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Forty Meals for a Drop of Blood …

Issa El Hamad, MD,*† Carmelo Scarcella, MD,*† Maria Chiara Pezzoli, MD, PhD,*†
Viviana Bergamaschi, MD,* and Francesco Castelli, MD‡; for the Migration Health Committee of the
International Society of Travel Medicine
*Department of Infectious Diseases, Spedali Civili General Hospital, Brescia, Italy; †Local Health Unit,
Center for International Health, Brescia, Italy; ‡Institute for Infectious and Tropical Diseases,
University of Brescia, Brescia, Italy

DOI: 10.1111/j.1708-8305.2008.00264.x

Downloaded from https://academic.oup.com/jtm/article/16/1/64/1803432 by guest on 28 October 2021

Increasing migration flow to Western countries poses formidable challenges from the epidemiological, clinical, and cultural stand-
points. A case of Dhat syndrome is presented in a young Pakistani male migrant living in Italy, which required integrated medical and
cultural approach to be solved after a through diagnostic workout that did not yield any result.

R ecently, Italy is experiencing an unprecedented mi-

gration flow. Brescia Province, in northeast Italy, is
the Italian territory with the highest proportion of non-
European persons living in the province, estimated at
14% of the 1,000,000 inhabitants. The public Local
Health Unit of Brescia (responsible for assuring preven-
tive services to the population), in collaboration with the
Spedali Civili General Hospital and the University of
Brescia, has established an Outpatient Department
(OPD) specifically dedicated to illegal migrants since
1989, which offers free access to all migrants, regardless
of their legal status. Since 1989, more than 81,000 con-
sultations have been provided.
Case History
A 27-year-old Pakistani man, illegally resident in Italy for
the past 12 months, complained of weakness, weight loss,
headache, disseminated myalgias, and sleeplessness.
Medical history and physical examination did not suggest
any specific etiology, and the patient was prescribed non-
steroidal anti-inflammatory drugs for the pain. After a few
weeks, the patient returned to the OPD with continuing
symptoms. Despite language difficulties preventing good
communication, he described a urethral discharge fol-
lowing sexual intercourse with a prostitute a few months
earlier. No discharge was observed on urethral inspec-
tion. A urethral swab for Neisseria gonorrhea and Chla-
mydia trachomatis tested negative (Figure 1), as did all
Corresponding Author: Francesco Castelli, MD, Institute for
Infectious and Tropical Diseases, University of Brescia, Piazza
Spedali Civili, 1, Brescia 25125, Italy. E-mail: castelli@med.
unibs.it
serological tests for other sexually transmitted infections
and urine culture. Urine microscopic examination
showed 20 white blood cells per field. Empiric treatment
for nongonococcal urethritis and urinary tract infection
did not resolve the symptoms.
During the following weeks, the patient reported pro-
gressive worsening of headache; presence of nocturnal
white urethral discharge, which was not observed by the
medical team; premature ejaculation; and sexual impo-
tence. His general condition worsened, and weight loss
was marked. Blood chemistry and inflammatory markers
were normal. Neurologic and urologic assessment and
gastroendoscopy were within normal limits. A tuberculin
skin test was 7 mm. A diagnosis of neurosis was made, and
the patient was prescribed antidepressant drugs and cog-
nitive-behavioral psychological support, based on reas-
surance and sexual education including anatomy and
physiology of sexual organs, particularly relating to se-
men loss. The encounters with the psychologist were fa-
cilitated by the active presence of cultural mediators, with
progressive improvement of symptoms.
Comments
The Dhat syndrome is a psychiatric condition classified as
neurotic disorder (F48.8) according to the International
Classification of Diseases1 and as culture-bound syn-
drome according to the Diagnostic and Statistic Manual of
Mental Disorders2. The word “dhat” derives from the San-
skrit word dhatus, indicating the seven essential elements
of the human body (rasa: fluid from digested food, rakta:
blood, masma: muscle, meda: fat, ashti: bone, majja: mar-
row, and sukra: semen),3 whose imbalance may damage
the health. Clinical symptoms of this syndrome, mostly
found in people from the Indian subcontinent and also in

© 2009 International Society of Travel Medicine, 1195-1982

Journal of Travel Medicine, Volume 16, Issue 1, 2009, 64–65
Migration and Dhat: A Culture-Bound Syndrome
Figure 1 Urethral swab, showing epithelial cells and
spermatozoa.
migrants from Europe in the past, are nonspecific and
vary widely among patients. Dhat syndrome is nowadays
reported mostly by people coming from the Indian sub-
continent4 and is defined as a culture-bound clinical en-
tity. There is historical evidence that the same syndrome
existed in Europe, United States, and Australia, mainly in
the 19th century, probably related to moral and religious
concerns, and that it disappeared as a consequence of eco-
nomical and social changes.5 Symptoms of Dhat syn-
drome are common to many other functional somatic
syndromes. What is different is their culture-specific in-
terpretation by the individual. Stress factors related to
migration can induce the onset of an anxious syndrome,
which is interpreted by the subject through his own cul-
tural identity and referred, in this case, to loss of semen.4
The symptoms often focus on and relate to anxiety about
loss of sperm, especially when sexual behavior is per-
ceived as socially reprehensible. Patients with Dhat syn-
drome may suffer from comorbid depression6 and sexual
dysfunctions. In the Ayurvedic medicine and in its Hindu
roots, sperm is regarded as the place where the key ele-
ments of life gather. Its loss is then perceived as a loss of
energy.6 (Forty meals make a drop of blood, 40 drops of blood
65
make a drop of bone marrow, 40 drops of bone marrow make a
drop of semen, the elixir of life, Veda, 1500 bc).7
Migration medicine poses two major problems to the
Western health provider. The first is related to the lack
of knowledge of diseases not endemic in industrialized
countries (so-called tropical diseases). The second, and
even more important, are the difficulties related to the
integration of concepts of health and disease. These con-
cepts are very different in cultures and societies across
the world. In addition to the usual divergence between
physicians and patients (disease vs illness) from the same
culture, the relationship between physicians and mi-
grants is often compounded by the difference in cultural
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beliefs and by the anxiety that is intimately tied to the
migration process itself. Health providers dealing with
migrants require cultural and migration medicine com-
petency extending across all aspects of health. The role
of cultural mediators is crucial to facilitate the diagnostic
and therapeutic process.
Declaration of Interests
The authors state that they have no conflicts of interest.
References
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J Travel Med 2009; 16: 64–65