The Challenge: Can you solve a medical mystery involving a 59-year-old woman who becomes deathly ill two weeks into what she calls the flu? Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult medical case and solve a diagnostic riddle. This month’s puzzle is a toughie because halfway through the doctor arrives at a diagnosis. The question then becomes: Is this the right diagnosis, or does the patient have something else going on? I’ll give you all the information that was available when the patient first presented to the emergency room. I’ll also give you the history, physical exam and test results obtained by the emergency room physician. After that, it’s up to you to use this information to make a diagnosis you think accounts for the sudden worsening of her symptoms. As usual, the first person to crack the case gets a copy of my book, “Every Patient Tells a Story,” and that warm smug feeling you get when you figure out a tough puzzle. The Patient’s Story: “Can you hear me?” the man said as he knelt by the limp form of his wife. She hadn’t been feeling well for the past several days, but she’d been up and awake when he’d gone to get her a cool drink. Now she lay on the floor next to the bed. Her eyes were open wide, but she didn’t seem to be able to see — or hear — anything at all. She lay completely still except for her right hand, which jerked and shook as if it had a mind of its own. Leaning over her he felt panic rise in his chest. “Talk to me, sweetheart,” he said. “You’re really scaring me.” She hadn’t been feeling well for more than a week now, but the past couple of days it seemed she was getting better — at least until that afternoon, when the nausea, vomiting and diarrhea that heralded the start of this illness came back with a vengeance. Her unseeing eyes rolled back in her head. The man hurried to the phone and dialed 911. He handed the receiver to his son. Tell them to be quick, he urged before rushing back to his wife. A Worried Nurse: “You need to see this patient,” the nurse told the doctor in the emergency room. “She doesn’t look too hot.” The physician, Dr. Thomas Robey, was fresh out of training and starting his second week in his first job as an emergency medicine physician at Waterbury Hospital in Connecticut, but he knew that these nurses knew sick when they saw it. If this nurse was worried, then so was he. He glanced at the brief nursing note put together by the triage nurse, then walked into the room. The patient, a 59-year-old woman, lay on the stretcher in her street clothes. She looked up as the doctor entered the room. He took in all the immediately available data — her face, tanned but strangely pale; the rapid beeps of the monitor, clocking her heart’s accelerated rate and dangerously low blood pressure — and knew she had come to the right place. He didn’t know what was wrong with her, but he knew the nurse was right. This woman was sick. The Patient’s History: She just didn’t feel well, she told the young doctor. She was tired, more tired than she’d ever been in her life. And she’d had this headache for almost two weeks. When she first got so sick, she was nauseated and vomiting and had this terrible diarrhea. That first day she spent in the bathroom or huddled under a blanket on the sofa. There had been a heat wave in central Connecticut that week, but she had needed the blanket. The next day she was a little better but still tired. She’d get up and start her usual bustle, but after an hour or two, she’d feel tired again. She hated the idea of getting back into bed in the middle of the day, so she’d taken to napping on the sofa. Over the past week she felt as if she’d spent more time on that sofa than she had since they bought the thing. She was tired, she had a headache that wouldn’t quit and her whole body felt sore and achy. She thought maybe she had the flu. These past few days the fatigue was the worst part. She liked to stay busy and, lord knows, she told him, she had a lot to do. It was pretty much a full-time job taking care of her husband and a son who was back living with them, spoiling their two grandchildren and working in her garden. It was midsummer and that garden needed lots of care. But she hadn’t been able to do much of anything lately. After a week of this her husband called her doctor. Hearing that the normally active woman had spent the past week on her sofa, he immediately suggested she go to a nearby urgent care center and get checked out. She didn’t want to go, though. She felt she was getting better. Her muscles didn’t ache quite so much, and she was able to get through more of the day before this strange and terrible fatigue put her back on the sofa. But that afternoon, just a couple of hours earlier, she had gone to the bathroom and — whammo — she suddenly felt awful. Her stomach hurt so much she doubled over and vomited. And