Sometimes a happenstance, a chance meeting with an absolute stranger can take you down a magical adventure. This is the story of an astute clinician, Dr. Rathinam, an ophthalmologist who saw a pattern forming in her clinic and connected the dots from the bench to bedside. This is the story of birds, snails and exuberant schoolboys jumping into the Kavery River to cool themselves on hot summer afternoons in South India.
We had an appointment to see Dr. Rathinam at the Arvind Eye Hospital in Madurai this morning. I loathe going to the doctors and I usually drag my feet, to find every excuse in the book to postpone my visits, unless I am dying. I was meeting Dr. Rathinam for the first time and I was understandably apprehensive and anxious, as I do not enjoy bright lights shining down my dilated pupils.
Dr. Rathinam walked into the room with her smile and I knew in my bones that I was going to be alright. Clad in a starched green cotton saree, she put me at ease instantly, as she listened intently to my history. I found myself warming towards her as she proceeded to examine me. When she finished, she said that I was fine and I slumped in relief. My uveitis out of the way, we relaxed and got chatting.
Sam in the meantime had googled her and found that she had done stellar pioneering work in the ocular manifestations of the Rat Fever, Leptospirosis . This piqued his interest . Prior to his retirement, Sam had worked in the TN Dr.MGR Medical University as Professor and HOD of the Dept of Experimental Medicine. When the epidemic broke in Chennai, their department had set up a diagnostic lab with PCR tests for Leptospira and he was was interested to know more about her work. They were delighted when they found that they had a great deal in common and they reminisced as both had worked in translational research. They agreed that often, it is the meticulous documentation of simple observations by a clinician in the Outpatient Department that lead to spectacular discoveries in labs, with new treatment modalities for the community.
In this context, she had a fascinating story for us.
It started in 1993, when 4 schoolboys aged 7-11 years, from the same village presented at the Uveitis Clinic at Arvind Hospital with itchy , inflamed Red Eyes. These boys were all from the same village and attended the same school on the banks of the Kaveri River, the 3rd largest River in India. The Kaveri starts from the Brahmagiri Hills of the Western Ghats and runs a revered course, horizontally across Karnataka, Tamilnadu and Puducherry forming a delta that opens into the Bay of Bengal. The boys from the delta region of the Kavery, had small lumps or granulomas in the eye, which were were diagnosed clinically as conglomerulate tubercle. However, it did not show the classical signs of Tubercle on biopsy, nor did they respond to standard Anti-Tuberculosis Treatment regimes. The biopsy slides showed numerous eosinophils, cells suggestive of an allergic reaction to something all 4 boys were exposed to.
Probing deeper into the history , Dr. Rathinam found that there were at least 40 other boys with the same condition in the village. Intrigued, Dr. Rathinam, took a team out to visit the 4 boys in their village, where she saw many more kids, strangely all male, affected with similar findings . All the boys gave a history of jumping into the river during the lunch break at school. The boys were not the only ones who swam in the river, but they were the only ones who swam at the same time around 1pm. The adults and the school girls who swam early in the day or late in the evening were unaffected. Was there something in the water in the hot mid afternoon she wondered.
Dr. Rathinam took the blood samples from all the boys affected with the itchy red eye to the reputed Vetinarian late Dr. Rathnam in his village who examined the sera. He encouraged her to pursue her research. She then travelled to the USA with biopsies of the granulomas and worked with Dr. Narasinga Rao and Dr. Fritsche TR who confirmed that the granulomas were suggestive of an allergic reaction possibly due to a flat worm , a trematode now identified as P varium.
Snails act as the first intermediate host for this trematode in regional ponds where they release cercarial larvae to infect the fish which act as secondary hosts. Infected fish then transmit the trematode to birds. Fish eating birds are the definitive hosts. The school kids who swam in the river were the accidental hosts.
Dr. Rathinam then traveled to China to the Sun Yet University where she learned snail collection and trematode isolation. The cercaria release peaked under warm conditions, which might explain why only the schoolboys who swam with the zenith of the sun over their heads, mid-afternoon ended up as the accidental hosts to the trematode. It could also explain why adult swimmers and girls were spared as they bathed early in the morning or late in the evenings.
Subsequently, Dr. Rathinam worked with Dr. Veena Tandon , the renowned parasitologist of the North Eastern Hill University, Shillong where a molecular diagnosis was established.
A cluster of 4 schoolboys presenting with similar histories and clinical presentation, an intelligent observation and the will to persevere at the grass root level and to pursue collaborative studies in sophisticated labs, equipped Dr. Rathinam with the clarity to connect the dots.
Thus it was established that swimmers who swim in warm infected water bodies could act as accidental hosts to the trematode P varis and present with ocular manifestations.
Another example of translational research and medicine which connected bench to bedside to community.