In High Spirits

“Who are you? What do you mean, my son Atul is in a coma?”

It was close to midnight in Satara, a small town in Madhya Pradesh, when Kailash Agarwal’s phone rang abruptly, disturbing his sleep. The ringtone was the one he had customized for Atul. So, although half-asleep Kailash had had no misgivings when he had picked up the phone. Atul was in Melbourne about four and a half hours ahead of Indian time. He never called very late at night but maybe he wanted to share some news that could not wait till a more decent hour. Of course, any time Atul called was a good time for Kailash and Sita Devi. Atul was their only child.

Kailash wasn’t ready for the strangely accented voice that broke the news to them. His loud reaction woke Sita Devi, who then tugged at his arm; incoherent with worry.

“This is Atul’s friend Noah. Atul is in a coma. Can you come down to Melbourne as soon as possible, sir?”

That was the first of a flurry of phone calls.

Sita Devi kept saying one thing over and over again, “When Atul was born, my Guruji cast his kundli and said he would have a long life and live every day in high spirits. My Guruji cannot be wrong. My Atul is just 24.”

***

Kailash and Sita Devi had no memory of how they managed Visas at short notice, booked flight tickets, locked the house, and caught the flight to Mumbai and thence to Melbourne. They had no memory of how they passed the long hours at the airport and on the flight. Sita Devi fingered her beads and silently repeated Guruji’s name while teardrops trickled down her eyes from time to time. Kailash sat in a stupefied silence with eyes too dry for tears.

They had spoken with Atul three days earlier. Atul had mentioned a pain in his leg. They had not paid much attention to it. Atul went jogging; and ran marathons. Maybe he had overdone things. Atul was good in sports and studies as well. He had seamlessly integrated into Aussie society. He had Aussie friends and was dating an Aussie girl. Secretly Atul and Sita Devi were a little chuffed. A gori bahu…that would show the relatives! What they did not approve of was that Atul went to the pubs with his friends. Sita Devi mightily disapproved of drinking. But Kailash had explained. “It is part of foreign culture…it is the social thing to do. Atul is not going to get drunk like Vermaji next door. I know he likes alcohol …but in the Western world everything is good quality.”

At the airport, Kailash and Sita Devi were met by Noah and Jacob. Atul had often spoken about them. They were the ones he studied with, ran marathons with, and went pub-hopping with. In the car, Noah explained that Atul had been complaining of pain in his legs. Jacob and he had rushed Atul to the hospital when he collapsed. The University’s HR- Head had been alerted.

Jacob drove the distraught parents directly to the hospital. Dr. Fiona Harris who was treating Atul succinctly briefed them.

“Atul and his friends had been drinking beer at an open-air restaurant when they spotted a tiny slug crawling up the table leg. A slug is a small snail…without a shell,” she explained when she saw the look on Kailash and Sita Devi’s faces.

“Shambuk,” whispered Kailash to Sita Devi, “Khol ke bina.”

Sita Devi sat there impassively. Why was the doctor talking nonsense about snails without shells? Who cared? Snails did not bite…she had never heard of snails biting anyone. Dogs bite people. Mad dogs gave you rabies. But snails? Nah, snails were delicate, harmless creatures.

“Atul swallowed the slug on a dare.”

The words reached Kailash from very far away.

A-T-U-L A-T-E      
T-H-E S-L-U-G O-N A D-A-R-E.

A dare! What was a dare?

A challenge.

Why would anyone challenge anyone else to eat a live slug? That too a friend…Noah or Jacob…it had to be one of the two. Why would they want to harm Atul? Because he was a brown man in a white man’s world?

Sita Devi’s rosary dropped from her hands; her mouth opened and closed in silent distress. Her son…Atul…her son had swallowed a live slug? How could he? She retched in disgust. Huge, dry retching that reduced her to a quivering mess. Dr. Harris rang a bell.

A nurse rushed in and began to attend to Sita Devi.

Dr. Harris addressed Kailash Agarwal. “The slug was infested with a parasitic worm called rat-lungworm. It infects rodents…mice and all…but also needs mollucs to complete its life cycle. The pain in the legs was an early sign of infection. It was due to the larvae released from the eggs that were carried by the slug. These larvae were jamming the blood vessels; impeding blood flow. However, your son ignored the symptoms.”

“So did we,” mumbled Kailash guiltily.

