Tag: Think Like a Doctor

Think Like a Doctor: Hurting All Over

The Challenge: Can you figure out what is wrong with a 36-year-old man who has had body aches for many years?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try to figure out a real-life diagnostic mystery. Below you will find the details of a case involving a middle-aged man with pains that seem to migrate from one joint to the next with no visible sign of injury.

The route to the final diagnosis was particularly circuitous. Below, I provide most of the records that were available when the diagnosis was made. As usual, the first person to solve the case gets a signed copy of my book, “Every Patient Tells a Story,” and the pleasure of puzzling out a difficult mystery.

Making a List

“Why don’t we make a list?” the young man’s wife suggested. Her husband, tall and slender, had been moving restlessly around the kitchen, but when he heard her words, he came and sat next to her. He was 36 and, for the past 20 years, had been plagued by pains that moved from one joint to the next. Sometimes it was an ankle; sometimes a knee. It could be his back or his hand or his wrist. And sometimes it was all of the above.

Over the years he’d seen a phalanx of doctors. They’d look him over, order an X-ray and then, seeing nothing, refer him to physical therapy. And he’d get better.

But then, within days or occasionally even weeks, something else would start up.

It didn’t seem right, his wife had said, over and over, during their years together. There had to be something else going on. Something bigger than whichever joint was hurting at the moment.

The Patient’s Story

The man had seen internists, orthopedists, rheumatologists. But after various thoughts and tests, none had seen a pattern that suggested anything more than the misfortune of frequent exercise-related injuries.

His wife had Googled his symptoms many times, but the only diagnosis she ran across regularly was fibromyalgia, a chronic pain syndrome. When she read up on that condition, though, it just didn’t seem to fit. Her husband sometimes had muscle pain, a characteristic of fibromyalgia, but most of the time his pain was in the joints themselves.

The patient had resigned himself to these aches and pains. His wife, however, had not. A friend of hers who’d suffered a lifetime of joint pain was recently given a diagnosis: rheumatoid arthritis. And that friend had enthusiastically recommended the doctor who had figured it out, a specialist in inflammatory diseases at Mount Sinai Hospital in Manhattan. Call her, her friend urged. She figured out a diagnosis that had puzzled others for years.

So she called. When her husband’s appointment was a week away, she suggested that they put together a list of everything odd that had happened to him. She could start the list, and he could add anything she left out.

An Expert Opinion

The day of the appointment, the wife tore the list out of her notebook and handed it to her husband. Don’t forget to show this to the doctor, she urged.

The man looked up when he heard his name called in the waiting room. The doctor smiled warmly as she walked toward him. She introduced herself and led him into the tiny exam room in the back. When she asked him about his medical history, he brought out his list.

In addition to his migrating joint pain, he’d had several other unusual medical problems that might be related. Most recently he’d been given a diagnosis of von Willebrand disease, a disorder of the blood coagulation system. He found that out after nearly bleeding to death following a colonoscopy.

He also had something called a geographic tongue. It wasn’t painful but looked odd. Areas of the tongue surface somehow are injured, leaving smooth, red, angry-looking patches amid the tongue’s normally velvety pink surface. Someone had told him that geographic tongue was a sign of psoriasis, but psoriasis typically causes a scaly skin rash, and he’d never had that. Plus he had scoliosis, or a curvature of the spine. He also had osteoporosis, even though everyone agreed he was way too young.

His symptoms dated back some 20 years. As a teenager, his lung had suddenly ruptured, a condition known as a pneumothorax. Doctors had fixed the collapsed lung, but then it happened again. That second time they’d fixed it permanently. No one could explain why that happened.

Indeed, no one could explain any of his weird medical problems.

Other people in his family were sick, but not in the same way. His mother and brother had Crohn’s, a form of inflammatory bowel disease. Crohn’s disease usually causes bloody diarrhea, but it can also make your joints and muscles ache, so one of his doctors suspected he might have it too. That’s why the patient had been given that colonoscopy that had gone wrong. But it turned out he didn’t have Crohn’s.

Normal Joints

Any redness or swelling in his painful joints?, the rheumatologist asked. Never, he told her.

Any joint stiffness in the morning? None.

Had he ever been tested for arthritis?, she asked. Oh, many times, he replied. The tests had all been negative.

