© 1999 by European Society of Cardiology
Copyright © 1999, European Society of Cardiology
A vicious backhand
Scientists and physicians from around the globe were drawn to scientific sessions held in Chicago in the fall of 1997. Prospects for an excellent learning experience were high. For Theodore Conrad, the meeting also offered an opportunity to meet with former post-doctoral trainees. Over dinner that evening he would dine with a contingent from South America: Jorge and Eduardo from Santiago, and Clovis and Felix from Sao Paolo. There would be much to discuss since they last had seen one another.
Seated in the restaurant of the headquarters hotel, Theodore listened with pride to their narration of scholarship achieved against a backdrop of tribulations not unlike those he would have expected in initiating basic and applied research studies in the States. But in addition, he learned about challenges of a kind quite unfamiliar to him. Issues, for example, related to a nation’s political and military infrastructure and their impact on the conduct of biomedical research. Undeterred, these clinician scientists had forged forward to achieve research objectives. Additionally gratifying was their involvement in population-based studies that addressed such issues as high altitude, cardiovascular risk and Chagas disease. Theodore was humbled by these recountings. Against such a backdrop, how could anyone in the States hope to make an educated assessment of the dedication and accomplishments of these individuals, working on another continent? Even more absurd a judgment would be one concerning their suitability for election into a U.S.-based academic society. Ah, the emptiness and bankruptcy of elitists, he thought.
"A remarkable set of achievements. You each have made an impact, and undoubtedly will continue to contribute substantively to our understanding of human disease and disability for years to come," noted Theodore. "Using the next millennium – now only months away – as an arbitrary target, we must rededicate ourselves to world health and to initiatives that will reduce human suffering."
"Many of your Conundra have emphasized this point for years now," remarked Jorge. "What’s the latest story you’re working on?"
"The topic is an important one," noted Theodore. "It was brought to my attention by a friend working in the medical examiner’s office here in Chicago. I would be honored to share it with you as we savor the remnants of this excellent 1995 Colchagua Valley Cabernet Sauvignon from the vineyards of Luis Felipe Edwards. Its bouquet and varietal flavors are excellent.
"However, before proceeding, I would note that these stories are merely a vehicle to deliver a message on a topic of worldwide importance. Community leaders such as yourselves need to become involved. Education is integral to the prevention of illnesses that challenge the public’s health."
Not even the bright easterly sun could keep Joel and his backhand from their appointed mission with Keith’s nasty serve. And this Saturday morning, August 13, 1994, was no exception. Keith Bradford lived next door to Joel and Harriet Singer in this fashionable suburb of north Chicago, lined with majestic oak trees. As was their custom each Saturday, weather permitting, Joel and Keith played a no-holds-barred game of tennis on the Singer’s court. Keith, a broker "downtown," thrived on intense competition. Joel, a successful dentist in the ’burbs, had been his match. Stride for stride, volley for volley, sweat band for sweat band, their game raged on for several hours. Pleasantly exhausted, they shook hands at center court and retired to the Singer’s screened-in patio for a pitcher of gin and tonic.
"So what’s new with the market?" asked Joel, still breathing heavily. "Industrials up and utilities down?"
"Don’t you wish!" replied Keith, knowing full well Joel’s financial portfolio. He wiped beads of sweat from his forehead and neck that rimmed a crown of curly blond hair. "With friends like you, who needs enemies?" he laughed. "By the way, I’m off to Puerto Rico in September for a little R and R. How about joining me? We can tear up the courts during morning hours, lounge poolside in the afternoon, and chase a few chickadees at night."
"Easy for you to say. You’re divorced," replied Joel. "Oh, hello, dear. What is the love of my life up to this fine morning?" he beamed as Harriet stepped onto the patio while easing the sliding door to a closed position. She wore a pure white, thigh length terry cloth robe splotched with embroidered yellow and red tulips, which covered her flaming pink, one-piece swim suit.
"I think it’s time for a swim while you two teenagers carry on with your fantasies," she replied, sauntering off to the pool. They both watched as she shed her robe and dove in.
"Still firm and fully packed," Joel sighed. He toweled his face and then sipped from his drink. "If only it weren’t for those ‘I’d rather nots’ and unpredictable mood swings."
