Well: Think Like a Doctor: Not Just the Flu, Solved!

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Updated, 12:53 p.m., Monday Aug. 5

On Thursday, we challenged Well readers to figure out why a 59-year-old woman who’d been sick for over a week with what she thought was the flu suddenly became deathly ill.

We got more than 300 responses from readers. Some of you got the right test, a CT scan of the abdomen, but only five of you figured out the correct diagnosis. The first right answer came in at 4:40 p.m. yesterday, from Patricia York of Ellicott City, Md. Ms. York is a nurse. She told me she read the case but didn’t figure it out right away. Later that day she was out grocery shopping and suddenly it hit her — this patient had babesiosis and some pain in the upper left part of her abdomen. That’s where the spleen is located, and Ms. York remembered that babesiosis could cause the spleen to rupture. Mystery solved! She hurried home and submitted her answer.

The correct diagnosis is…

A splenic rupture, an unusual complication of babesiosis.

The Diagnosis:

Babesiosis is a disease caused by a protozoa called Babesia – usually Babesia microti – and transmitted by the deer tick, Ixodes scapularis. As noted by many of the commenters, this tick can also transmit Lyme disease and a disease now known as anaplasmosis (formerly called erhlichia).

Babesia is most frequently seen in the spring and summer months, with a peak in July and August. Those infected may be totally asymptomatic or have a mild illness, with fever, fatigue and malaise, that resolves on its own without medical intervention. Headache, nausea and vomiting and body aches have also been seen.

Severe forms of illness are less common. Patients are more likely to have a severe form of the illness if they are older than 50 or have some type of immune deficiency or other chronic illness. It is also more common in those who, for various reasons, no longer have a spleen.

Complications of Babesiosis include sepsis, in which the body’s immune system goes into overdrive to fight an overwhelming infection; heart or kidney failure; and, as was the case in this patient, a rupture of the spleen.

The cause of splenic rupture is not fully understood but thought to be a consequence of the accumulation of damaged red cells in the spleen. In most of the cases reported in the medical literature, the spleen was not enlarged at the time of the rupture. Treatment is usually the surgical removal of the spleen, although there are several case reports in which the spleen was allowed to heal in place. Concern for uncontrolled bleeding was the usual indication for surgical removal.

How the Diagnosis Was Made:

Although the patient had a diagnosis of babesiosis, Dr. Thomas Robey, the emergency room doctor who saw the patient, was still concerned that there was something else going on. Babesiosis is usually a mild disease and the patient reported feeling better, until the afternoon she came to the hospital when she suddenly felt much, much worse, with terrible abdominal pain, nausea and vomiting.

In the E.R., her blood pressure remained dangerously low and her heart rate dangerously high, despite being given three liters of intravenous fluids as well as antibiotics for the Babesia. She was also treated empirically for Erhlichia and Lyme disease, the two infections that can be transmitted by the same tick that carries Babesia. But she wasn’t any better. If anything, she looked worse.

Dr. Robey reviewed the labs once more. They didn’t suggest someone as sick as the woman who lay before him. She looked like she was dying.

He considered the types of disease processes that could kill you quickly. Like many of the commenters, he thought that it was likely that whatever was going on was unrelated to the babesiosis diagnosed by the lab. Could this be some kind of intra-abdominal infection? Or could she have some unknown source of bleeding? Could this be an infection in her brain? A Lyme meningitis?

A Telling CT Scan:

Well: Think Like a Doctor: Not Just the Flu, Solved! In this CT Scan, the area outlined in red indicates a pool of blood in the abdomen.

Dr. Robey decided to get a CT scan of her abdomen and, if that was unrevealing, he’d get a spinal tap to look for an infection or other abnormality in her brain.

The CT scan revealed that her belly was filled with blood. You can see an image from the CT scan here.

In addition, her spleen was clearly ruptured. The medical team worked to stabilize the patient as the surgeons prepared the operating room. She was in surgery within an hour of her CT scan.

Dr. Robey stopped in to see her in the I.C.U. at the end of his emergency room shift. Although she was still on a ventilator (breathing machine), there was color in her face. Her blood pressure and heart rate were normal. He breathed a sigh of relief; she was going to be all right.

It’s a terrifying sensation, watching a patient die and not knowing why. “When I don’t know what’s going on, a picture is worth a thousand words,” he told me, referring to his decision to get a CT scan. “And this picture saved a life.”

The Patient’s Recovery:

The patient stayed in the I.C.U. for three more days. She was home by the end of the following week. She’s still amazed by the whole experience.

When I spoke with her recently, she told me that she was still sore at the site of her incision but otherwise felt a whole lot better. She’s started working in her garden again, but right now it’s tough to bend over. Still, she’s certain she’ll be back in there in time to pull in the harvest. There will be plenty to be thankful for come this fall.

