Tagged Gardens and Gardening

Think Like a Doctor: The Tired Gardener Solved!

On Thursday, we challenged Well readers to solve the case of a previously healthy 67-year-old gardener who abandoned his garden one summer, alarming his wife and adult children. For weeks this vibrant and energetic man had been the last one out of bed — something his family had never seen before. And his days were interrupted each afternoon with a fever that left him shaking and pale. More than 300 readers suggested diagnoses for this classic presentation of an unusual disease, and a couple dozen of you nailed it.

The correct diagnosis is…

Babesiosis

The first person to identify this unusual infection was Dr. Paige Szymanowski, a resident in her second year of training in internal medicine at the Beth Israel Deaconess Medical Center in Boston. She said she recognized the pattern of a fever with a low blood count, low platelet count and evidence of liver injury. Dr. Szymanowski hasn’t made up her mind what kind of doctor she’s going to be, but she is thinking of subspecializing in infectious diseases. I think she shows real promise in this area. Well done!

The Diagnosis

Babesiosis is caused by the parasite Babesia microti, a protozoa. It is usually transmitted by Ixodes scapularis, better known as the deer tick, the same small arthropod that transmits Lyme disease. Sometimes the two diseases occur together, passed on in the same bite. The disease can also be spread through blood transfusions from an infected donor.

Babesiosis is rare and occurs primarily in the Northeast and Upper Midwest — Minnesota and Wisconsin — regions of the United States. In healthy people it often causes no symptoms. However, those who are over 65 or who have some type of immune suppression – because of a chronic disease or medication – or those who don’t have a spleen are more likely to develop symptoms and can become quite ill or even die from this infection.

Easy to Miss

Babesiosis is difficult to diagnose, and the diagnosis is often overlooked, even in areas where infection is most common. Patients with babesiosis have few, if any, localizing signs to suggest the disease. Fever — which can be constant or, as was the case with this patient, intermittent — is common. So are shaking, chills, fatigue, loss of appetite, abdominal pain and headache. These symptoms, however, are seen in many infections. And indeed, our patient had all of these symptoms, but it took many weeks for him to get a diagnosis.

The diagnosis is confirmed when the ring form of the protozoa is seen on a blood smear, or when the Babesia DNA is detected in the blood. Doxycycline, which is used to treat other tick-borne diseases, is ineffective against this organism. An antimalarial medication (atovaquone) plus an antibiotic (azithromycin) are first-line treatments against this infection. Improvement is usually seen within 48 hours of starting the drugs.

Although the infection will often resolve without treatment, all who are diagnosed with the disease should be treated since, in rare cases, the bug will persist and become symptomatic if a patient later develops some immune system problem or has his spleen removed.

How the Diagnosis Was Made

Dr. Neil Gupta was leading the daytime on-call team at Saint Raphael’s hospital in New Haven, Conn., where the patient’s daughter had taken him. Dr. Gupta heard about this patient when the night team handed off the patients they had admitted on their shift and met him that morning. Seeing how well the patient looked, and hearing that he’d been given the usually benign diagnosis of hepatitis A, he turned his attention to patients who seemed sicker and more in need of thought and care. Until the patient spiked his usual afternoon fever.

One of the ways the doctor’s mind works is to put together pictures of what a disease looks like in a patient. We put these so-called illness scripts together based on our knowledge of the disease plus the patients we have seen who have had it.

When Dr. Gupta heard that the patient had spiked a temperature, he went back to see how he was doing. The patient was pleasant but didn’t say much. Perhaps there was a language barrier — he spoke with a thick Italian accent. Or perhaps he was one of those patients who just don’t focus on what ails them.

Hearing From the Patient’s Family

The patient’s wife and daughter, however, had been much more attuned to the changes in his health and behavior, and what they reported didn’t really sound like hepatitis. Was this the right diagnosis, Dr. Gupta wondered?

He sat down with the family in the nursing lounge and let them tell the whole story as they recalled it. The man had actually been sick for several weeks. He’d had a fever every day. And he was tired. Normally he never sat down, was never idle. These days it seemed he never left the house anymore. Never went into the garden. He just sat on the sofa. For hours.