"I know that story. That’s why I’m a free man again," Keith said. He gave Joel a knowing look. "Give that trip some thought."
"Maybe I can arrange something. Sounds like fun."
Duties at the office on Monday came all too quickly for Joel. Root canals, fillings and extractions had become such a bore, and his patients didn’t enjoy a moment of it. Ridden with guilt, Joel felt as if he were the minister of pain. Little wonder suicide rates were so high amongst dentists. Seated in his office, slowly browsing through the afternoon mail, his outlook brightened when he saw Bambie, his recently hired hygienist, sway past his door with her suntanned body. She exuded sensuality and knew just how to tease him with her feminine charms. Is this a midlife crisis, he wondered? It had been 20 years since he’d graduated from dental school, and his receding hairline was one indicator. And then there were the minor accumulating health problems. For instance, the menacing itch of his fissured dry skin that caused him to knead his reddened hands. His dermatitis had become a chronic problem over the last year – probably a result of many years of frequent washings. That pH-adjusted soap he used was no doubt an irritant. And then there were those infernal gloves he now had to wear whenever dealing with patients. The consequences of a 1987 mandate by OSHA (Occupational Safety and Health Administration) seemed worse than the omnipresent risk of HIV transmission between dentist and patient. Within a week’s time, ragweed would be abloom to herald the onset of another hay fever season. This year his allergies seemed to have started earlier. Take today, for example. He had experienced conjunctivitis, rhinitis and sneezing soon after working on Mrs. Fateema, the last of today’s patients. He needed a few days off, away from the office, perhaps alone or with someone like Bambie. Just to get his life back in order. He sat up suddenly. There it was in today’s mail. The brochure announcing this year’s annual meeting of the Midwestern Dental Association, which was coincidentally being held in Puerto Rico the same week as Keith’s planned visit. What luck!
That night over dinner, Joel broached the subject with Harriet. "On September 11–14, our dental association will hold its annual meeting in Puerto Rico. Everyone I spoke to is going, and there’ll be lots to learn. It’ll only be for a few days. Would you mind, honey?"
"Whatever you think is best," Harriet said with resentment in her voice. "You know I need to stay here and be sure the children get to school."
"Thanks. I’ll make plans and be sure patients aren’t scheduled that week."
"Is Keith going, too?" asked Harriet.
"Why, yes," he stammered. "Didn’t I mention that?"
September weather in San Juan was excellent. Keith and Joel were lounging at the hotel’s pool enjoying the sights and appreciating the gene pool Ponce de Leon and crew had introduced to this part of the world. "Let’s try snorkeling tomorrow afternoon," remarked Keith. "It’s the only time we have left. We’ll have to leave by Wednesday afternoon."
"Gee, I don’t know. I’ve never tried it," said a hesitant Joel.
"It’s easy. You only have to learn to breath through the mouthpiece. We won’t go out far. We’ll stay close to the shoreline."
"Okay then, let’s do it", agreed Joel.
"Good, if you’ll excuse me, I need to make a phone call back to Chicago. I’ll be back in a flash," shouted Keith as he bounded off toward the hotel.
Monday evening found Keith and Joel at a swinging night spot. The thundering sound of rock music filled the air. "Just remember to protect yourself from communicable diseases later tonight," Keith shouted into Joel’s ear, and off he went to the dance floor, not to be seen again for the rest of the evening.
Tuesday afternoon again featured brilliant sunshine. Joel and Keith had rented the necessary equipment and were ready for their try at snorkeling. They stood on the shoreline with swim fins and a strapped-on swim mask perched at the forehead. "Practice breathing with the snorkel," suggested Keith.
Joel raised the air tube into position perpendicular to his head with his right hand and eased the mouthpiece in place between teeth and lips with his left. It didn’t seem so bad nestled against his gums. He only had to remember not to breath through his nose or allow the tubing to dip below the water’s surface. They made their way out into the calm waters of the blue lagoon, where each began to swim underwater.
Joel suddenly noted a sense of breathlessness. What’s going on, he wondered. I’m not afraid of the water or snorkeling. Nevertheless, his breathing was becoming quite labored. He could barely catch his breath. Trembling, he jumped up immediately and called out to Keith for help.
