Monday, August 30, 2010
I've had a lot of friends who aren't in the medical field ask me if medical school is like TV.  Between Scrubs, Grey's Anatomy, House, ER, and all the other medical shows, you can pretty much get a totally clear picture of what being in medical school is like...

Okay, maybe not.  But there are occasions when it feels like I'm living in a TV show.  Sometimes it's when rumors spread about who is dating who.  But sometimes, it's because of a patient who actually fits the picture of one you might see on TV.  It's especially rare to have a patient resembling a patient that you might see on House.  Mostly, that's because those patients don't really exist.  Sure, there are crazy odd diseases that you only learn about it books and rarely see.  But when someone has one of those, you generally end up ruling out the normal stuff in a couple days, and then shotgunning until you find the one strange disease.  And it takes longer than normal to make a diagnosis... maybe a week.  But you find it.  And treat it.  And they get better, or not.  But it's exceedingly rare to have a patient who you can't diagnose, and when you do, you treat them, and then their spleen blows up, or their eyes start to bleed, or their blood turns green.  That's just not how it happens. 


Which means that occasionally, VERY VERY occasionally, you get one of those patients.  I have one of them now.

Back in January, she started having some muscle weakness.  Nothing major, just felt like she didn't have the strength she usually did.  They didn't find anything obviously wrong with her, and thought it was likely related to a sinus infection, which was treated with antibiotics.  She had a bit of a reaction to the antibiotics, but seemed to do okay.  Through the spring, her muscle weakness got a progressively worse, and she started having regular fevers to about 101F.  Workup didn't reveal any source of infection, and neurology didn't initially know why she was weak. 

In May, she came into the hospital because of abdominal pain.  If you go back a couple days, you'll see my post on abdominal pain, and how easy it is to figure out what's wrong.... right.  So she got the whole workup, including ultrasounds, CT scans, blood work, etc.  It revealed that she has many enlarged lymph nodes throughout her body, and a splenic infarct.  There was concern for some sort of cancer, which would explain the lymph nodes, as well as the clot causing her splenic infarct.  She was stabilized, and sent home to continue the workup as an outpatient.  During the next few months, her muscle weakness progressed to the point where she could no longer stand, and barely could lift her arms.  She continued to have fevers, was anemic, and underwent two lymph node biopsies that did not show any cancer.  They decided to get a muscle biopsy to see if it would reveal the cause of her weakness.  It showed likely dermatomyositis, and inflammatory myopathy that is an autoimmune disease frequently (about 25% of dermatomyositis cases) associated with cancer. 

So she was admitted to the hospital again to begin treatment for the dermatomyositis.  Rheumatology recommended high dose steroids, as well as IVIG.  She started this therapy, and was also seen by nephrology because her kidneys were not working.  Previous biopsy of her kidney showed glomerulonephritis likely caused by Lupus or something similar.  But all of her lupus labs had been negative.  Lupus would likely also respond to the steroids, which it did initially, then her kidneys started getting worse again. 

A couple days after her steroid dose was decreased, she suddenly developed a hemolytic anemia, and her hemoglobin dropped from 8.9 to 6.2 in about 24 hours, and her platelets dropped to 30 (from about 200).  We called heme/onc again (they had signed off on her, saying they couldn't find any source of cancer that might be associated with her dematomyositis).  They listed a number of things that might be causing the anemia, and wanted to do a bone marrow biopsy to see if they could find anything.

Meanwhile, our patient had worsening of some "floaters" in her vision, so ophthalmology saw her and said she has some sort of vasculitis or inflammatory process affecting the capillaries in her retina. 

So, after the bone marrow biopsy, nephrology and rheumatology wanted to start cytotoxic therapy for her likely lupus/autoimmune overlap syndrome, but they wanted to make sure she wasn't infected at all because if she was, she could quickly become very very sick.  As if on cue, she started spiking fevers to 104F, became short of breath, and started coughing up blood. 

We got a chest CT that showed "ground glass opacities" (no one really knows what that signifies), which could be bacterial, fungal, PCP, hemorrhage, fluid, or something else.  She also had pleural effusions that were pretty large.  Because no source of infection can be identified, infectious disease was consulted, and recommended bronchoscopy to get a sample from inside her lungs, and also recommended draining the pleural effusions to look for infection or occult malignancy.  Heme onc agreed, and also wants to do a core biopsy of one of her lymph nodes.  Most people thinks there is still a high likelihood that there is underlying cancer, but we can't find it.  She's had everything scanned, had endoscopy and colonoscopy, and biopsies.

We've consulted infectious disease, rheumatology, nephrology, pulmonology, and ophthalmology (interventional radiology and anesthesiology are likely on the list for tomorrow...).  She's also seen neurology and neurosurgery. 

And we still can't figure out what is causing all this. 

I think I'm going to call House and see if he can help.


About Me

I am a Family Medicine intern at a community hospital in Indiana, navigating the new world of being a physician. I am privileged to work in a field I love, where every day is a new and unpredictable challenge.
I am not only a doctor, but also a cyclist, runner, DIYer in the making, lover of the outdoors, traveler, and human.
Human, MD is a glimpse into the world of a young doctor who is just trying to stay true to herself through the grueling whirlwind of residency.


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