Sometimes he had pain in his upper abdomen, but never any nausea; he had never vomited. But he did have a cough. This was not the man they knew, the women told him.

Reviewing the Symptoms

Dr. Gupta returned to the patient and examined him, this time quite carefully, looking for the signs common in hep A. The man’s skin was dark but not yellow; and his eyes, while appearing tired, showed no hint of yellow either. His liver was not enlarged or tender. He didn’t look to Dr. Gupta like a patient who had hepatitis A.

The patient did have tests that were positive for hepatitis A, however. Could these tests be wrong? Dr. Gupta suspected that was the case. O.K., if not hepatitis A, what did he have?

The young internist made a list of the key components of the case: He had recurring fevers every afternoon. He had a cough and some upper abdominal pain. Not very specific — except for the repeating fevers.

The labs were a little more helpful. His liver showed signs of very mild injury — again, not consistent with hepatitis A, which usually causes significant liver insult.

However, he did have a mild anemia that had gotten worse over the past three days. He’d had his blood count drawn two days earlier, when he went to the emergency room at Yale–New Haven Hospital. That showed a very mild anemia – slightly fewer red blood cells than normal. The evening before, the patient’s red blood cell count had dropped further. And today, even further. So his red blood cells were being destroyed somehow. To Dr. Gupta, that seemed to be a second important clue. In addition, his platelets were quite low.

Many Possiblities

So, the patient had cyclic fevers, a worsening anemia and a mild liver injury. That suggested a very different set of diseases.

The patient was a gardener and had been treated for Lyme disease. Could he have a different tick-borne illness?

Certainly a number of illnesses could present this way. The cyclic fevers were suggestive of malaria — rare in this country, but still worth thinking about.

Could this be mononucleosis? Or even H.I.V.? Those diseases can affect red blood cells and the liver. And they can last weeks or months. If those tests were negative, he would need to start looking for autoimmune diseases or cancers.

Finally, he would need to review the blood smear with the pathologist. Several of these diseases can provide clues when you look at the blood itself.

An Answer in the Blood

A call came to Dr. Gupta late the next day. The pathologist had tested the patient’s blood for the presence of the Babesia gene, and found it. The patient had babesiosis.

Dr. Gupta went down to look at the blood smear with the pathologist. There, in the middle of a sea of normal looking red blood cells, was a tiny pear-shaped object. It was one of the protozoa.

Dr. Gupta was excited. He pulled up a picture of the tick that spreads the disease and the tiny bug that causes it to show to the family. This was what was making the patient so very sick.

How the Patient Fared

The patient was started on the two medications to treat babesiosis the same day. Twenty-four hours later he spent his first day completely fever-free —the first in several weeks.

After a couple more days, the patient was up and walking around, asking to go home. He went home the following day, with instructions to take his two medications twice a day for a total of 10 days.

That was last summer. This summer, the patient is back in his garden. He is a little more careful to avoid getting tick bites. He wears his long pants tucked into his socks and his wife looks him over every night — just to be sure.

Walk, Jog or Dance: It’s All Good for the Aging Brain

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Credit Illustration by Sam Island

More people are living longer these days, but the good news comes shadowed by the possible increase in cases of age-related mental decline. By some estimates, the global incidence of dementia will more than triple in the next 35 years. That grim prospect is what makes a study published in March in The Journal of Alzheimer’s Disease so encouraging: It turns out that regular walking, cycling, swimming, dancing and even gardening may substantially reduce the risk of Alzheimer’s.

Exercise has long been linked to better mental capacity in older people. Little research, however, has tracked individuals over years, while also including actual brain scans. So for the new study, researchers at the University of California, Los Angeles, and other institutions analyzed data produced by the Cardiovascular Health Study, begun in 1989, which has evaluated almost 6,000 older men and women. The subjects complete medical and cognitive tests, fill out questionnaires about their lives and physical activities and receive M.R.I. scans of their brains. Looking at 10 years of data from nearly 900 participants who were at least 65 upon entering the study, the researchers first determined who was cognitively impaired, based on their cognitive assessments. Next they estimated the number of calories burned through weekly exercise, based on the participants’ questionnaires.