"What is it, old man?" yelled an onrushing Keith.
"I can’t breathe. Get me to a hospital," Joel shrieked between gasps, panic in his eyes.
"Your eyelids, lips and face are all puffy," shouted Keith.
In the emergency room, Joel received intravenous epinephrine, intramuscular diphenhydramine and supplemental oxygen. Relief soon followed. What a harrowing experience that was, he thought. He’d not been certain he would make it. The attendant physician inquired if he had been bitten by a fish. Was he allergic to fish? Perhaps he pricked his hand or foot on coral. He appeared to be negative to all potential allergens the doctor posed.
"I only have hay fever, and that hasn’t been bad here in San Juan," Keith told him. "Well, whatever it was, I feel better. No more snorkeling for me. Thank you, doctor, for your help. You saved my life."
"It’s 3:00 p.m. back in Chicago. I think we should call Harriet to let her know what happened," noted Keith as they left the ER, his arm around Joel’s shoulder.
Harriet’s voice over the telephone sounded anxious when she heard about Joel’s near encounter with disaster. "Relax for the remainder of the day, honey. Get some rest and take your expected flight home tomorrow afternoon. Don’t forget, I know what’s best for you."
"You’re right, dear. I’ll do as you say," Joel responded. He then paused. Had he just heard laughter and a man’s voice in the background? Must be the television, he thought and hung up.
Wednesday night, Harriet and Joel were seated on their living room sofa discussing recent events, which included his trip to Puerto Rico. "You know, honey," Joel announced, "after coming to grips with my own mortality, I think I’d like to take a few months off. Get my mind together and our house in order, just in case it should happen again. What do you think?"
"It certainly wouldn’t hurt us financially for you to take off," Harriet said. "And I think it would be a good idea to update our life insurance policies. We need to protect one another and the children."
And so weeks passed with Joel home from the office. He had tied up several loose ends, among them an upgrade to all Singer family insurance policies. Tomorrow was Sunday, October 9, his daughter’s 8th birthday. Would Harriet have any special plans?
He awoke late Sunday morning, dressed in sweat pants and shirt, and found Harriet down in the kitchen – an unusual touch. "Hi, Joel," she purred. "I’ve prepared you a special brunch. Fresh exotic papaya, kiwi and avocado, with imported brie and cheddar cheeses, whole wheat bread, chestnuts and an aged port from one of Portugal’s finest vineyards. Enjoy." She gave him a glancing kiss to his cheek. "The children and I need to go over to the mall and do some shopping. We’ll be back by late afternoon. And by the way, for Alice’s birthday I invited a few of her friends over for early dinner tonight. Would you be a dear and put out the paper cups, plates and matching napkins? Oh, and would you blow up the balloons I left on the table? Thanks." With that they were off.
Next door, Keith had grown bored with the late afternoon football game of the Sunday double header, a runaway between unmatched teams. He decided to visit with Joel. Perhaps they might go hit a few golf balls over at the driving range. Keith knocked at the Singer’s front door. There was no answer. Strange. Just yesterday after tennis Joel had said he would be at home, and to come over. Harriet’s car was gone and the children were nowhere to be seen. Maybe Joel had fallen asleep. As Keith peeked in the bay window to the Singer’s living room, he was startled to see Joel lying on the dining room floor, his outstretched arm clutching the table cover that had been pulled down from the table. Keith frantically searched for an open window. Nothing. He was finally able to enter the house through the sliding patio door that had been left open. His heart racing, sweat poring from every pore, he sprinted toward the dining room. Was Joel having another life-threatening episode?
Good God! Joel was not breathing and there was no carotid pulse. Death was unmistakable. It couldn’t be! He ran to the phone to call for help, his hand shaking as he dialed 911. What could have happened? Joel’s face appeared puffy, just like in San Juan.
Oak Lawn police were on the scene when Harriet pulled the car into the driveway. Neighbors were milling around on the front lawn, and dogs were barking. Shock and grief were evident all around. The Singer children were escorted away to be comforted by neighbors.
"My God, what’s happened?" shrieked Harriet.
