He passed out three times in 10 days. What was wrong?

The 75-year-old was sprawled on the floor between the kitchen counter and the island, surrounded by a halo of pills. “What happened?” ...

The 75-year-old was sprawled on the floor between the kitchen counter and the island, surrounded by a halo of pills. “What happened?” his wife asked, rushing to his side, even though she suspected she already knew it.

He wasn’t sure, he told her. For a minute he was standing at the counter, preparing to take his morning meds; the next one, just like that, he was on the floor. She helped him sit up. When he could, he stood up slowly. It was the third time he had passed out in a week and a half. The first spell came when his wife was out of town. He was dozing on the patio and woke up hot and sweaty. As he entered the house, he felt unsteady and leaned against the wall. He got to a chair but passed out several times just sitting there. And when he woke up he was confused. He was trying to read a text from his daughter but couldn’t remember how.

The next time, a few days later, he woke up to go to the bathroom. He stood up, then suddenly found himself on the ground. A sharp pain in his forehead told him that he had cut off the bedside table on the way down. His wife helped him get up and go to the bathroom. He found he had been incontinent. He was embarrassed in front of his 53-year-old wife. He called his doctor’s office the next morning and arranged to come the next day. He hasn’t been feeling well for the past two weeks, he told the young medical assistant. He had woken up sweating a few times recently, and his wife told him he was shaking the bed with her chills. He felt feverish. Tiredness. No appetite. No ambition. Misty. One night he wasn’t even able to remember the prayer he always said before going to bed. And urinating was oddly uncomfortable.

After completing his examination, the physician assistant sent him to the laboratory. It was most likely a urinary tract infection, she told him after reviewing his test results. These are not uncommon in older men, as an enlarged prostate can make it difficult to urinate. She put him on an antibiotic that is often used to treat this kind of infection.

It was just two days before this last episode. The AP told him to go to the hospital if he felt worse. He definitely felt worse.

In the emergency room at Yale New Haven Hospital, it was clear the old man was ill. He had a fever of 101, his heart was pounding, and his blood pressure was abnormally low, even though he had not taken his blood pressure medication that morning. The lab results confirmed this first impression. His kidneys were failing, even though they were fine two days earlier. He was given intravenous fluids and started taking broad spectrum antibiotics. The medication he had been taking for the past few days did not seem to do the trick.

Upstairs, the first clinician the patient encountered was Alan Lee, who was in his final year of medical school and was an intern. Lee was delighted to see this patient. Because the hospital was so crowded, in part thanks to the recent resurgence of Covid-19 cases, patients often spent hours, sometimes days, in the emergency room waiting for a bed. By the time they got to a medical floor, they might already have a doctor assigned. This meant that most of the thinking about the patient had been done, and the agreeing doctor was usually just implementing the first doctor’s plan. This Sunday morning admission came during a lull in the action, so Lee’s team would have the first chance to figure out what was going on.

Emergency room doctors focused on the man’s failing kidneys, but what hurt those kidneys? What caused the fever? These were the questions Lee had to answer for himself and for the patient. The young man entered the room accompanied by his resident supervisor, Dr. Roger Ying. They introduced themselves and Lee started asking questions. The patient told the story of his three episodes of fainting, how he felt feverish and sick, and how he lost 10 pounds over the past week because he felt too sick to eat or drink.

After Lee finished his questions, Ying asked the patient if he had been bitten by a tick recently. Absolutely not, the man replied promptly. He often took his dog on wooded paths along the Connecticut River, but once he got home he was careful to check his body for ticks.

Dr Joseph Donroe, the attending physician, joined the trainees at the bedside. Lee acknowledged that a urinary tract infection may have caused the man’s urinary problems as well as the fever. These symptoms could cause the patient not to want to eat or drink, which would allow him to become dehydrated. This, in turn, could have caused him to pass out and even damage his kidneys. But a 10-pound weight loss was not a common finding in a urinary tract infection. Night sweats either. Could it be a tick-borne disease like Lyme’s?

Donroe agreed that these symptoms were atypical. It seemed likely that the patient was now suffering from urosepsis – an infection that started in the urinary tract but then spread throughout the body – and that the cause of his symptoms was a urinary tract infection. But because he was already on antibiotics, they probably wouldn’t see anything in the urine if they tested him now. Lee is expected to call the patient’s primary care physician on Monday morning to get the results of the tests done before starting the antibiotics.

The next day the patient felt much better. He had had fluids and a good night’s sleep. No fever, no chills. Maybe the antibiotics were working. Still, his kidneys weren’t getting any better.

After the rounds, Lee called the patient’s doctor. The urine culture had grown nothing at all. The only anomaly was that the urine contained a lot of blood. Now what? Lee went to the presenter with the news. Together, Lee and Donroe reviewed the data once again. One of the labs ordered suggested that red blood cells were being destroyed somewhere in the body. Suddenly it all made sense.

The man had been ill for almost two weeks with fever and chills, and he had something that was destroying his red blood cells. To Donroe, it looked like a tick-borne disease. No Lyme, but a different disease carried by the same type of tick: a disease called babesiosis. They should order a test for Babesia as well as another for Lyme, ehrlichiosis and anaplasmosis – the most common tick-borne diseases in Connecticut.

It was late afternoon when the first result came back. Inside the patient’s many red blood cells, the lab technician saw a single small black circle – a parasite. The patient had babesiosis.

Babesia is a protozoan, a single-celled parasitic organism carried by the deer tick. This arachnid catches the insect by feeding on a white-legged mouse and delivers it to the next mammal it bites. Once the organisms enter the circulation, they invade the red blood cells, where they multiply. Under the microscope, organisms look like a circle or a cross depending on where they are in maturation and reproduction. Then the progenitor and the offspring come out of the cell, enter the neighboring red blood cells, and the process continues.

In the Northeast, the deer tick is best known for carrying Lyme disease. And in fact, up to 42% of ticks carrying Babesia are also carriers of Lyme disease, according to a study from a Connecticut state lab. The next day, the team learned that was also true for the tick that bit this patient. He had both Lyme and babesiosis, so he had to be treated with three drugs – two for Babesia and one for Borrelia, the bacteria that causes Lyme disease. He should take them for about two weeks.

The patient could feel the difference the day after starting the medication. His appetite had returned. His energy too. Now that he’s back home, he’s thinking about how to deal with these ticks. He knows they’re not going anywhere, but neither do he and his wife. He’s already using a spray to discourage their bites. Obviously, he will just have to look for a lot more after his walks with the dog. He won’t let the arachnids win.

Lisa Sanders, MD, is a contributing writer for the magazine. His latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries”. If you have a resolved case to share with Dr. Sanders, email him at Lisa.Sandersmd@gmail.com.

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Newsrust - US Top News: He passed out three times in 10 days. What was wrong?
He passed out three times in 10 days. What was wrong?
Newsrust - US Top News
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