A young couple with neurologic symptoms and loss of appetite

You are consulted by a couple in their mid-20s who moved to your southern rural community about 2 years ago and purchased an old farm. They have not felt well since their first winter in the home, when they began to experience general malaise and loss of appetite. They both have had transient nasal congestion and severe headaches that lasted 2 to 3 hours, sometimes accompanied by lightheadedness. These symptoms are especially noticeable after they work in their basement workshop. Once or twice, the wife was nauseated when she returned from the basement after several hours in the workshop.

In a recent conversation with their neighbor, your patients learned that the previous occupants, a young couple, had left the farm convinced that the wife’s two miscarriages were due to termite fumigation of the house carried out 3 years before your patients moved in. They ask you if the association is possible, and whether this pesticide may also be the reason that they have not been able to conceive; they have not used birth control for about 1 1/2 years.

On further questioning, you learn that the couple had been well before their move; they exercise regularly and are quite health-conscious. Neither has ever smoked tobacco, and they rarely drink alcohol. It was their desire to start a family and to seek a less stressful life that prompted them to leave their jobs in the city and to attempt organic farming. Further history reveals that the woman’s last menstrual period was 5 weeks ago, but her menses have always been irregular. She has had no previous pregnancies.

Physical examinations are generally unrevealing. Complete blood counts, urinalyses, and chemistry profiles are all within normal limits, except for slight elevations of LDH and alkaline phosphatase in the man.

Answers to the Pretest questions are on page 17.