Fascinomas -Fascinating Medical Mysteries.
Clifton K. Meador, M.D.
“Fascinomas” are fascinating by their very nature; they are stories that illustrate the reasoning of the master diagnostician faced with the complexities of daunting clinical challenges... They are object lessons in the essence of the shared journey between patient and physician: both are immersed in a particular clinical narrative, both hope for insights that can solve the illness experience, both try to fathom the idioms each contributes to the dialogue, and both are committed to this trusting alliance... Every patient is his or her own fascinoma.
Nortin M. Hadler MD MACP MACR FACOEM
Professor of Medicine and Microbiology/Immunology
University of North Carolina School of Medicine
Author of The Last Well Person, Worried Sick, Stabbed in the Back,
Rethinking Aging, and Citizen Patient
Clifton Meador is a superb story-teller who has been teaching and practicing medicine for more than 50 years. He knows how to “plot” a Medical Mystery. At the same time, he reveals how some of our best doctors arrive at the right diagnosis the old-fashioned way-by listening to their patients.
His experience has taught him that touching, asking questions, listening, and truly “seeing” the patient are the sensory arts that may be lost if physicians become too dependent on “reading” tests. His tales tell us what health care reformers mean when they talk about “patient-centered medicine.”
Maggie Mahar
Author of Money Driven Medicine
Editor of Healthbeatblog.
Using a simple and direct language, Dr. Meador delivers charm, wit, and always surprising stories that carry fundamental teachings dedicated to the best service to the patients and the profession. I have been reading his books with great delight since the 1990’s, and have enjoyed translating them into Spanish for discussions with my students. The curious cases he presents in his books underscore how difficult it can be to reach the proper diagnosis and the right treatment without the dedication of true doctors.
Ximena Páez M.D.
Professor
Laboratory of Behavioral Physiology
School of Medicine
Universidad de los Andes
Mérida-Venezuela
Copyright 2013 Clifton K. Meador, M.D.
ISBN: 1491029277
ISBN 13: 9781491029275
Library of Congress Control Number: 2013913504
CreateSpace Independent Publishing Platform
North Charleston, South Carolina
Other Books
by Clifton K. Meador, M.D.
A Little Book of Doctors’ Rules, Hanley & Belfus, 1992
With R. H. Lanius, A Little Book of Nurses’ Rules, Hanley & Belfus, 1993
With W. Wadlington, Pearls from a Pediatric Practice, Hanley & Belfus, 1998
A Little Book of Doctors’ Rules II, A Compilation, Hanley & Belfus, 1999
With C. M. Slovis and K. D. Wrenn, A Little Book of Emergency Medicine Rules, Hanley & Belfus, 2000
With W. Wadlington and M. Howington, How to Raise Healthy and Happy Children, iUniverse, 2001
Med School, Hillsboro Press, Providence Publishing Corporation, 2003
Symptoms of Unknown Origin, A Medical Odyssey, Vanderbilt University Press, 2005
Twentieth Century Men in Medicine: Personal Reflections, iUniverse, 2007
Puzzling Symptoms: How to Solve the Puzzle of Your Symptoms, Cable Publishing, 2008
Med School, Revised Edition, Cable Publishing, 2009
True Medical Detective Stories, CreateSpace, 2012
Clifton K. Meador, M.D.
