On Thursday, we challenged Well readers to take on the complicated case of a 50-year-old woman who felt feverish and couldn’t stop vomiting and who ended up losing a lot of weight. Like the doctors who saw her as she searched for a diagnosis, many of you focused on her recent journey to Kenya as the source of her symptoms. It was a completely reasonable approach, and one that was extensively explored by the doctors who cared for her. But ultimately it was incorrect.
This was a really tough case. Indeed, only three of you got it right. The correct diagnosis was:
The winning answer came from someone I wasn’t able to reach as of the time we posted the answer – identified only as Cynthia from Edwardsville, Ill. We had a little trouble with our comments software, but her answer came in just 35 minutes after our glitch was overcome. Congratulations to our winner!
Thyroid hormone controls metabolism. The more of this hormone flowing in the body, the harder the body works. Because this hormone plays such an important role in how we function, the body tightly regulates how much of it is released and when. But just like every other system in the body, that regulatory mechanism can mess up, releasing either too little hormone (hypothyroidism) or, as in this case, too much.
The usual symptoms of hyperthyroidism are pretty apparent: The heart races; patients are sweaty, shaky, itchy and sometimes feverish. The appetite increases, but because the entire body is revved up, there is often weight loss. Bowel movements become more frequent and sleep harder to come by. Frequent and uncontrolled vomiting is less common but has been reported. This patient had all of these symptoms.
The most common cause of hyperthyroidism is an autoimmune disorder known as Graves’ disease, named after Dr. Robert Graves, a 19th-century Irish physician who wrote about the phenomenon of rapid and violent palpitations associated with an enlarged thyroid gland. In the 20th century it was discovered that the symptoms result when antibodies, the foot soldiers of the immune system, cause excess stimulation of the thyroid gland, resulting in the uncontrolled production and release of thyroid hormone.
These antibodies are usually produced in response to some type of infection. Once the infection is eliminated, these tiny infantrymen are supposed to return to their barracks and wait for another invasion. Sometimes, though, a few go AWOL and attack a person’s own healthy body parts. In Graves’ they attack the thyroid gland and, in the process, send a message to make and release thyroid hormone, whether it is needed or not. The result is much too much hormone and much too much stimulation.
The disorder can be treated either with drugs that slow the production of the hormone within the gland or by radiation, which can destroy the gland itself. After radiation treatment, patients usually have to take thyroid hormone to replace what their gland would have made otherwise.
If untreated, hyperthyroidism can be life-threatening. The rush of thyroid hormones that ensue can cause heart failure or abnormal rhythms, leading to sudden death. Indeed, up to 90 percent of patients with untreated severe hyperthyroidism – a condition called thyroid storm – will die without treatment.
How the Diagnosis Was Made
The patient, a 50-year-old woman recently returned from a monthlong visit to family in Kenya, had felt pretty bad almost from the moment she got off the plane. She felt tired, sweaty, feverish and nauseated.
Initially she attributed it to jet lag, but after a week she thought she must have some kind of flu. When she didn’t feel better after two weeks she went to a doctor. Her theory was that this was malaria. She’d had it as a kid, and this was the way she remembered feeling back then.
It was a compelling theory, and many of the doctors she saw over the next couple of months agreed that it could be malaria, which is caused by a parasite. Although the patient had taken a medication to prevent her from getting the infection, there are some forms of the parasite that aren’t stopped by the prophylactic drugs.
She was treated for malaria, and when she continued to worsen she was sent to a hospital. Three times her blood was examined for any signs of malaria. Three times they found nothing.
During the patient’s second hospitalization the doctors broadened their search. If it wasn’t malaria, what other infection might it be? They searched for every parasite, bacteria and virus they could think of. All were negative.
Was it a rheumatologic disease? They sent off a few tests. All negative.
Was this a side effect of some kind of cancer? They looked but didn’t find any sign of malignancy.
Finally, the team sent her home, telling her to check back with the infectious disease specialist. There were still a couple of test results that hadn’t come back that would need to be followed up. Plus, even though they hadn’t figured out what was making this woman so sick, they figured it was probably some kind of infection.
A Friend’s Help
When the patient returned home, after nearly three months of this terrible illness, she was still sick and weak. She called her closest friend. She was too ill to care for her children or even herself. Could she come and stay with them until she got better?
Of course, her friend told her. But when she arrived, the friend was horrified by how bad she looked. She needed to see her own doctor. That doctor had been out of town when she first got sick, and she’d been too sick to even think beyond the doctors at hand. But as soon as her friend suggested it, she knew it was the right thing to do. This doctor that she’d known for nearly 20 years, she would know what to do.
