Uncontrollable vomiting, convulsions and megaloblastic anemia

In July 1996 a 43-year-old illiterate Hispanic woman presented with uncontr ollable vomiting, palpitations and confusion. In 1994, despite several hosp italisations in other medical centres where a cerebral CT-scan, oesogastrod uodenoscopy, colonoscopy and abdominal ultrasound were performed, no satisf actory diagnosis could be found. A psychiatric origin was finally considere d. On admission, the laboratory findings showed severe metabolic alkalosis wit h associated hypokalaemia, confirmatory evidence of vomiting. The ECG showe d tremendous P waves (5 mV) in the standard derivations, which can be expla ined by the hypokalaemia, with multiple supraventricular extrasystoles. Ech ocardiography and pulmonary scintigraphy ruled out pulmonary hypertension a nd a pulmonary embolus. After additional discussion with her daughter we discovered that the patien t had been treating chronic headaches for years with 4-5 Cafergot-PB suppos itories per day. This drug contains 2 mg ergotamine tartrate, 100 mg butalb ital, 100 mg caffeine and 0.25 mg belladona alkaloids. As is known, vomitin g is a classical symptom of ergotamine intoxication. After rehydration we d iscovered 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 establis hed 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 !.