Dr. Harris appeared not to have heard because she continued. “Humans are not part of its life cycle. However, if at all it enters the human system, the larvae that hatch out of the eggs use the bloodstream to migrate to the brain. There they dig in and stay for years. The situation is made worse if the larvae are themselves parasitized by a bacterial species…those microbes can remain for decades in the brain because they breed and establish a self-perpetuating colony.”

Atul whispered Kailash to. What did you swallow? A slug that carried eggs of a parasitic worm. A parasitic worm that was in turn…parasitized by microbes! What were you thinking, Atul? You were dead drunk…so drunk that you were incapable of thinking straight.

“Atul Agarwal was admitted here with acute meningitis which is only to be expected. The larvae have infiltrated the brain. We have started treatment for meningoencephalitis but Atul is in a coma-like condition.”

“Tell me he is not going to die, doctor. He is our only child.”

“We are doing our best. He is young and resilient. I just pray the rat-lungworm larvae did not enter loaded with bacteria. Usually, the larvae can be eliminated. However, if the microbes dig into the brain; there is little I can do.”

The next few weeks passed in a blur. Atul was quasi-paralyzed but he could talk a bit; a few words at a time. Anything more than that tired him out. His mental faculty had not been affected. Dr. Harris said that the larvae had taken refuge in that part of the brain that affected movement. She said Atul was lucky it had not damaged more vital areas of the brain.

The first thing Atul said when he was capable of proper speech was that the dare had been spontaneous and light-hearted. It had been a joke. He had not been targeted in any way. They had each “dared” the others. He had been swifter than the other two. He had scooped up the slug and swallowed it with the beer he had been drinking. “I did not know what I was doing, Ma. I was somewhat tipsy. Guruji spared my life.”

Sita Devi wiped her eyes. What was done was done. No one could turn back the clock. At least Atul was getting better. “It is OK, beta. Rest now.”

The antibiotic drip worked. Slowly, the dose was tapered down and Atul was weaned off the antibiotics. The day the drip was removed was the day Sita Devi smiled for the first time. “We will be taking you home soon. All praise to Guruji.”

However, the hospital did not discharge Atul immediately. Rather, Dr. Harris set up a consultation with a brain specialist.

Kailash who had established a rapport with the doctor asked why she felt the need to consult with a brain specialist. “I thought you said he is getting better …in the coming days he will recover fully.”

“He is getting better, yes. But he is not fully cured yet. Have you not noticed the localized quivering of the limbs, the sudden spasms, and almost- epileptic fits? These are of very short durations I agree, but may be worrisome symptoms of a deep-rooted microbial colonization of the brain. Also, though we have wiped out the rat-lungworm larvae in the blood I fear, a few have made their home in the brain and have not been eliminated.”

“Yes, but won’t more antibiotics kill them all? If you discharge him with a prescription, I promise you we will adhere most strictly to it. One year. Two years. His whole life. You tell me how long he must take the antibiotics; I will see to it that he complies. With my last breath. We just want to take our son home.”

“I cannot do that yet. It would be unethical to discharge an unfit patient. Besides there is a limit to the amount of antibiotics I can pump into a person. Dr. Ted Woodwards is going to take a look at Atul tomorrow. Let us see what he has to say.”

***

Dr. Ted Woodwards did not have good news and he did not mince words. “The rat- lungworm larvae have almost been eliminated but the few that reached the brain have formed a cyst. And deep inside the cyst are the microbes that were ferried there by the larvae.”

“Can’t you take out the cyst, surgically?”

“We cannot operate because the cyst is too deep inside the brain and there is the risk of damaging the brain. The rat-lungworm larvae are safe inside the cyst; as are the microbes. Additionally, the bacterial species is resistant to most antibiotics. Because these are so deeply embedded in the brain tissue, plus protected by the cyst wall, the amount of antibiotics reaching them is very little. Even if we continue, the sustained low-level exposure will simply lead to antibiotic resistance.”

Dr. Harris interjected, “As it is most antibiotics cannot cross into the brain because of the blood-brain barrier…or BBB”

“What is this 3-Bs you are talking about?” asked Kailash.

“Think of it as a membranous curtain that shields the fluid bathing the brain from the circulating blood.”

Kailash was slightly confused. “Blood is good…it carries oxygen and nutrients …why would the brain need a shield against it?”

