The Unreal World: It’s a bird, it’s a pain, it’s gout
“Royal Pains”
10 p.m. Aug. 12, USA
Episode: “Whole Lotta Love”
The premise: A North Dakota couple, Roy and Ginnie, win the lottery and buy a mansion in the Hamptons on Long Island. After they arrive, Ginnie develops a rash and seeks the help of concierge doctor Hank Lawson ( Mark Feuerstein), who determines that she’s allergic to her fake gold jewelry and treats her with hydrocortisone cream.
In the meantime, Roy has developed a red swollen wound on his wrist. At first Dr. Hank believes a flesh-eating bacteria is to blame, and he treats the wound with an intravenous antibiotic. When the wrist worsens and Roy develops a cough, Dr. Hank decides that Roy has contracted a psittacosis infection from the couple’s pet macaw. He changes the antibiotic to oral tetracycline, but Roy’s wrist remains painful and swollen. At this point, Dr. Hank sticks a needle in the wound and withdraws synovial fluid from the joint. The fluid is found to contain needle-like crystals (birefringent), and Dr. Hank decides that Roy has gout, caused by excess uric acid that crystallizes in the joints. He tells Roy that the gout has been precipitated by eating the rich party food of the Hamptons, and he places Roy on the drug allopurinol for treatment.
The medical questions: What are “flesh-eating” bacteria, and are the wounds they cause easily treatable with intravenous antibiotics? What is psittacosis? Can you contract it from a macaw, would it cause a cough and a localized skin infection, and is it treatable with tetracycline? Does gout commonly involve the wrist, and could it cause a wound? Is it diagnosed by looking for birefringent crystals under the microscope? Would acute gout be treated with a change in diet as well as allopurinol?
The reality: Flesh-eating bacteria cause the infection known as necrotizing fasciitis that affects deeper layers of the skin and the fat and tissue covering the muscles. The infection can lead to pain, swelling, redness, a drainage of pus from the wound and fever. It can be caused by several kinds of bacteria, including streptococcus, and is indeed treated by intravenous antibiotics. Because such an infection can quickly spread and become life-threatening, it should always be treated in the hospital, says Dr. Shawn Skerrett, professor of infectious diseases and pulmonary medicine at the University of Washington. One out of four patients with this infection die of related complications. The key is aggressive surgical removal of dead tissue.
Psittacosis is an infectious disease of birds caused by the Chlamydia psittaci bacteria. It can be spread to humans through the air from feces, urine or respiratory secretions of infected birds of any type, including a macaw, Skerrett says. Human cases often result from contact with psittacine birds (parrots, macaws) that are kept as pets, and the patients are treated with tetracycline. Psittacosis most commonly causes a cough and an atypical pneumonia, Skerrett says, along with fever, headache and muscle aches. Skin rashes can occur, but according to Skerrett, a localized skin infection producing a swollen wound “would be very unusual.”
Acute gout attacks occur when uric acids form crystals in the joints. Gout can affect the wrist, though not nearly as commonly as the feet, especially with first attacks, says Dr. David Wofsy, chief of rheumatology at the San Francisco Veterans Affairs Medical Center. Gout can cause severe swelling and discoloration and resemble a soft tissue infection, Wofsy says, but a first attack would not be expected to cause significant skin breakdown or resemble an open wound.
Acute gout is diagnosed by identifying the needle-like crystals that appear under a polarizing microscope, says Dr. Rodanthi Kitridou, professor of rheumatology at USC.
Acute gout is treated with anti-inflammatory medications (colchicines, steroids or non-steroidal drugs such as ibuprofen), Wofsy says, in order to end the attack. “Neither dietary changes nor a urate-lowering drug like allopurinol would be used to treat an acute attack but would only be considered afterwards, with the goal of lowering serum urate levels and reducing the risks of subsequent attacks.”
Dr. Hank’s flashy, impulsive actions have some basis in fact but reside mostly in the world of risky medical fiction. No competent physician would treat a seemingly life-threatening infection outside the hospital, blindly treat presumed psittacosis just because a bird was nearby or jab a needle into a patient’s joint to diagnose gout at a party. A real patient could easily be misdiagnosed or even die under the hands of such a doctor.
Siegel is associate professor of medicine at New York University’s Langone Medical Center. In the Unreal World, he explores the medical reality of fictionalized TV and film.
marc@doctorsiegel.com