Abstract
In 1996, the Journal published a single case report [1] concerning a patient with severe recurrent vomiting. Our involvement with this young man began when he presented to our emergency department debilitated by severe vomiting. He had been heavily abusing marijuana, was anxious, panicky and suicidal. Prolonged vomiting had rendered him dehydrated, necessitating intravenous fluid replacement and admission. Later, it became clinically and radiologically apparent that he had also sustained a spontaneous pneumomediastinum.
A psychiatric consultation liaison assessment was undertaken because of his suicidal ideation and agitated state. Noclear-cut psychiatric syndromewas immediately apparent and a working diagnosis of separation anxiety disorder was made. However, an odd behavioural feature noted by both medical and nursing staff was the patient's compulsive desire to repetitively bath and shower while on the ward, sometimes spending several hours per day in the bathroom. On discharge the patient was followed up in Psychiatric Outpatients and it was felt that this case unusual enough to warrant publication in the Journal as a single case report.
Seven years following publication, Dr Allen, a General Practitioner in Adelaide contacted me. Dr Allen, working independently with substance abusing patients, had encountered several cases with a similar clinical picture to our published one. These cases, from the Adelaide Hills, presented with a triad of cyclical vomiting, chronic marijuana abuse and compulsive bathing. These patients had responded so well to cannabis cessation that the argument was being put forward that cannabis toxicity, rather than anxiety, was the underlying cause.
This led to the recent publication of a case series in Gut [2]. Since the publication of the case series in Gut, clinicians within Australia and Overseas have communicated similar cases [3]. The prospect that we may be looking at a new clinical syndrome is promising, although it is still early days.
The original authors of the single case report in the Journal made no claim of having insight into a possible new syndrome. But we did three important things. First, we described the phenomenology accurately; second, we recognized the importance of the bizarre bathing rituals; and third, we appreciated the unusual nature of the case. The recognition of the patient's compulsive bathing also highlighted the important role of nursing observations.
In an era where there is a temptation to believe that all discoveries must have an attached p-value, it is the single case report that still affords any clinician the aperture through which to make a significant contribution to knowledge.