“The blood-brain barrier protects the brain from circulating toxins and pathogens in the blood that may injure the brain if these reach it. Unfortunately, the same blood-brain barrier also hinders the delivery of most therapeutic agents to the brain.”

“But how did the antibiotics kill most of the larvae in the brain initially? The antibiotics did breach the blood-brain barrier.”

Kailash was surprised to see how he was arguing with foreigner-doctors; that too in English. His arguments made sense too because Dr. Ted Woodwards explained patiently.

“The blood-brain barrier becomes more permeable during inflammation, allowing antibiotics to move across the BBB. Unfortunately, this also means that microbes also find easy entry into the brain. Think of it like having a broken door. Friends can enter at will but then, so can those with malafide intentions. Now, the inflammation is almost gone, the blood-brain barrier is up again…bacteria and virus will find it difficult to enter but so will therapeutic agents.”

“Can nothing cross the BBB? Nothing that we can use as medicine? There must be something…there are so many medicines, so many chemicals, and compounds in the world…is there nothing that can cross the barrier and kill the germs? Oh, Guruji, shine a light, show us the path.” Sita Devi howled.

Kailash thought the doctors would throw her out. “Hush,” he said. But to his great surprise, he saw Dr. Harris flash a conspiratorial look at Dr. Woodwards. “We do have an agent that can cross the BBB and it is lethal to the microbes too. Should we call in Dr. Grace Edwards? She is on call today. What do you think Dr. Woodwards?”

“Gastroenterologist Dr. Grace Edwards? You read my mind, Fiona. Indeed, let’s hear what she has to say.”

It was as if a slight breeze of hope blew through the room. Both Sita Devi and Kailash sensed it; and read it in the sudden relaxation of the facial muscles of the doctors. But a gastro doctor? Gastros took care of digestion, Kailash knew that. Atul had a problem with microbes in the brain…what would a gastro have to say? But any port in a storm. A dying man clutches at straws…all the clichés rang true. If a gastro could cure Atul’s brain, Kailash was not going to object.

Dr. Grace Edwards agreed to read up Atul’s files over the weekend and consult on Monday. Dr. Edwards and Dr. Woodwards left together talking animatedly about Brewer’s yeast.

“Dr. Harris, please tell us what you are thinking…we cannot last two days without knowing,” pleaded Kailash.

“These are very early days…Grace has not read the reports…so I do not even know if what we are thinking is even feasible. Suffice that there is one agent that can easily cross the BBB and it is also lethal to microbes.”

Kailash would have danced a jig had he been able to…but he merely said, “Guruji be praised…what is this agent? Is it a very expensive or rare medicine? Why did you not try it earlier?”

“It is alcohol. Ethanol, to be precise.”

***

On Sunday, Amal Kothare, a young Indian intern working under Dr. Harris, sat down with Kailash and Sita Devi to explain a few things.

“Can you tell us honestly just what is happening with Atul?”

“You know he had two different infections of the brain…the rat- lungworm larvae and the bacteria. Antibiotics have killed most of the larvae and so, you see a distinct improvement.”

“Blessed is my Guru,” said Sita Devi.

“The bacteria carried by the Lungworm is a resilient one that can only be killed by exposure to alcohol. It is sensitive to alcohol; and yet appears to be resistant to almost all other agents that can cross the blood-brain barrier.”

“You mean alcohol can cross the blood-brain barrier?”

“Of course, it can,” snapped Sita Devi. “Such a foolish question. Wasting time. If alcohol did not cross the barrier of the blood and the brain would Verma ji get drunk and lose all sense of shame and dance half-naked on the terrace? You go on beta, ignore silly questions.”

Kailash’s face was a sight to behold but Amal pretended not to have noticed. “As I was saying we need the alcohol to reach the brain in high enough amounts so that it percolates into the deeper parts of the brain. However, the blood vessels this deep in the brain are extremely thin and delicate. So, unless have a significantly high alcohol level in the blood, the amount will be minimal by the time it reaches the brain parts we are targeting.”

“Guruji, save us…will Atul have to drink alcohol?” Sita Devi sounded horrified and her husband still smarting from the snubbing he had received snapped right back at her, “Drinking alcohol is what made him end up here. He lost his senses under the influence of alcohol; now the same alcohol will be his medicine.”

“I have heard, like cures like…go on, beta,” said Sita Devi.