He never smoked, never drank, never used any illegal drugs. He hardly even took Tylenol. He was vegan and took vitamin B12 daily to make certain he didn’t run out of this essential nutrient, which is found in meats. He was married, had two children (both pretty healthy) and worked as a lawyer. He exercised most days, even when his joints hurt.

On exam, the doctor found a few clues. There was the geographic tongue he’d already told her about. And his fingernails had tiny longitudinal ridges, something that can be normal but that is also seen in certain types of arthritis. However, his joints, the source of his main complaint, seemed completely normal. There was a little bit of tenderness in the sacroiliac joint, where the two bones that make up the hip girdle meet. However, even here there was no redness, no swelling, nothing abnormal.

A Confusing Picture

Whatever the patient had, it certainly wasn’t obvious, the rheumatologist told him once he’d gotten dressed.

One possibility she was considering was a condition called psoriatic arthritis, or PsA, an unusual and aggressive type of inflammatory arthritis that can affect people with psoriasis. The geographic tongue, the ridged nails, the family history of Crohn’s disease were all seen in psoriatic arthritis. And in PsA, the usual tests for arthritis will be negative.

But it wasn’t a slam dunk. The patient clearly didn’t have psoriasis — at least not yet. But the arthritis could precede the skin rash, sometimes by years. And although most people with psoriatic arthritis have pain, swelling and redness as well as severe bone destruction, some have only mild symptoms, like this man.

She’d get some blood tests to look for inflammation, she told the patient, and gets X-rays to look for the kind of bony destruction psoriatic arthritis can cause. But even if those tests weren’t informative, she planned to start him on a very gentle medicine that was effective in reducing the pain and joint destruction.

A Drug Trial

The blood tests and X-rays were unrevealing, and so at the next visit she started the patient on sulfasalazine, one of the oldest drugs used to treat both inflammatory arthritis and inflammatory bowel diseases (like Crohn’s).

He took the drug for three months. No relief. She gave it another few weeks. Still, nothing. Perhaps this wasn’t an inflammatory arthritis after all.

There was one final treatment she could try. If he didn’t respond to a week of daily prednisone, a steroid pill, he wasn’t likely to respond to any of the other anti-inflammatory medications used in the treatment of these diseases.

The steroid did nothing but keep him awake at night. The constant roving joint pains continued unabated.

The doctor was disappointed but clear. Whatever he had, it wasn’t an inflammatory disease. She was sorry, but she didn’t think she could help him.

You can view the rheumatologist’s notes here.

Rheumatology Notes

These are the doctor’s notes.

You can view the lab results here.

The Patient’s Labs

Here is a copy of the lab report.

Solving the Mystery

The patient was discouraged but not surprised. Yet another doctor was unable to figure out why he had all these weird problems. His wife was crushed. This doctor had figured out what was wrong with her friend; why not her husband? Maybe it was just fibromyalgia. Or just really bad luck.

But the patient did end up getting a diagnosis. From an unexpected quarter. Can you figure out what this patient has?

The first person to figure out the diagnosis will get a signed copy of my book, and that great feeling you get which you solve a tough case.

I’ll post the answer tomorrow.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Think Like a Doctor: Drowning on Dry Land Solved

On Thursday we challenged Well readers to unravel the case of a 67-year-old healthy retiree who suddenly developed knife-like chest pain and a worsening cough. Maybe this case was too easy because more than a quarter of you figured it out.

The correct diagnosis is:

Eosinophilic pneumonia, caused by the antibiotic daptomycin (brand name Cubicin)

The first reader to make this not-quite-as-tough-as-I-thought diagnosis was Francis Graziano, a second-year medical student at Georgetown University School of Medicine. He had just learned about daptomycin and recalled that there were some pretty dramatic side effects linked to it. And the time course seemed right. So he went to the Wikipedia page on the drug and saw that this type of pneumonia was a known adverse reaction to it. Francis is another two-time winner, having solved another tough case two years ago. Well done, Francis.

The Diagnosis

Daptomycin is an antibiotic used primarily to treat drug-resistant staph infections. It was approved by the Food and Drug Administration in 2003.

The first report suggesting a link between this antibiotic and pneumonia was made in 2007. An 87-year-old man who, like this patient, was being treated with daptomycin for an infection after knee surgery lost 15 pounds over the course of just a few weeks and became increasingly fatigued. A CT scan of his chest revealed multiple nodules, and when these nodules were biopsied, the patient was found to have a pneumonia.