Author of True Medical Detective Stories
Table of Contents
Foreword
Acknowledgements
Chapter 1 A Puzzling Paralysis
Chapter 2 A Sticky Situation
Chapter 3 The Cause of Some Symptoms Can Be Illusory
Chapter 4 Seasonal Disorder
Chapter 5 Snakes on a Porch
Chapter 6 A Lag in Medical Knowledge
Chapter 7 A Dose by Any Other Color
Chapter 8 First Diagnosis of Death
Chapter 9 Medicine Can Be a Humbling Profession
Chapter 10 Mysterious Mammaries
Chapter 11 The eye does not see what the mind is
not prepared to know
Chapter 12 A Drug to Prevent a Complication Causes
the Complication
Chapter 13 Miss Information
Chapter 14 An Uncommon Cure
Chapter 15 Shining a Light on the Problem
Chapter 16 What You Don’t Know Can Kill You
Chapter 17 Out of the Mouths of Babes
Chapter 18 Keeping Secrets
Chapter 19 2+2=Fortunate
Chapter 20 A Korean Experience
Chapter 21 Gut Reaction
Chapter 22 Bite the Hand That Feeds You
Chapter 23 Remembrance of Things Past — Marcel Proust
Chapter 24 Sometimes the cause for a disease can
only be heard
Chapter 25 Labels That Stick
Chapter 26 Learning to Speak the Language
Chapter 27 Sometimes the Answer to a Single Question
Solves the Mystery
Chapter 28 Strange Intuition
Chapter 29 “Extratebreastrial” Communication
Chapter 30 The Honeymoon
Chapter 31 A Case of Overkill
Chapter 32 Some Mysteries Remain Mysteries
Chapter 33 A Case of the Blues
Chapter 34 Open and Shut Case
Chapter 35 Itch in a College Student
Chapter Notes
Biography of Clifton K. Meador, M.D
Fascinomas – fascinating medical mysteries
Foreword
Fascinoma combines the words “fascinate” with “oma.” The suffix “oma” usually denotes a growth or tumor. The Merriam-Webster Collegiate Dictionary defines fascinating as “to be irresistibly attractive or to command the interest of or to be extremely interesting.” Thus a fascinoma is medical slang for an unusually interesting medical case.
Fascinomas are patient stories that are indelibly stored in the minds of physicians. They are stories told over and over in hospital medical lounges. Every physician has at least one fascinoma to tell.
Following publication of True Medical Detective Stories this past year, I have been flooded with requests for more patient stories. True Medical Detective Stories was dedicated to the memory of Berton Roueche’, noted writer for the New Yorker and the creator of the genre of medical detective stories. There were 19 patient stories in the book, most of which were solved by listening and talking.
Fascinomas, in most cases, are also medical detective stories. They often require some special effort by the patient or the physician or both to unravel the underlying causes. The causes of the illness may be obscure or rare or even unheard of before. Many fascinomas are so rare they are one time occurrences – unique to the particular patient. Some, as you will read, are self inflicted.
Over the past year I have asked colleagues to share patient stories with me. This book is a compilation of 35 such medical mysteries or fascinomas. Nearly all emphasize the need for the physician to hear and understand the life narrative of the patient. They reinforce the old dictum that it is as important to know the patient with the disease as it is to know the disease.
My method in writing these patient stories has been to stick very closely to the clinical story and facts. By facts I mean all symptoms, physical findings, laboratory findings, and results of any imaging studies; these are
all true. All of the patient identifiers have been changed. None of the patient names are true nor are any of the geographic details accurate. All have been altered to protect the privacy of the patient.
Some of the physicians allowed me to use their real names in the stories. All of the other physicians’ names are fictitious. At the end of each chapter, the physician who shared the clinical facts is identified.
Acknowledgements.
Many friends, colleagues, and physicians have contributed to this book.
I want to thank especially those physicians who have shared patient stories or who made editorial suggestions and comments about the manuscript. These physicians are Paul Barnett, Sidney R. Block, Jack Fisher, Robert Foote, Rand Fredericksen, Alan Graber, Jim Jirjis, Lloyd King, Robert Latham, John Newman, Ximena Paez, Alan Siegal, Betty Ruth Speir, William Stoney, Curt Tribble, Will Van Derveer, Larry Wolff, and Michael Zanoli.
I appreciate the suggestions or editorial comments of Virginia Fuqua-Meadows and my daughter Mary Kathleen Meador. I am thankful for the encouragement from Dr. Nortin Hadler and Maggie Mahar. My classmate Dr. Oscar Crofford and his wife Jane made many helpful suggestions.
I especially appreciate the superb editing job done by Beth Stein. She added so much to the telling of the stories.