Encouraged, Amal went on animatedly, “No, no he does not have to drink the alcohol because a large part will then be degraded and unavailable to provide the benefit we want. To make blood concentration levels what we want he will have to drink copious amounts of alcohol…not feasible. Or recommended.”

“Then?”

“We will deliver it via a drip…the sort we used when we gave him intravenous antibiotics.”

“Do you have alcohol drips?”

“Yes, it is used for treating alcoholics who wish to kick the habit; we arrange it such that they get less and less alcohol every week but we ensure that the blood alcohol level never becomes nil; or else they get withdrawal symptoms and fall off the wagon.”

“Oh!” said Sita Devi. “So, with Atul, you will inject via a drip alcohol into his blood and the blood vessels will take it to the brain where it will cross the barrier and reach the bacteria and kill them.”

“That is the plan, yes. We can adjust the dose and the rate of alcohol infusion. We will use alcohol like medicine.”

“Will Atul become drunk?” Kailash asked.

Amal fidgeted a little but answered truthfully. He knew counseling sessions with families of patients were recorded and monitored for legal reasons. He knew better than to lie.

“Hmm, that is likely. Yes. It varies from person to person depending on their enzymatic ability to break down the alcohol. But do not worry. He will not become violently drunk. We can restrain him if it looks to be going that way. In any case, that will only be for the first few days till we tweak the dosage and get it right.”

***

“Dr. Harris was beaming. “Congratulations, Mr. and Mrs Agarwal. I have some good news. I can confirm that Atul no longer has any Lungworm larvae in his body. His antibody test came back negative. So, you can relax a little, now.”

Kailash and Sita Devi were overwhelmed with gratitude. “Thank you, Thank you, doctor.”

However, Dr. Harris was not through yet. “However, while we have been able to eliminate the larvae from Atul’s body the same cannot be said for the bacteria in his brain. From his latest reports, you can see that his C-reactive protein levels are very high.”

Kailash whispered, “Is that bad?”

“C-reactive protein levels rise if there is a bacterial infection. We also checked the fluid taken from Atul’s brain and there are bacterial proteins in it. Much lower levels than what we had found earlier but the presence of proteins indicates that the infection still exists. We need to continue with the alcohol therapy perhaps indefinitely…depending on results.”

Two weeks later, Dr. Harris called Kailash and said essentially the same thing. “The C-reactive protein levels are standing steady. It means that although the infection is not spreading it has not been eliminated either. I have asked Dr. Grace Edwards to join us for a discussion. You see, we need to continue the alcohol treatment indefinitely but Atul is no longer ill enough to remain in hospital. He can be treated as an Out-patient.”

“An Out-patient with that drip attached 27 X 7?”

Dr. Harris smiled wanly. “That is why we have Dr. Edwards joining us. She has a solution.”

***

The first thing Dr. Edwards said was, “Mr. and Mrs. Agarwal, I am sure you know that there are pathogens or bad microbes and there are the good microbes…like the ones that give us yogurt and make Vitamin B for us.”

Kailash and Sita Devi nodded in silence. Their stress levels were extremely high…anticipating what new medical googly awaited them had increased it further.

“We have lots of friendly bacteria in our gut. Some of these species ferment the partially digested food and the end product is alcohol. It is very little so we do not experience any symptoms of alcoholism. Also, this tiny amount is easily metabolized or broken down by the body.”

“Yes, it also produces gas that leads to bloating…I suffer a lot.” Kailash blurted out.

Dr. Edwards ignores him. “There are many bye-products as you can imagine because, at an estimate about 100 trillion bacteria, both good and bad, live inside our digestive systems. This population is known collectively as the gut microbiota.”

Sita Devi silently mouthed 100 trillion…Guruji!

Dr. Edwards went on, “Of course, his gut microbiota, both good and bad species, has been largely wiped out because Atul has been on antibiotics for so long. In the last few days, we have also dosed him with probiotics…to re-establish the good bacteria in his gut. This is because the good bacteria do more than just help with digestion. They multiply swiftly and out-compete the bad bacteria for space. Like tenants in a high rise, the good bacteria occupy all the niches, and the bad bacteria have no place to call home.”

She looked at Dr. Harris who picked up the narrative. “You see we have tried to selectively introduce high levels of friendly bacteria that ferment the partially digested food into alcohol. This is so that Atul’s body endogenously produces alcohol in amounts that are more than normal. Even if it is broken down by the body’s enzymes, some amount will still enter the bloodstream and find its way to the brain. Unfortunately, ….”