"I’m sorry to put you through this, ma’am. It’s your husband," said Frank Kilroy. "I’m a police sergeant in charge of the investigation." His tone was conciliatory, his head bowed. "We need for you to identify the deceased. We believe it’s your husband, but you can’t go near him. The area is protected – a potential crime scene. We need to determine what happened."
"Yes, that’s him," sobbed Harriet as they entered the dining room. "What could have happened? We left him just a few hours ago. Was he murdered?"
"We don’t know just yet," Kilroy responded. "Was he in good health? Any history of heart disease or high blood pressure?"
"No," replied a sobbing Harriet.
"Sir," Kilroy said, turning to Keith, who was squatting in a corner of the dining room. "You found the body?"
"Yes, I did."
"Please tell me what you saw."
Keith provided a tearful recounting of discovery.
"Did you touch or move anything at the scene?"
"No. Except I did feel if he had a pulse." Then he continued, gesturing toward Joel. "Look at his puffy face. In Puerto Rico last month, Joel had an episode where his face became swollen, just like that."
"Let me ask each of you to wait in the living room while I attend to some details," requested Kilroy. He then proceeded to call the Cook County Medical Examiner’s Office and sound the alert that an inquiry into a sudden, unexpected and perhaps suspicious death was in order, including an investigation of the scene.
This call from law enforcement activated various experts who would become involved, including the assistant medical examiner on call, crime scene technician, and a forensic pathologist who would carry out the autopsy back in Chicago.
Cadwallader Obadiah Jones, aka C. O. Jones, was the assistant medical examiner on call today. He was relaxing with his friend, Sue Kim, an anthropology student at the University of Chicago. When the phone rang in his 32nd floor condo in Hyde Park, it set off a startle response in both C.O. and Sue.
"I’m on my way. Wait around ’til I get there, and keep the area free of trespass," he told Kilroy. He quickly dressed in his usual garb: khaki pants, a blue button-down shirt, V-neck navy blue sweater, tweed sports jacket with leather elbow patches, and brown shoes. His mind was racing with possibilities. Breaking the stare out the window at Lake Michigan, he said, "Sue, I’ve got to go."
"I understand. I’m off to the library, anyway. Catch you later," She paused at the doorway. "And by the way, thanks for last night. You were great. As usual."
C.O.’s silver BMW made its way north on Lake Shore Drive to the Stevenson Expressway, then headed west to Oak Lawn. He had little difficulty finding the neighborhood, having been there many times as a child to visit friends with his parents. Flashing strobe lights from police vehicles and an ambulance parked on the street signaled the exact location. He had made good time. It was 6:24 pm.
"What’ve we got?" he asked Kilroy as they huddled together on the lawn.
"The deceased is Dr. Joel Singer, a dentist here in Oak Lawn. There’s no obvious evidence of foul play or a botched burglary. Seems his wife and kids left the deceased to go shopping about the time he was sitting down to brunch. By her count it was between 11:30–11:45 this morning. A neighbor found the deceased about 4:15–4:30. Recalls it well because it was half-time of the NFL game. It looks as if Dr. Singer was having brunch at the dining room table when he collapsed. He grabbed the table cover and pulled it and his food down with him. His meal is scattered all over the floor. The neighbor, Keith Bradford, claims Singer’s face was puffy, and he had a similar episode in San Juan last month."
"What was he eating? Can you tell?" queried C.O.
"Nothing out of the ordinary. Fruit, cheese and bread, mainly. There’s also an open bottle of port and a broken wine glass on the floor."
"Let’s have a look."
C.O. Jones was known for his perceptive eye and sharp analytical mind. He was also a keen observer. He took in every inch of the scene. "It looks like rigor mortis is setting in, confirming he died within the last 3–4 hours. Must’ve happened soon after the wife left. He’s dressed only in sweats. No underwear, no shoes. Probably never left the house. Kilroy, what about the birthday party effects? You hadn’t mentioned them."
"Wife reports that today is their daughter’s 8th birthday. A party was planned for early this evening."
"Okay, while I talk with his wife and the neighbor, let’s have a complete analysis of the scene. Cordon off the dining room. Have the crime scene technician provide a diagram and photographs. Collect samples of food and wine, party effects, broken wine glass, carpet fibers, etc. Dust for fingerprints." He added, "And Kilroy, be sure both inflated and noninflated balloons are collected for analysis."