And most of all I appreciate the support and editorial comments of my wife Ann Cowden Meador.
Cover Design:
Mark Cowden
Nashville
Chapter One
A Puzzling Paralysis *
Being clumsy is one of the many unfortunate symptoms that often plagues young teenagers. But when Julia Wilkinson began bumping into furniture with some regularity, her mother Marie took note.
It was just a week after Julia turned 13. The healthy adolescent had celebrated the milestone with family and friends on a warm July evening. But in the past few days, Marie had begun to notice what she thought was more than a typical lack of coordination on Julia’s part. When her normally careful daughter dropped a bowl at dinner, shattering it on the floor, Marie became concerned.
She asked Julia to walk in a straight line across the room from one wall to the other. The request seemed silly to the 13-year old, but Julia complied. She began tracing an imaginary line towards the kitchen counter.
It only took a few steps to see something was seriously wrong: Julia was swaying dramatically from left to right. Unable to maintain her balance, she fell to the floor. The family left dinner on the table and rushed Julia to the emergency room of the University Hospital.
When the Wilkinsons came through the big glass doors of the ER supporting and practically dragging Julia, the first person they encountered was Dr. James Reese, the senior resident in the ER. Dr. Reese went into full action, guiding the threesome into the closest exam room.
Julia was now barely able to move her feet. Dr. Reese quickly assessed her neurological status, noting absent tendon reflexes in both legs and definite weakness in her foot and thigh muscles. Julia’s arms and upper body strength remained normal, however, and there was no loss of feeling to touch or pin prick. The findings suggested an ascending paralysis, most often associated with Guillain-Barre syndrome. Polio would also have been a consideration in years past.
Guillain-Barre syndrome is an uncommon disorder that causes the immune system to attack the peripheral nervous system (PNS). The PNS nerves connect the brain and spinal cord with the rest of the body. Damage to these nerves makes it difficult for them to transmit signals, so the muscles have trouble responding to the brain. No one knows what causes the syndrome. Sometimes it is triggered by an infection, surgery or a vaccination.
Immediately, Dr. Reese ordered a series of tests. A CT scan of Julia’s brain and spinal cord was normal, as were the blood chemistries and examination of her urine. A spinal tap revealed completely normal spinal fluid, ruling out a number of infectious causes including all forms of meningitis. It also ruled out Guillain-Barre.
Dr. Max Wellborn was senior attending physician in the ER. He and Dr. Reese began reviewing his long list of possible causes for Julia’s ascending paralysis. One by one, they ordered the remaining tests and procedures to rule out each cause on the list.
With no immediate explanation for Julia’s ascending paralysis, she was admitted to the Intensive Care Unit (ICU) for close monitoring. A ventilator was brought bedside for possible artificial ventilation, since breathing would become difficult or absent should the paralysis involve her chest muscles. In a few hours, Julia noted weakness in her arms and shoulders but could still move them. Meanwhile, her bewildered parents spent a sleepless night in the ICU waiting room.
The next morning when pediatric residents made their 7 a.m. rounds, they were astounded to see Julia sitting on the edge of the bed swinging her feet back and forth. Grinning broadly, she got up and wobbled towards them. She held the edge of the bed to steady herself, but the near full recovery was miraculous.
The evening nurse told residents that at every neuro check during the night there was more and more unexplained return of strength to Julia’s legs and arms. When Dr. Wellborn caught up with the residents’ group, he was smiling.
“I know the etiology of Julia’s paralysis and also what cured her,” Wellborn said. “My conversation just now with Ms. Toll, the evening nurse, was the key. She told me the intervention she made last night. Anyone care to guess?”
The residents looked completely puzzled. No one ventured a guess.
Wellborn continued. “Last night, Ms. Toll noticed a small lump deep in Julia’s hair behind her right ear. On closer inspection, it was a swollen tick, which the nurse promptly removed. Although Ms. Toll had no idea she had initiated the cure of the paralysis, that’s precisely what happened: Julia is recovering from Tick Paralysis. Julia had no idea about the hidden bite, so it was pure luck — and a nurse’s careful attention to detail — that the tick was found and removed.”
