Celebrated
NYT Magazine column "Diagnosis" tells the story of one woman's
mysterious heart palpitations finally being diagnosed as Lyme carditis.
But how many Lyme diagnoses fall through the cracks because of
"undifferentiated" or overlapping symptoms--or because of lack of
education among doctors and patients? What's your story? http://ow.ly/dwFRb
A Crazed Fish on a Line
The
31-year-old woman floated in the cool lake while her cousins basked in
the late-morning sun. It was nearly 100 degrees, and she felt awful. The
heat was suffocating, and she couldn’t shake the bone-deep fatigue and
muscle aches that had dogged her for days. Suddenly she felt her heart
flipping around inside her chest like some kind of crazed fish on a
line. She felt dizzy and out of breath. Was she having a heart attack?
A New Kind of Sick
Until
that moment, the young woman had been willing to attribute the past few
bad days to her overactive thyroid. She had Graves’ disease, an
autoimmune disorder that causes the immune system to mistakenly attack
the thyroid gland, making it overproduce its hormone and revving the
body into a perpetually hyped-up state. Her heart often ran as high as
120 beats a minute (between 60 and 80 is normal). She always felt antsy.
She rarely wanted to eat and had trouble sleeping.
Her Graves’
was diagnosed a decade earlier, and she had been on medicine to control
it. That changed the previous winter when she lost her job and, with it,
her health insurance. For the last several months, she was without
medication and at the mercy of her cranked-up thyroid. She was like a
car with a broken carburetor — her engine was always racing.
Occasionally that felt kind of good — as if she had all the energy in
the world. Most of the time, though, she felt jittery, sweaty and
nervous. But it had never felt this bad.
The Patient Examines Herself
At
home, the woman took her pulse. Although she had done this before since
stopping her thyroid medication, she wondered if she was feeling the
right place. The pulse she felt was slow and erratic, which scared her.
She asked her cousins to look after her 10-year-old son, then drove
herself to the closest emergency room, at Waterbury Hospital in
Connecticut.
In the Emergency Room
The
nurse looked at the young woman oddly when she said that her heart
wasn’t beating as fast as it should. On exam, her pulse seemed normal
enough, but once she was hooked up to a heart monitor, the erratic beats
were obvious. Her heart was a little slow but very irregular.
In the Hospital
The
patient was sitting up when Dr. Sarita Soares, a resident just starting
her second year, entered the room. Right away, Soares noticed that the
woman looked ill — flushed and sweaty — as if she might have a fever.
(She didn’t.) The cardiac monitor showed an unexpectedly slow heart rate
at times — around 50 beats a minute. But what concerned her most was
the heartbeat’s strikingly irregularity. There were frequent,
frighteningly long pauses between the few, more regular beats.
The
patient told the doctor her story. She was laid off from her job as a
counselor in a group home eight months earlier and no longer could
afford her thyroid medicine. Earlier that week, she started feeling achy
and tired. And then that morning in the lake, her heart just went
crazy.
She smoked about a pack a day — and had for the past 16
years. She rarely drank. She wasn’t taking any medication. She had been
in the hospital only once — 10 years ago when she had her son — and
never had surgery.
The doctor found some subtle traces of the
patient’s history of Graves’: her eyes were a little prominent — the
whites clearly visible both above and below her irises. Her thyroid was
slightly enlarged, her reflexes brisk.
Contemplating the Data
After
the examination, Soares excused herself and went out into the noisy
E.R. to think. A patient with a history of hyperthyroidism who develops a
slow heart rate might have de Quervain’s thyroiditis — when
inflammation of the thyroid first causes the symptoms of too much
thyroid hormone but ultimately leads to the injury of that gland and a
deficiency of the hormone. Despite the patient’s slow heart rate, it was
clear to the doctor just from looking at her that this patient had too
much of the activating hormone. A blood test confirmed her suspicions.
The
patient’s EKG suggested that her heart was trying to beat faster; the
tracing showed that the heart’s natural pacemaker was working to speed
the heart along at a rate of 140 beats a minute. But it was equally
clear that most of these signals were not getting through, leaving her
heart rate slow and erratic.
Possible Diagnosis
1. Scar tissue can block the signal from the heart’s pacemaker. Did she have a heart attack that destroyed the signal’s pathway?
2.
Some medications, like beta blockers, slow the transmission of the
pacemaker’s signal for the heart to beat. But this patient wasn’t taking
any medications.
3. Diseases like sarcoidosis can block
heartbeats. In this disorder, the immune system hijacks tiny pieces of
tissue anywhere in the body and turns them into nonfunctioning colonies
of inflammatory cells. Could this patient have sarcoidosis?
4. Or
could this be Lyme disease? Lyme is common in the Northeast and this
kind of slowed, irregular heart rate was an unusual but well-known
complication of early Lyme disease. But Lyme carditis usually slows the
heart even more drastically, around 30 to 40 beats per minute.
More Data
Soares
went back into the exam room with more questions.The patient said she
had one episode of chest pain earlier that day but never before.The
blood tests showed no sign of recent heart injury, so it probably wasn’t
a heart attack. She had some of the symptoms seen with chronic
sarcoidosis — especially recently. The past few days, she was plagued
with fatigue, body aches, shortness of breath. But her chest X-ray
showed no sign of sarcoidosis, making it less likely.