“Unfortunately?” Kailash almost wailed. “Unfortunately, what?”

Dr. Harris said, “We had taken Atul off the alcohol drip. Unfortunately, the alcohol being made in Atul’s guts is just not enough and in the absence of enough alcohol in the blood, the C-reactive levels are increasing slowly and steadily. The microbes are increasing in number. That is why Dr. Edwards thinks a slightly more radical protocol is needed.”

“Tell us…what we need to do for Atul.” Sita Devi said.

“Well, like I said everyone has bacteria in the gut whose activities lead to the production of small levels of alcohol.”

“Yes…yes.”

“There are some people whose bacteria produce copious amounts of alcohol. So much so that the body cannot break down and eliminate it…it often leads to the patient appearing to be intoxicated. We call it Auto-brewery syndrome.”

Kailash asked, “My Atul does not have it…others may have …how is it relevant to him?”

“In a minute…let me explain the process first. These microbes…these are yeasts…like we use to bake bread or brew beer. The yeast converts sugar and carbohydrates from our food such as rice or potatoes into alcohol. Taking antibiotics upsets the balance between the helpful and harmful bacteria in the gut, potentially providing yeast with the opportunity to gain a foothold. This is happening in Atul’s case. We just want to accelerate the process.”

“Help the process?”

“If we can introduce a colony of high-alcohol producing yeasts taken from a patient of auto-brewery syndrome and use that to re-colonize Atul’s gut, we believe that the alcohol produced by Atul will be enough to kill the bacteria in his brain.”

Sita Devi smiled. “Atul will not have to be tied to a drip, 24 X 7”

“Where will you get the yeasts? Auto-brewery syndrome must be rare.”

“Yes, auto-brewery syndrome is quite rare. It was first reported from Japan and a colony of that yeast is available for research. We have a cell line in our Hospital too. Getting the yeast is not a problem…but we need your permission to operate on Atul.”

“Operation…Guruji!”

Dr. Edwards went on. “Do not worry, the operation will be a small one. We will create a new appendix and colonise it with the bacteria. The idea is that for the next few months… maybe a year or a lifetime…Atul’s circulating blood will have a higher-than-normal alcohol level. No matter how deep in the brain the bacteria is; no matter how protected it remains inside its cysts…sooner or later the sustained, low-level exposure will prove to be lethal. We will need to keep checking for bacterial proteins and C-reactive proteins and monitor Atul’s diet. Apart from that he should be Ok.”

Dr. Harris added, “Once that is done, we will observe Atul for a few days. If the plan works you can take him home.”

Take him home …the words were like an intoxicating tonic for Atul’s parents and after that getting them to sign the formal legal papers was a breeze. Everything went as planned.

***

Amal was there to say goodbye to the Agarwals’. He also had a few words of advice for Sita Devi, “To keep Atul’s alcohol levels high. Please feed him a lot of carbohydrates…potatoes, pasta, and rice for example. Goes without saying that Atul should not drive a car or operate heavy machinery for a few months…and here is a certificate from the Hospital. Atul should keep it on him at all times. It is to certify that he is not drunk but under treatment with alcohol. Once his report normalizes, any general surgeon can remove the appendix-like structure.”

Noah and Jacob came to drop off Atul and his parents at the airport. Atul, assisted by his parents, was wheeled into the terminal building. Having been bed-bound for so many months, Atul was unsteady on his feet. And then, there was the alcohol in his blood.

***

Four years later.

“I do not know why you won’t agree to have that appendix with its yeast colony removed…you are fine…have been for two years now. We can’t get you married because all the girl’s families say you have an alcohol problem. They do not even believe the certificate the Australian hospital gave; they say you can get certificates like that for Rs. 500. Atul…Atul…I am talking to you.”

Atul smiled the lazy and languid smile of a person on the borderline of intoxication. “Oh Mummy, don’t be such a bore. It is such a wonderful feeling; I feel I am floating outside my body. Am I a fool to remove the wonderful brewer’s yeasts from my body? I am high all the time and need not even pay for the booze. Didn’t Guruji say I would be in high spirits all my life…I am. Jai, Guruji.”

Tags: Sukanya Datta, নবম বর্ষ প্রথম সংখ্যা