Neither Max Wellborn nor any of the residents had ever heard of Tick Paralysis. “I didn’t even have Tick Paralysis on my list. I had to look it up,” the doctor confessed. “But I’ll never miss that again.”
Tick Paralysis is a different disease from the more common tick-borne diseases Rocky Mountain Spotted Fever, Erlichiosis or Lyme Disease. These are infectious diseases with the infectious agent injected via the saliva of the tick. The infecting agents are classified as a Rickettsia. The same species of ticks that transmit these infections can also transmit a nerve toxin that caused Julia’s paralysis, but in a different fashion
With Tick Paralysis, if the tick remains attached to the human for several days, the salivary gland of the tick produces a nerve toxin. This nerve toxin is then secreted into the human and produces an ascending paralysis. The nerve toxin has a very short half life so that removal of the tick leads to a rapid recovery in an average of one and a half days. The disease is worldwide and probably transmitted by over 40 species of ticks. (1) Some wild animals also become paralyzed and die from the toxin.
The incidence of Tick Paralysis in humans is unknown. Most would classify it as a rare cause of ascending paralysis. The reason tick paralysis is rare is that the ticks usually fall off or are removed before secreting the nerve toxin. One meta-analysis of the medical literature found only 50 reported cases in a 60-year period. If the tick is not removed, the mortality rate can be as high as 6 to 10 percent, death coming from respiratory failure. Since the advent of ventilators, the death rate is probably below 6 percent.
Young girls seem to be more susceptible to Tick Paralysis, because they favor long hair — the perfect cover for marauding ticks. In Julia’s case, the nurse’s discovery produced the cure unwittingly, which proves that serendipity can be the only source of evidence in some medical mysteries.
+ When faced with a patient with an ascending paralysis, the physician detective must consider a large number of possibilities; acute peripheral nerve inflammation after infection with Campylobacter; porphyria, a defect in hemoglobin synthesis;
periodic paralysis from low or high blood potassium; organophosphate insecticide poisoning; heavy metal poisoning from arsenic or mercury; Elapid snake bites; botulism from food poisoning; psychogenic hysterical paralysis; Marine fish poisonings; and of course Tick Paralysis.
*This case was shared by:
Dr. Jim Jirjis, MD MBA
Assistant Chief Medical Officer for Vanderbilt Medical Group
Assistant Professor of Medicine
Department of Medicine, Vanderbilt University School of Medicine.
Chapter Two
A Sticky Situation *
Ethyl Snodgrass and her husband Grady came together for their visits to see Dr. Paul Barnett. Ethyl called Grady “Big Daddy,” and Grady called Ethyl “Little Mama.”
Big Daddy and Little Mama lived on a small farm about 30 miles from town. Both were in their early 60s and in general good health, except for their shared weight problems. Big Daddy called it their “acute and chronic biscuit intoxication.”
Ethyl was genuinely interested in losing weight and asked the doctor about a diet. Grady, on the other hand, could not have cared less. He was certainly no help. “In fact, the older I get, the more meat I like on my women,” he said with a hearty laugh. Ethyl swatted him playfully and rolled her eyes.
After a normal baseline workup, both patients met with a dietician and an exercise trainer to set up a healthy weight loss program they could follow. Dr. Barnett talked to them about expectations and some challenges of dieting and warned them about products that promised fast weight loss. He stressed especially the danger of diet pills and told the Snodgrass’s to stay away from those.
About a week after starting the reduced calorie diet, Ethyl called Barnett. She had started to have diarrhea daily, reporting frequent, large volume, almost liquid bowel movements. Barnett thought perhaps too much roughage in their healthier diet was the culprit, so he told her to cut back. The diarrhea continued. Barnett then launched a full diarrhea workup including multiple stool cultures, checks for ova and parasites, a colonoscopy, small bowel x-rays and multiple blood tests for malabsorption studies. All test results were normal. The diarrhea continued, now even worse in frequency and volume.
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