Soares asked
if she had been camping this summer. Several times, the patient
answered. Ever have any tick bites? The patient said that she was always
very conscientious about checking herself and her son for ticks. She
pulled at least one off her body earlier this summer. Any rash? Not that
she noticed.
Still, intrigued by the report of known tick
exposure, Soares re-examined the patient’s skin. On her left arm, near
the wrist, the resident saw something she missed earlier: a fading red
weal. It wasn’t the bull’s-eye rash classically described in Lyme but it
didn’t have to be. Most Lyme rashes are solid red circular lesions that
expand over the course of several days, then disappear. But one in five
patients with documented Lyme infections say they never saw a rash at
all.
That clinched it for Soares. This was Lyme. She told the
patient her suspicions and ordered the confirming test to look for the
antibodies, then immediately started the patient on antibiotics without
waiting for the results. Though the patient’s heart rate was nearly
normal, Lyme carditis often slowed the heart to dangerously low rates.
The sooner she got the antibiotics going, the better the doctor would
feel.
Celebrated
NYT Magazine column "Diagnosis" tells the story of one woman's
mysterious heart palpitations finally being diagnosed as Lyme carditis.
But how many Lyme diagnoses fall through the cracks because of
"undifferentiated" or overlapping symptoms--or because of lack of
education among doctors and patients? What's your story? http://ow.ly/dwFRb
A Crazed Fish on a Line
The
31-year-old woman floated in the cool lake while her cousins basked in
the late-morning sun. It was nearly 100 degrees, and she felt awful. The
heat was suffocating, and she couldn’t shake the bone-deep fatigue and
muscle aches that had dogged her for days. Suddenly she felt her heart
flipping around inside her chest like some kind of crazed fish on a
line. She felt dizzy and out of breath. Was she having a heart attack?
A New Kind of Sick
Until
that moment, the young woman had been willing to attribute the past few
bad days to her overactive thyroid. She had Graves’ disease, an
autoimmune disorder that causes the immune system to mistakenly attack
the thyroid gland, making it overproduce its hormone and revving the
body into a perpetually hyped-up state. Her heart often ran as high as
120 beats a minute (between 60 and 80 is normal). She always felt antsy.
She rarely wanted to eat and had trouble sleeping.
Her Graves’ was diagnosed a decade earlier, and she had been on medicine to control it. That changed the previous winter when she lost her job and, with it, her health insurance. For the last several months, she was without medication and at the mercy of her cranked-up thyroid. She was like a car with a broken carburetor — her engine was always racing. Occasionally that felt kind of good — as if she had all the energy in the world. Most of the time, though, she felt jittery, sweaty and nervous. But it had never felt this bad.
Her Graves’ was diagnosed a decade earlier, and she had been on medicine to control it. That changed the previous winter when she lost her job and, with it, her health insurance. For the last several months, she was without medication and at the mercy of her cranked-up thyroid. She was like a car with a broken carburetor — her engine was always racing. Occasionally that felt kind of good — as if she had all the energy in the world. Most of the time, though, she felt jittery, sweaty and nervous. But it had never felt this bad.
The Patient Examines Herself
At
home, the woman took her pulse. Although she had done this before since
stopping her thyroid medication, she wondered if she was feeling the
right place. The pulse she felt was slow and erratic, which scared her.
She asked her cousins to look after her 10-year-old son, then drove
herself to the closest emergency room, at Waterbury Hospital in
Connecticut.
In the Emergency Room
The
nurse looked at the young woman oddly when she said that her heart
wasn’t beating as fast as it should. On exam, her pulse seemed normal
enough, but once she was hooked up to a heart monitor, the erratic beats
were obvious. Her heart was a little slow but very irregular.
In the Hospital
The
patient was sitting up when Dr. Sarita Soares, a resident just starting
her second year, entered the room. Right away, Soares noticed that the
woman looked ill — flushed and sweaty — as if she might have a fever.
(She didn’t.) The cardiac monitor showed an unexpectedly slow heart rate
at times — around 50 beats a minute. But what concerned her most was
the heartbeat’s strikingly irregularity. There were frequent,
frighteningly long pauses between the few, more regular beats.
The patient told the doctor her story. She was laid off from her job as a counselor in a group home eight months earlier and no longer could afford her thyroid medicine. Earlier that week, she started feeling achy and tired. And then that morning in the lake, her heart just went crazy.
She smoked about a pack a day — and had for the past 16 years. She rarely drank. She wasn’t taking any medication. She had been in the hospital only once — 10 years ago when she had her son — and never had surgery.
The doctor found some subtle traces of the patient’s history of Graves’: her eyes were a little prominent — the whites clearly visible both above and below her irises. Her thyroid was slightly enlarged, her reflexes brisk.
The patient told the doctor her story. She was laid off from her job as a counselor in a group home eight months earlier and no longer could afford her thyroid medicine. Earlier that week, she started feeling achy and tired. And then that morning in the lake, her heart just went crazy.