A Familiar Face
Dr. Marie T. Brown was shocked by the appearance of this patient she knew so well. Normally she’d see her once a year for a routine physical; they’d catch up on life and health and then say goodbye until the next year. She always looked healthy and robust. But not now.
She had clearly lost a lot of weight; her eyes were prominent in her much thinner face. She was hunched over a basin, and the acrid scent of vomit filled the air. Her left leg trembled and jerked uncontrollably. What in the world happened to you, the doctor asked?
The patient, helped by her friend, filled in the doctor about the events of the previous weeks. Dr. Brown didn’t have access to the hospital’s electronic medical record so she knew only what the patient could tell her. That she hadn’t felt well since returning from Kenya. That the doctors initially thought she might have malaria but now they weren’t sure what she had. And that she had never felt so sick and weak in her life.
A Physical Exam
Could she get on the exam table, Dr. Brown asked the patient? The doctor and the friend helped the patient up.
Starting at the head, Dr. Brown worked her way systematically down the body. At her neck she stopped. The patient’s thyroid gland was much larger than normal. It wasn’t tender, but it was big. And Dr. Brown was pretty sure that was new.
She finished the exam quickly. The patient’s reflexes were wild. A little tap sent arms and legs flying. And the left leg seemed to have a life of its own: shaking, jerking, trembling. She excused herself and stepped out, “to read up on something.” She was back a few minutes later.
Confirming the Diagnosis
When Dr. Brown returned she was pretty certain of the diagnosis: The patient had hyperthyroidism. She might even be in thyroid storm – the most severe form of the disease.
She’d called an endocrinologist friend and arranged for her to meet the patient in the emergency room as quickly as they could get there. They had to confirm the diagnosis with a blood test and then start the treatment.
By late that afternoon, the diagnosis was confirmed. The patient was started on a medicine to slow her heart down and another to block the release of more thyroid hormone.
How the Patient Fared
That was just over three years ago. It took more than a year, but the patient recovered and these days feels pretty well.
Dr. Brown was grateful that she could figure out what was going on but wanted to reach out to the institution where her patient had been seen and share the true diagnosis with the doctors who had missed it. They were shocked. And horrified.
Dr. David Ansell, the chief of medicine at Rush Medical Center, the hospital where the patient had gone, felt that this case was too important to not use it to teach other doctors about the errors we make in medicine. “I’m a big believer that every defect is a treasure,” he told me.
Dr. Ansell organized a daylong conference for the doctors on staff at the hospital and invited the patient and the doctors who cared for her — both Dr. Brown, who got the diagnosis right, as well as all those who didn’t — to come and discuss how this diagnosis was missed and what they could learn from the case.
Autopsy of a Medical Error
It was certainly a difficult diagnosis. The patient felt feverish and tired after a trip to Kenya. She thought she might have gotten malaria again – even though she’d taken the meds – because she thought she felt as bad as she had when she’d gotten malaria as a child.
It’s not surprising that the doctors went along with that diagnosis, since the No. 1 cause of fever in a returning traveler from that region is malaria. And, since she’d had it before, she was more of an expert than any of them were.
And then, once it was clear that it wasn’t malaria, it was hard for the doctors caring for the patient to completely divorce themselves from the idea that this was an infectious disease. That is certainly the most common cause of fever and one of the most important causes of nausea and vomiting. And once they had started down this pathway, it was difficult to change direction.
If there was another failure here, I think it must have been a loss of faith in the physical exam. As far as I could tell, the patient never had a documented fever, though she felt hot. She was tachycardic, sweaty, tremulous. And she had an enlarged thyroid. Although this last piece of data, the enlarged thyroid, was never noticed by the hospital doctors, even without it she was a perfect picture of too much thyroid hormone. Still, the story she told trumped the story told by her body.
Dr. Brown didn’t have access to the whole story. She had the vomiting, tremulous patient and her friend who told the story as well as they could. She had to rely on the data provided by the exam to augment that provided by the patient.
When she felt the enlarged thyroid, she immediately considered hyperthyroidism. Everything fit — except the vomiting. She excused herself in order to make certain that vomiting could be part of that diagnosis. Seeing that it is an unusual symptom, but one that has been well described, she concluded that hyperthyroidism was the most likely diagnosis, and she made arrangements for the patient to be seen by an endocrinologist right away.
Dr. Ansell is a firm believer that patient safety requires doctors and hospitals to be transparent about errors that occur and reflective about how they were made. Shouldn’t this be the attitude everywhere?