Kilroy commandeered the police politely standing around the living room. "Boys, let’s make way for forensics to do their stuff."
C.O. introduced himself to Harriet and stated his official responsibility in the investigation. He extended his sincerest condolences and inquired into Joel’s past medical history. C.O. made notes about hay fever and chronic dermatitis involving hands. No history of heart disease, irregular heart beat or hypertension. He was active, played tennis regularly and golf occasionally. No history of drug abuse. No enemies, no gambling debts, no scheduled guests.
"He seemed depressed lately. Stressed out. Maybe it was a midlife crisis or something," noted Harriet. "After his spell in Puerto Rico he wanted time off from his practice. I tried to cheer him up this morning with a special brunch. Do you think he took his own life?"
"We’ll have to wait for the results of the autopsy and lab tests," answered C.O. "Thank you for your cooperation." He next met with Keith.
"Yeah, I found him, poor guy," said a visibly shaken Keith. "Just as I told Mr. Kilroy, he was lying on the floor when I found him. Blue hands and face. That face! Those puffy lips and eyes, just like it happened in San Juan when we were snorkeling. The doctor there couldn’t determine what caused it, but called it angioedema. Joel couldn’t breathe when it happened. The doctor thought it was all part of an anaphylactoid reaction. They gave him several shots and he got better."
"How were the deceased and his wife getting along?"
"An average marriage, I’d say. No physical or verbal abuse between them. Joel had been stressed lately. He was looking to get his head straightened out. We spent time together in Puerto Rico, as I mentioned, and he’d recently stopped working to sort out his life. His allergies were becoming more troublesome, interrupting his dentistry with sneezing, watery eyes, and runny nose. Come to think of it, he was probably difficult to live with since Harriet and the children don’t have allergies and couldn’t sympathize with his miseries."
C.O. left the crime scene. His drive back to Chicago was filled with thought, his trusty pipe ablaze. He would call forensic pathologist Dr. Marvin Abrahms to recount today’s findings and indications for a full autopsy and battery of laboratory tests. As he neared the all-too-familiar Chicago skyline, surrounded by his pipe’s smoky tendril, he had an idea.
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Was Dr. Singer’s death by natural causes, an accident, a suicide, or a homicide? |
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 Top Was Dr. Singer's death... Answer:Postscript |
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The idea had spurred a rush of adrenaline. A flight of additional ideas followed. C.O. Jones worked late into the night pursuing possibilities, searching his computer database of medical literature, reading printouts. By early Monday morning his idea had begun to take shape. He nodded off to sleep.
Marvin Abrahms called C.O. at the office Monday afternoon. "This is what I found at post on the Singer case: facial edema, laryngeal edema and bronchospasm. Looks like a severe anaphylactoid reaction. Cause unknown. The deceased’s stomach contained fruit, bread, cheese, and chestnuts. Except for the cheese, all were only partially digested, indicating he died early in the afternoon, likely while he was eating. No evidence of coronary thrombosis, pulmonary embolus or cerebral hemorrhage. I looked closely for needle marks. Nada. He did have trophic changes of his hands consistent with chronic dermatitis."
"When will the microscopic and toxicology studies be available?" C.O. asked, as if he didn’t know.
"Tomorrow. What are you thinking about?"
"I’ve developed a theory, a hypothesis about Singer having a latex allergy. Allergy to latex rubber is reaching epidemic proportions amongst health care workers. Joel Singer was an atopic person. As a dentist, he had to wear many latex gloves daily. I’ll bet this accounted for his chronic dermatitis. According to his friend Keith, Joel’s allergic reactions had recently worsened, suggesting increased sensitization. In Puerto Rico, with the rubber mouthpiece of the snorkel in contact with his oral mucosa, Joel had an anaphylactoid reaction."
"It all makes sense so far," responded Marvin with enthusiasm. "But what accounts for his fatal event? He was having brunch, not snorkeling or wearing gloves."