The scans showed that the top quartile of active individuals proved to have substantially more gray matter, compared with their peers, in those parts of the brain related to memory and higher-­level thinking. More gray matter, which consists mostly of neurons, is generally equated with greater brain health. At the same time, those whose physical activity increased over a five-year period — though these cases were few — showed notable increases in gray-matter volume in those same parts of their brains. And, perhaps most meaningful, people who had more gray matter correlated with physical activity also had 50 percent less risk five years laterof having experienced memory decline or of having developed Alzheimer’s.

“For the purposes of brain health, it looks like it’s a very good idea to stay as physically active as possible,” says Cyrus Raji, a senior radiology resident at U.C.L.A., who led the study. He points out that “physical activity” is an elastic term in this study: It includes walking, jogging and moderate cycling as well as gardening, ballroom dancing and other calorie-burning recreational pursuits. Dr. Raji said he hopes that further research might show whether this caloric expenditure is remodeling the brain, perhaps by reducing inflammation or vascular diseases.

The ideal amount and type of activity for staving off memory loss is unknown, he says, although even the most avid exercisers in this group were generally cycling or dancing only a few times a week. Still, the takeaway is that physical activity might change aging’s arc. “If we want to live a long time but also keep our memories, our basic selves, intact, keep moving,” Dr. Raji says.

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How the ‘Dirt Cure’ Can Make for Healthier Families

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Credit

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Dr. Maya Shetreat-Klein

Dr. Maya Shetreat-KleinCredit Tanya Malott

Dr. Maya Shetreat-Klein has a message for the parents of small children: Don’t be afraid of dirt.

She is a firm believer in the idea that children in Westernized countries today grow up in a world that can be too sanitized. They spend less time outdoors exploring nature and more time in front of screens than they did two decades ago. They eat foods that are heavily processed. Many do not know what it’s like to taste fresh, seasonally grown foods plucked from a garden with nutrient-rich soil.

Dr. Shetreat-Klein, a pediatric neurologist in New York and an instructor at New York Medical College, explores these themes in a new book, “The Dirt Cure: Growing Healthy Kids With Food Straight from Soil.” The book delves into research that suggests that spending time around farms, parks and other green spaces can benefit children in surprising ways, protecting against allergies, enhancing immune function and potentially even improving attention span and academic performance.

Dr. Shetreat-Klein wrote the book after a frightening experience with her youngest son, who started wheezing, breaking out in rashes and showing signs of delayed cognitive development after his first birthday. Various doctors suggested it was nothing to worry about.

But Dr. Shetreat-Klein eventually went to see an allergist who determined that her son was severely allergic to soy. Weaning him off of soy, which is added to many processed foods, proved difficult at first. But a week after eliminating soy from her son’s diet, Dr. Shetreat-Klein noticed that his problems began to dissipate.

She and her family then set out on a journey to reconnect with nature. Despite living in the Bronx, one of the most densely populated, urban counties in the country, they started growing their own food, taking trips to farmers’ markets and going on nature hikes. They even raise their own chickens.

Recently we caught up with Dr. Shetreat-Klein to talk about her book, why she feels so strongly about exposing children to “good old-fashioned dirt,” and what families who live in urban areas can do to get closer to nature. Here are edited excerpts from our conversation.

Q.

You’ve said that your son’s allergy was part of the impetus for this book. How so?

A.

It was the beginning of my investigation into how food impacts children’s health, why children are so allergic today, and how this impacts their cognition, development and behavior. I learned for one thing that food has changed dramatically in the last 20 years – from the way it is grown literally from seed to sprout to plate, how it’s processed, and the kinds of additives that are used. Children’s environments have changed, and so have the foods they’re eating.

Q.

Explain what you mean by “dirt cure” in the title of your book.

A.

Dirt means three things to me. It’s eating nutrient-dense food from healthy soil. It’s being exposed to certain microbes. And it’s spending time outdoors in nature.

Q.

Why is it that children who grow up on farms tend to have lower rates of asthma and other allergies?

A.