But it was an unusual pneumonia. Instead of finding bacteria or the usual infection-fighting white blood cells in the lungs, the sample showed a handful of eosinophils (or eos), a type of white blood cell that normally fights off parasites (like intestinal worms) but can also be seen in allergic reactions. The doctors suspected that the pneumonia was an allergic reaction to the daptomycin. They stopped the drug, and the pneumonia resolved.

As a result of this case report, the F.D.A. put eosinophilic pneumonia on the list of possible adverse reactions. By 2011, 11 cases had been reported, enough to convince the F.D.A. that the link was real.

Eosinophilic pneumonia is an unusual disorder and is usually caused by exposure to certain drugs or toxins or radiation therapy. The most common trigger is cigarette smoke, and the illness may occur in those who recently started or restarted smoking. More than 300 different medications have been linked to eosinophilic pneumonia; antibiotics and nonsteroidal anti-inflammatory drugs such as ibuprofen are most commonly cited.

How or why this pneumonia develops is not clear. Men are more likely to be affected than women. In the cases of eosinophilic pneumonia associated with daptomycin, patients were all over age 60.

How the Diagnosis Was Made

Dr. Robert Centor was the doctor on call when the patient was admitted to the hospital. The patient was seen by the resident on his team, who called to tell him about the 67-year-old man with the infected knee and a week-long pneumonia.

Dr. Centor was intrigued. Why would a pretty healthy guy on antibiotics for one infection develop a second infection? He was getting his antibiotics through an intravenous catheter than ran from a vein in his arm into his heart. Could some type of skin bug have traveled up the catheter into his heart, and from there into his lungs?

He asked the resident to make sure that the patient had a CT scan of his chest to look for tiny pieces of infection, known as septic emboli, which might be clogging up the blood vessels in his lungs. The patient got the scan, which showed only the fluffy clouds dotted throughout his lungs.

The next morning, Dr. Centor went to the radiology suite to review the chest X-ray and CT scan with the radiologist. No septic emboli were present. After confirming what he’d already heard the night before, the internist headed up to see the patient with his team.

Looking for Answers

After talking to the patient and examining him, Dr. Centor was certain of two things. First, that the patient was seriously ill. Second, that he wasn’t sure why. It didn’t make any sense at all that this youthful 67-year-old retiree should suddenly develop a whopping double pneumonia.

Certainly bad things can happen to healthy people, but Dr. Centor liked to understand why. In this case, “I was completely befuddled,” Dr. Centor told me in his thoughtful Southern twang. We were old friends; he had been a wonderful teacher and mentor to me. “But whenever I am befuddled, I just talk to other people,” he told me.

I know from my own experience that often enough, just posing a case to a colleague as a question can prompt you to see it in a different light and reveal an answer you hadn’t considered. And if you’re really lucky, the answer comes from asking someone who has previously come across a similar case. So Dr. Centor, who was the dean of his residency program, headed to the cafeteria, where he grabbed a cup of coffee and scanned the room for familiar faces. He settled down at a table full of doctors and residents and quickly outlined the case.

The Right Place, the Right Time

Mohamed Raja, a resident in his second year of training, listened carefully to the case. “It was a matter of being in the right place at the right time,” he told me. Because as soon as Dr. Centor mentioned the name of the antibiotic the patient had been getting, the resident realized with a jolt that he knew the diagnosis.

Well, he said to Dr. Centor, he had been reading up on Cubicin just the week before. And there was this rare complication associated with the drug that had caught his attention. It was an allergic reaction that manifests itself as a terrible and painful pneumonia, caused not by an infection but by the patient’s own white blood cells, the eosinophils.

Hearing of this unusual reaction, Dr. Centor quickly pulled out his cellphone and looked up Cubicin and eosinophilic pneumonia. Sure enough, this unusual side effect, first described just a few years earlier, seemed to fit his patient exactly.

The only way to know for certain was to get a lung doctor to put a scope into the patient’s lungs and see if these specialized cells, the eosinophils, were there. They shouldn’t be. But first he had to stop the medication.

Dr. Centor called the nurses to make certain the patient didn’t get his next scheduled dose. Then he went upstairs to tell his team and the patient.

