The Element of Surprise

One of the stimulating privileges of working as a medical practitioner is the element of surprise in clinical practice, the patient who survives despite all reasonable expectations, or the unexpected response to medication, usually an unwelcome adverse effect. Occasionally, a novel application emerges, quite tangential to the original goal of the medication, of which thalidomide treatment of erythema nodosum leprosum, type I1 lepra reactions is one notable example', or nifedipine for the treatment and prophylaxis of altitude sickness2. The report by Mejia, Hernandez and Kitchen published in this issue (p 55) , concerns nonparasitological applications of diethyl carbamazine (DEC) whose role has previously been confined to microfilarial infestations. There is a limited body of data suggesting antiviral, antibacterial and antifungal effects. The clinical course of HIV infected patients is highly variable even in late stage disease. This case report is not an indication for widespread use of DEC in HIV patients but hints at possibilities for further research and we publish it to stimulate further comment and investigation.