schlaeppi
authors.forename: L
authors.initials: L
authors.lastname: Humair
authors.forename: A
authors.initials: A
authors.lastname: de Torrenté
mesh_terms: D000328:Adult; D000749:Anemia, Megaloblastic / Q000139:chemically induced*; D001463:Barbiturates / Q000009:adverse effects*; D002110:Caffeine / Q000008:administration & dosage / Q000627:therapeutic use*; D003937:Diagnosis, Differential; D004338:Drug Combinations; D004878:Ergotamine / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use*; D005260:Female; D006261:Headache / Q000188:drug therapy*; D006801:Humans; D008487:Medical History Taking; D012640:Seizures / Q000139:chemically induced*; D014839:Vomiting / Q000139:chemically induced*
chemical_list: D001463:Barbiturates; D004338:Drug Combinations; C037330:caffeine, ergotamine drug combination; D002110:Caffeine; D004878:Ergotamine
vernacular_title: Vomissements incoercibles, convulsions et anémie mégaloblastique: l'anamnèse, clé du diagnostic.