"My reading of the literature indicates that in individuals with marked latex sensitivity, inflating a balloon and inhaling latex rubber proteins could precipitate anaphylaxis. And here’s the kicker. In a report that will appear in this month’s Annals of Allergy, a cross-reactivity exists between latex allergens, proteins from trees, with certain fruits. Guess which ones, Marv?"
"Kiwi, papaya, avocado and chestnuts."
"Bingo. It’s called a ‘latex-fruit syndrome.’ Was it a coincidence that Singer was inflating party balloons while eating kiwi?"
"But C.O., how would his wife have known all these nuances about latex allergens?"
"She had to have help. A knowledgeable accomplice," C.O. said, smiling with satisfaction. "I’m working it out. They don’t call me C.O. Jones for nothing."
C.O. and Marvin agreed to talk again on Tuesday.
There was much paperwork to be completed. The dull, routine part of the job. However, C.O. kept coming back to the Singer case, his mind abuzz with suspicion.
He decided to call the telephone company to obtain a log of calls placed from the Singer household during September and October. A several-page printout arrived in his office later that afternoon. One phone number, 417-446-5656, a Winetka exchange, appeared repeatedly – nearly a daily listing, in fact – except for September 13, where there were no entries. C.O. decided to call the number.
"Hello, Dr. Gilbert Roth’s office. May I help you?" replied a pleasant-sounding woman on the other end of the line.
"Yes, my name is Jones. I wonder if I have the right Dr. Roth. Does he specialize in stomach diseases? I think I have an ulcer."
"No," she giggled. "Dr. Roth is an allergist."
"Sorry to have troubled you, ma’am. I must have the wrong Dr. Roth," he said, and hung up.
There it was. An allergist in Winetka, and neither Harriet nor the children had allergies! Joel had been in San Juan on September 13. How to further confirm the link between Harriet Singer and Gil Roth? thought C.O. Information about latex allergies had only begun to appear in the literature over the past five years. The report from Spain by Carlos Blanco and coworkers, which C.O. had found through his website, would appear only this month.
That was it. His website! That could prove another link between Harriet and Gil, and an incriminating one at that. Gil might have an online subscription to a local server, where he could access medical literature. Winetka was not far from a medical school in North Chicago. Gil probably subscribed to their database.
C.O. called the server and requested a record of incoming and outgoing e-mail in September between the school and Roth’s office. There it was! Gil had sent Harriet a number of reprints on latex allergies, including the abstracted summary of the recent Blanco report.
I believe it’s time for me to have a chat with Frank Kilroy, C.O. mused as he lit his pipe and blew a plume towards the exhaust fan.
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TopWas Dr. Singer's death...Answer:Postscript |
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Latex, or natural rubber, is a cytoplasmic exudate extracted from a tree of the sapodilla family, Hevea brasiliensis, found in South America, Africa and Asia. Its commercial value and many uses are based on its desirable mechanical properties: elasticity, strength, tear resistance and barrier qualities. Latex products are all-pervasive in our environment. Coincident with the implementation of universal precautions among health care workers during the last decade, the prevalence of latex allergy has reached epidemic proportions. In the U.S., OSHA reports that 5 million health care and other workers use an estimated 7 billion pairs of gloves annually. Water-soluble, starch-bound, and latex-bound latex proteins are potent allergens that can induce potentially fatal, IgE-mediated anaphylaxis, particularly when these allergens are in contact with mucosal surfaces, are inhaled, or are given parenterally. Systemic reactions are commonly preceded by a history of contact dermatitis. Risk of latex sensitization is increased in individuals with multiple exposures to latex products. Atopic individuals are more likely to develop latex allergy. Epitopes, or proteins that cross-react with latex, include certain fruits, a "latex-fruit syndrome".
Diagnostic testing at present involves sequential use of serologic assays for latex-specific IgE, a use test (application of fingertip from cut surgical glove), and skin prick tests, which have been associated with anaphylaxis and mandate proper safety measures.
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A latex-safe environment is necessary if latex-sensitive individuals are to undergo medical procedures or work in a health care-related workplace. This would include the exclusion of latex gloves and accessories that would come in contact with such a person.
The FDA has established more stringent industrial guidelines for the manufacturing of gloves used during surgery and medical examination.
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