she felt so weak she had to lie on the floor. She didn’t remember passing out, but both her husband and the emergency medical technicians told her she had fainted at home and again in the ambulance. Emergency Room Findings: The patient had no medical problems. She didn’t smoke or drink. She had been outside a lot tending her garden but didn’t recall any recent tick bites. On exam, the patient looked sick. Her skin was sallow and felt cool and clammy to the touch. Her heart was beating rapidly but was otherwise normal. There was nothing to suggest she had pneumonia. Her belly, which she said was bothering her before she came to the hospital, was unremarkable. She was a little tender just below the ribs, but even that was unimpressive. A Dangerously Low Blood Pressure: It was her blood pressure that worried the doctor the most. He wasn’t sure what her blood pressure usually ran, but it was undoubtedly higher than the 70s and 80s it was being measured at now. With pressure that low it would be hard to supply enough oxygen-carrying blood to all the parts of the body that needed it. Dr. Robey asked the nurse to start intravenous fluids to help bring the woman’s blood pressure back up. Why was her blood pressure this low? The woman had been vomiting; the loss of fluids could bring blood pressure down. And she probably hadn’t been eating or drinking since she got sick. If that were the case, her blood pressure should respond quickly once the fluids were started. Infection was the most worrisome possible cause of her hypotension, but seemed less likely. She had been sick, but why an indolent and apparently resolving infection should suddenly worsen was not at all clear. Dr. Robey ordered a few blood tests to look for signs of infection and a chest X-ray, then waited for the fluids to do their work. Test Results: Results of the tests came in over the course of the next hour. Her chest X-ray was normal. You can see that image here. Her blood test showed that her low blood pressure was taking a toll. Her liver and kidneys showed signs of injury, and levels of lactate, an acid made by cells when they are deprived of oxygen, was starting to go up. She was anemic, but it wasn’t clear to Dr. Robey how that could cause this woman to be this sick. An Abnormal Blood Finding: Dr. Robey heard his name called. The lab was on the phone for him. The lab technician suggested that he might want to look at the patient’s blood under the microscope. There was something abnormal visible inside her red blood cells. Because technicians are not allowed to “interpret” laboratory data, she couldn’t tell him directly what she thought was going on, but her clue was enough. This woman, who spent so much time outside tending her garden, had something inside her red blood cells. To Dr. Robey it was clear: the patient had babesiosis. Babesiosis is a parasite spread by deer ticks and was a growing problem in the Northeast. Once the tick starts taking its blood meal, it releases the tiny parasite, called Babesia, into the circulation. The organisms invade the red blood cells and begin to replicate, using the energy and products within the cell to sustain them. Eventually the red blood cell ruptures, dumping its load of parasites back into the circulation, where they are free to continue their cycle of reproduction and destruction. Dr. Robey immediately ordered the test to confirm that the patient had Babesia and started the woman on intravenous antibiotics. She had babesiosis, but was that causing her to be this sick? It was a diagnosis, but was it the right diagnosis? Most of the time babesiosis is a mild disease. You get sick for a few days and then you may feel tired until you replace the red blood cells destroyed by the bug. Indeed, many of those with this infection have no symptoms at all. Could this typically mild disease make this woman this sick? Solving the Mystery: The doctor went in to see the patient again, armed with this new data. Her blood pressure remained dangerously low, even though she had received three liters of fluids. And she still said she felt awful, though she could not describe exactly what felt bad. Suddenly she stopped talking. Her eyes rolled up and her right arm began to twitch and shake. The episode lasted only a few seconds. It looked to Dr. Robey as if she had fainted – except she was lying down. There was something more going on here – Dr. Robey was certain of that. Dr. Robey ordered one more test and the diagnosis was made. What test would you order? And what did she have? Think Like A Doctor Solve a medical mystery with Dr. Lisa Sanders. Related Articles Also Tagged: Think Like a Doctor: A Mysterious Fever Should Hospitals Be Run by Doctors? Diaries From I.C.U. Aid Mental Rec New York Times
Posted on: Thu, 01 Aug 2013 16:30:17 +0000
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