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10 Comments

  1. Patrick

    March 12, 2014 at 6:30 pm

    I went to the doctors today to get these weird stomach pains and headaches solved. Now whenever i eat i feel nauseous.

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  2. Andres C

    March 16, 2014 at 2:16 pm

    My partner fell ill over a week ago, on the Friday, he started off with a headache and slight nausea which we just dismissed as possible sunstroke. Next day he had worsened and was vomiting constantly and still had a headache, so he just decided to take paracetamol and then rest for the weekend. However, there was not much improvement by Monday so his GP came round and checked him over and then diagnosed him with possible appendicitis as his abdomen caused him pain when touched. Went to the hospital as soon as we could, where he had blood tests done, and after waiting for hours finally got results back – they were all clear. The doctor there prescribed him some Co-Codamol (he isn’t allowed to take ibuprofen as he’s asthmatic, so the next best pain killer for him is paracetamol) and told him that it’s likely to just be the flu or a viral infection that should go away in a couple of days. By Thursday he was feeling much better, slight headache with dizziness and drowsiness but that was likely just a side effect from the medication. Unfortunately on Friday night he was constantly vomiting again and the pain in his abdomen has increased over the last 2 days to the point where he can’t even move without causing himself terrible pain and discomfort. Also he’s unable to eat anything as he can’t keep it down, so now when he vomits its mainly bile. He’s made an appointment with his GP for tomorrow to find out what they think it could be, although to be honest I don’t think they will do much – probably just prescribe some more painkillers and tell him to rest. (Which clearly isn’t working). So my question is, has this happened to you or anyone you know? – If so, could you please tell me what caused it, or at least what you did to relieve the pain? Please help if you can!

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  3. Keegan

    March 20, 2014 at 2:04 am

    I have sore places on my skin, at first it was my legs, then my thighs, my feet, hip and now my arm … I didn’t knock myself and there’s no bruises… It’s the kind of sensitive skin you get when you have the flu or a cold… When cold or myself touches it, I feel like dying. Except going to the doctors, what can I do, it’s really painful… HELP !!!!

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  4. sakyue1993

    March 20, 2014 at 2:13 am

    Hi,
    i care for a lady and at the moment am seeing her nearlly everday. She told me yesterday that her husband had been in contact with someone that has just gone down with swine flu. This means that he or she may have caught it too

    For about 3 days i have been feeling very unnwell… I’v got constant stomach cramps, diarreah, terrible headache’s, have an upset stomach am very tired and keep shivering.

    I wasn’t really worried about any of this. But after finding out about my carer and hern husband im quite worried. I went to my doctors yesterday morning and he said it was probably just gastrolitus.But he did not know about my carer’s possible swine flu contact or any fo the symptoms apart from the stomach cramps as i wasn’t really worried. Im 16.

    (0)
  5. Miguel M

    March 1, 2014 at 8:06 am

    Hello everyone :) Okay, I’m going to try and answer all of the questions that never end about this swine flu. Bottom line is that we don’t know when the flu will vanish, could be anytime. Stay clean, wash your hands frequently and just if you have any symptoms, go to the doctors. Bring hand sanitizer where ever you go and don’t panic. Panicking won’t help to solve the flu. Stay positive and clean and you’ll be okay. So please anyone who would like to add to this, answer with any other answers. Just needed to get this out because every other time I go to the disease section, it’s ALL about the swine flu.

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  6. vanvark83

    February 23, 2014 at 4:17 am

    i know that they are the closest people we have to solve our medical mysteries, but why is it that we are embarrassed to talk to them about stuff besides the flu?

    (0)
  7. Austin

    December 23, 2013 at 4:53 am

    If you get bit by a deer tick, it might show a ring around it to show lyme disease. How long does it take for the ring to appear?

    (0)
  8. borabora5524

    December 26, 2013 at 3:07 pm

    when i was 4 yrs old my parents found a tick in my head half way under my scalp, but i never got lyme disease, how come? can a reg blood test tell you if you have it or not? or is their a special test you have to take to know if you are infected with the disease?

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  9. happyha31

    February 5, 2014 at 7:29 am

    My boyfriend got the flu shot 3 days ago (thursday), and his arm is still swollen and red at the injection point.
    on a scale of 1-10 he said its a 4 in itchiness.

    Is he fine or should he go back to the doctor?

    (0)
  10. ouch

    December 13, 2013 at 7:34 am

    My stomach has been queasy for a week now everyday at different times.Im not pregnant or on any meds. I don’t understand Im trying to see if I can solve the problem without going to my doctor I don’t think its anything serious just been feeling sick to my stomach from time to time everyday! Please help any feedback would be appreciated!

    (0)

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