Waiting for Watson

It is the nature of medical knowledge that no one knows everyone. We doctors all learn the same basics, and what we add depends on the patients we see and the interests we pursue. One of the key skills all doctors must hone is how to recognize and supplement these almost inevitable gaps.

The Internet has made this kind of supplementation much, much easier. For example, when Dr. Centor first told me about this case, he gave me the outline and asked what I thought was going on – a game we often play. I didn’t know, but what I call “test logic” told me that if he was telling me the name of the antibiotic, it had to be part of the answer. So I Googled the terms “daptomycin” and “pneumonia” and whammo, I got the answer immediately.

Last fall, IBM announced that it is developing a health care business based on its supercomputer, Watson. Using the same data-accumulating skills that allowed Watson to conquer “Jeopardy!” in 2011, the goal is to master all medical knowledge – new and old – so that we won’t have to. But until then, doctors must continue to rely on their own data accumulating skills.

Dr. Centor turned first to the traditional method, the who-wants-to-be-a-millionaire option of phoning a friend, before turning to other sources. Will Watson – or any of the other emerging databases – fully replace human recall and thought? They haven’t so far.

How the Patient Fared

The patient had the bronchoscopy the next day. He had eosinophils and no signs of infection. He was started on high-dose steroids to calm the allergic reaction, and the Cubicin was replaced with another antibiotic for the last weeks of treatment.

It’s been four months since his scary pneumonia episode, and the patient tells me he feels just fine. He’s resigned to the fact that his knee may never be perfect. But breathing? No problem.

As for his fishing camp, it’s closed for the winter. But he’ll be back as soon as the weather, and his knee, allow.

Think Like a Doctor: Drowning on Dry Land

The Challenge: A healthy 67-year-old man develops an annoying little cough that, over the course of a week, worsens and nearly takes his breath away. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine challenges Well readers with a real-life diagnostic question. In this case, a retired Air Force officer shows up in an emergency room with chest pain so severe he can barely breathe.

I will provide you with the history, data and imaging available to the doctor who made the diagnosis. It’s up to you to make it all make sense.

The first person to identify the cause for these symptoms will win a copy of my book, “Every Patient Tells a Story.”

The Patient’s Story

“I think you’re dying,” the anxious wife told her husband of 38 years. Her 67-year-old spouse sat propped up at the head of the bed. His chin rested on his chest and his face bobbed up and down with each rapid fire breath. He gazed up at her from beneath his shaggy gray eyebrows.

“I’m going … to be … O.K.,” he panted in a whisper.

She didn’t think so, and she wasn’t alone. She had just spoken to one of his oldest friends, and he was worried too, she told her husband. The friend thought they should go to the hospital.

“Now?” the man breathed.

She nodded. He finally nodded in return. He would go.

A Knife in the Back

It all happened so fast. An annoying little tickle that started maybe a week before was now a great wracking cough. Every breath felt like a knife cutting through to his back. The pain was so severe he couldn’t take a deep breath, and he felt like there was so much stuff in his lungs that the little breaths he could take didn’t bring in enough air.

As he sat on his bed struggling to breathe, he suddenly flashed back to a morning many years ago when, as a small child, he’d fallen into the deep end of the pool. He sank to the bottom, arms and legs flailing, the need for breath overwhelming. Suddenly he saw an explosion of bubbles, then felt strong hands lift him up, back into the air. Back where he could breathe.

Now more than 60 years later he felt like he was struggling the same way. This time without the water, but still in need of rescue.

The 30-mile drive from their home to Huntsville Hospital in Huntsville, Ala., was mostly on the interstate, but every tiny bump or dip brought a soft grunt of pain. The man held onto the strap above the window, willing himself motionless.

His wife walked him into the emergency room, then hurried to park the car. By the time she got back he was already in a bed and, with oxygen piped into his nose, a little more comfortable.

Downhill at the Fishing Camp

Dr. Robert Centor, the attending physician on call at the hospital, had heard about the patient the night before and was eager to see him the next morning on rounds.

He’d started off with a little nothing of a cough, the man told Dr. Centor. He mentioned it to his own doctor just before he went out to his fishing camp with some pals. After listening to his lungs, his doctor had pronounced him “just fine.”

But the cough kept getting worse, going from occasional to constant practically overnight. He couldn’t read or eat or sleep. Lying down made it even harder to breathe, so he spent two nights in a recliner. And the friends who’d come to the camp with him got absolutely no sleep because of his persistent hacking.