She smoked about a pack a day — and had for the past 16 years. She rarely drank. She wasn’t taking any medication. She had been in the hospital only once — 10 years ago when she had her son — and never had surgery.
The doctor found some subtle traces of the patient’s history of Graves’: her eyes were a little prominent — the whites clearly visible both above and below her irises. Her thyroid was slightly enlarged, her reflexes brisk.
Contemplating the Data
After
the examination, Soares excused herself and went out into the noisy
E.R. to think. A patient with a history of hyperthyroidism who develops a
slow heart rate might have de Quervain’s thyroiditis — when
inflammation of the thyroid first causes the symptoms of too much
thyroid hormone but ultimately leads to the injury of that gland and a
deficiency of the hormone. Despite the patient’s slow heart rate, it was
clear to the doctor just from looking at her that this patient had too
much of the activating hormone. A blood test confirmed her suspicions.
The patient’s EKG suggested that her heart was trying to beat faster; the tracing showed that the heart’s natural pacemaker was working to speed the heart along at a rate of 140 beats a minute. But it was equally clear that most of these signals were not getting through, leaving her heart rate slow and erratic.
The patient’s EKG suggested that her heart was trying to beat faster; the tracing showed that the heart’s natural pacemaker was working to speed the heart along at a rate of 140 beats a minute. But it was equally clear that most of these signals were not getting through, leaving her heart rate slow and erratic.
Possible Diagnosis
1. Scar tissue can block the signal from the heart’s pacemaker. Did she have a heart attack that destroyed the signal’s pathway?
2. Some medications, like beta blockers, slow the transmission of the pacemaker’s signal for the heart to beat. But this patient wasn’t taking any medications.
3. Diseases like sarcoidosis can block heartbeats. In this disorder, the immune system hijacks tiny pieces of tissue anywhere in the body and turns them into nonfunctioning colonies of inflammatory cells. Could this patient have sarcoidosis?
4. Or could this be Lyme disease? Lyme is common in the Northeast and this kind of slowed, irregular heart rate was an unusual but well-known complication of early Lyme disease. But Lyme carditis usually slows the heart even more drastically, around 30 to 40 beats per minute.
2. Some medications, like beta blockers, slow the transmission of the pacemaker’s signal for the heart to beat. But this patient wasn’t taking any medications.
3. Diseases like sarcoidosis can block heartbeats. In this disorder, the immune system hijacks tiny pieces of tissue anywhere in the body and turns them into nonfunctioning colonies of inflammatory cells. Could this patient have sarcoidosis?
4. Or could this be Lyme disease? Lyme is common in the Northeast and this kind of slowed, irregular heart rate was an unusual but well-known complication of early Lyme disease. But Lyme carditis usually slows the heart even more drastically, around 30 to 40 beats per minute.
More Data
Soares
went back into the exam room with more questions.The patient said she
had one episode of chest pain earlier that day but never before.The
blood tests showed no sign of recent heart injury, so it probably wasn’t
a heart attack. She had some of the symptoms seen with chronic
sarcoidosis — especially recently. The past few days, she was plagued
with fatigue, body aches, shortness of breath. But her chest X-ray
showed no sign of sarcoidosis, making it less likely.
Soares asked if she had been camping this summer. Several times, the patient answered. Ever have any tick bites? The patient said that she was always very conscientious about checking herself and her son for ticks. She pulled at least one off her body earlier this summer. Any rash? Not that she noticed.
Still, intrigued by the report of known tick exposure, Soares re-examined the patient’s skin. On her left arm, near the wrist, the resident saw something she missed earlier: a fading red weal. It wasn’t the bull’s-eye rash classically described in Lyme but it didn’t have to be. Most Lyme rashes are solid red circular lesions that expand over the course of several days, then disappear. But one in five patients with documented Lyme infections say they never saw a rash at all.
That clinched it for Soares. This was Lyme. She told the patient her suspicions and ordered the confirming test to look for the antibodies, then immediately started the patient on antibiotics without waiting for the results. Though the patient’s heart rate was nearly normal, Lyme carditis often slowed the heart to dangerously low rates. The sooner she got the antibiotics going, the better the doctor would feel.
Soares asked if she had been camping this summer. Several times, the patient answered. Ever have any tick bites? The patient said that she was always very conscientious about checking herself and her son for ticks. She pulled at least one off her body earlier this summer. Any rash? Not that she noticed.
Still, intrigued by the report of known tick exposure, Soares re-examined the patient’s skin. On her left arm, near the wrist, the resident saw something she missed earlier: a fading red weal. It wasn’t the bull’s-eye rash classically described in Lyme but it didn’t have to be. Most Lyme rashes are solid red circular lesions that expand over the course of several days, then disappear. But one in five patients with documented Lyme infections say they never saw a rash at all.
That clinched it for Soares. This was Lyme. She told the patient her suspicions and ordered the confirming test to look for the antibodies, then immediately started the patient on antibiotics without waiting for the results. Though the patient’s heart rate was nearly normal, Lyme carditis often slowed the heart to dangerously low rates. The sooner she got the antibiotics going, the better the doctor would feel.