We used to think that children who grew up on farms were healthier than children in urban environments because they were exposed to more microbes. But studies have found that the number of bacteria in urban environments and on farms is similar. The difference is the diversity of the bacteria. Microbial diversity seems to have a very powerful impact. Children’s immune systems are very social: They like to meet and greet a lot of things. It seems the more they meet and greet, the more likely they are to be in balance, and the less likely they are to let any one microorganism grow out of control, as occurs with infection.

Q.

What is the microbial diversity like in soil?

A.

In one teaspoon of soil there are more organisms than there are humans on our planet. Soil houses about 25 percent of the world’s biodiversity. What we also know from studies is that when children spend time in green environments – in natural playgrounds, for example, or in parks and forests – they perform better on standardized tests, they’re more creative, they’re happier and their cortisol levels are lower, so they’re calmer and less stressed. And I think that might be somewhat related to the kind of organisms they’re exposed to when they’re playing outdoors.

Q.

Can you talk about how microbial diversity in soil relates to food?

A.

The organisms in soil have an impact on the health of our food. Part of what makes fruits and vegetables good for us is the phytonutrients in them – the things that make cranberries red or coffee bitter. Phytonutrients are part of the plant’s immune systems. Organisms in the soil that we might think of as pests actually stimulate plants to make more phytonutrients. So these small stressors actually in a sense enhance our health. Being exposed to different organisms improves the health of the plant and it improves our health as well.

Q.

Based on your research, what are some things you would like to see change?

A.

I think we need more outdoor and nature-based curriculum in schools because this actually benefits children from a health perspective and a learning perspective. Children are more focused and they perform better on tests after they’ve spent time outside in nature. In Japan there’s this idea called “Shinrin-yoku,” or forest bathing, which means taking short visits to the forest. It’s been shown to reduce inflammatory markers in the body and boost beneficial hormones. We know there are many physical benefits to children being outdoors and being physically active in nature

Q.

As someone who lives in New York City, how do you manage to spend time in nature?

A.

We live in the Bronx, and although a lot of people may not realize it, the Bronx actually has a tremendous amount of parkland. We go to Van Cortlandt Park as well as the Bronx Zoo and the New York Botanical Garden, which are all very close by. We live by Riverdale Park, which is a beautiful little forest. We visit Bear Mountain and Rockefeller State Park and go on beautiful hikes. And we go to Central Park. It’s actually not that difficult to get to a lot of these places for a day trip.

Q.

How do you incorporate the food philosophy you’ve talked about into your life?

A.

When I was initially going through this journey, I lived in an apartment. But I found an office in the Bronx that had an empty lot out back and I decided to start a garden there. The soil was like dust, so we had to enrich it. And we planted a food forest. There were fruit trees. I grew cold-hardy kiwis, beans, melons, berries and then vegetables. We ate fresh produce that we grew in the garden. And I decided to keep chickens.

Q.

Do you still maintain it?

A.

Now I live in a house with a little yard so I keep the chickens in my garden and we grow vegetables there. I like to know where my food is coming from. I want to eat eggs from chickens that are scratching outside and exposed to the sun and nibbling on greens. So I did those things and although it was difficult, it wasn’t nearly as difficult as I thought it would be. It was far more accessible than most people would imagine. We also shop at farmers’ markets once or twice a week to stock up and add to what we’re growing.

Q.

How does your family get involved?

A.

I have three kids and they love it. It’s a family affair. They help me plant. They help me weed. They run outside when I’m cooking dinner to harvest celery, parsley or tomatoes. Sometimes in the morning they run outside to see if the chickens have laid eggs. My husband helps too. He appointed himself keeper of the chickens.

Q.

What are some recommendations for people who live in very urban environments?

A.

Take a trip to the forest with your family. It may be difficult during the week, but maybe you can do it on the weekends. That’s another reason why we should also be valuing green spaces in cities. Community gardens are also wonderful. So are farmers’ markets. They expose children to fresh foods, which taste completely different. And it also exposes them to potentially healthy microbes through the traces of soil that might be left over on the fruits and vegetables when you buy them at a farmers’ market.