The third day of their trip, his chest began to hurt. Every breath felt like a dagger. Moving made it worse. So did breathing. He got out of breath just walking to the kitchen. His friends were worried. And, finally, so was he.

As soon has he got home his wife took him to the local emergency room. A chest X-ray showed cloudy white patches over both lungs. He had no fever nor any sign of infection, and so the E.R. doctor figured it was probably his heart. The patient could stay in the hospital and see his doctor there or go home and see her in her office the next day.

It was an easy decision: He’d much rather go home. The E.R. doctor admonished the patient to see his doctor as soon as he could and let him leave.

A Problem Heart?

The patient saw his doctor a couple of days later, and a brief exam convinced her that the E.R. doctor was right: It probably was his heart. It was hard to imagine any other reason for there to be clouds all over both of his lungs. Not too many things could do that. You could see it with a whopping pneumonia – but he had no fever or other signs of infection. Or you could see it with something known as congestive heart failure, which is what the emergency room doc thought he had.

Congestive heart failure reflects a problem not with the lungs but with the muscle of the heart, the doctor explained. It gets injured somehow – maybe because of a heart attack or infection – and suddenly it can’t beat as strongly as it had. Fluid from the blood, which should have been pumped out into the body, was instead backing up into his lungs.

She sent him home on a powerful diuretic to help draw the water out of his chest and arranged for him to have an echocardiogram, an ultrasound of his heart, to confirm her diagnosis.

The diuretic kept him in the bathroom for much of the next two days, but it didn’t seem to help at all. And so his wife, with the support of his friends, finally convinced the breathless man not to wait for the “echo” but to go right then to the big university hospital in Huntsville.

A Healthy Guy, Until Now

As the man and his wife told their story, Dr. Centor took a good look at his new patient. He was tanned and trim – clearly not someone who spent much time being sick. But he coughed frequently, and every paroxysm brought a grimace of pain to his face.

Before this, the man told him, he’d been pretty healthy. He took a medication for high blood pressure and another for his heartburn. A month earlier, he’d had knee surgery, an operation that left him with a big pus-filled wound – red, hot and incredibly painful. So, for the past few weeks his wife had been injecting a syringe full of an antibiotic, called Cubicin, into an intravenous line he had snaking up through his left arm. It was clearly doing its job because, although his knee was still pretty sore, there was no more pus and it looked a whole lot better.

He quit smoking five years ago. He drank sometimes with his pals on special occasions but hadn’t had anything since he started taking the antibiotic. He exercised regularly, at least before the surgery.

The couple had a dog, but no birds or other pets. He had retired five years earlier, but during his career he had been assigned to bases all over the world – especially the Middle East. He spent a lot of time in Afghanistan. And he’d done some time as a pilot in Vietnam, where he’d been exposed to Agent Orange, the herbicide used there that had been associated with many health problems later in life.

Working to Breathe

On exam, the patient’s breathing and heart rate were high and his oxygen level was low – a bad combination.

Dr. Centor gently placed a hand on each side of the patient’s neck and could feel the strap muscles there tense with every breath. These muscles are recruited to help breathing when needed; they pull the rib cage up to help the patient suck in more air. And when Dr. Centor listened to the patient’s lungs he heard a cacophony of tiny snaps with every breath, as if inside his ribs a sheet of bubble wrap was exploding. His knee revealed a well healing surgical scar.

Dr. Centor had already seen the X-ray and CT scan done the day before. You can see the chest X-ray and the CT report here.

The chest X-ray showed cloudy white patches over both lungs.

The chest X-ray showed cloudy white patches over both lungs.

The CT Report

Reviewing the Notes

The radiologist thought it was an infection, and so the patient had been started on the usual antibiotic combination for pneumonia. But why had this healthy retiree developed a whopping pneumonia – not in part of one lung, which is usually what occurs with pneumonia, but all over, and in both lungs?

Dr. Centor reviewed the notes from the E.R. and from his resident, and the data from the labs. You can see those notes and labs here.

Emergency Room Note

The Resident’s Note

The Lab Reports

Solving the Mystery

What was he missing? Dr. Centor asked himself.

He figured it out. Can you?

Submit your responses in the Comments section. As usual, the first person to figure out the diagnosis gets a copy of my book. And that warm satisfaction that comes from solving a mystery.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.