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