Fascinomas- Fascinating Medical Mysteries

by Clifton K Meador

  Frustrated, Barnett had the couple come in for a review of the history. They sat down in his office and began going over in detail the last few weeks. Ethyl said the diet had been a big change for both of them and she found herself hungry much of the time. With that, she took a stick of gum from her purse and began to chew. She told Barnett it helped the cravings.

  Grady said he had no diarrhea, which ruled out any infection at work. Other than grumbling about how much he missed his favorite foods, he had no physical complaints. As Grady talked, Ethyl kept putting one stick of gum after another in her mouth. She realized Barnett was watching her unwrap yet another piece and suddenly remembered her manners. “Want a stick?” she asked, holding out the package. That’s when he saw the world “sugarless” on the label. A light bulb came on in his mind.

  “That stuff has sorbital. How much do you chew a day?” he asked.

  “Oh, ’bout 10 packs.” Ethyl answered. Grady nodded agreement.

  “It’s no wonder you have diarrhea,” Barnett said. “Sorbital is not absorbed in the intestines and it pulls huge amounts of water into the gut. It’s almost like an internal enema.”

  Sugarless gum is a well known cause of diarrhea when chewed in large amounts of more than 6 or 7 sticks a day. Each stick has around one and a half grams of sorbital. The non-absorbability of the sorbital causes a shift of water into the gut. The large volume of water is quickly passed down the intestine causing the watery diarrhea.

  “But I like the sweet taste,” Ethyl protested. “I kept hoping it would help me not eat so much, so I could lose weight.”

  Barnett said he sympathized, but no more sugarless gum for her — period.

  Grady could only say, “Well I‘ll be. Well I’ll be.” As the two toddled out of the office, he kept elbowing Ethyl, “Little Mama, I told you that you was chewing too much gum. I told you.”

  *Case shared by:

  Paul Barnett, M.D.

  Associate Clinical Professor of Medicine

  Department of Medicine

  Vanderbilt University School of Medicine”.

  Chapter Three

  The Cause of Some Symptoms Can Be Illusory*

  Veronica Settler had been coughing up blood for more than a year when she went in to see Dr. William Stoney. Stoney was a noted thoracic and cardiac surgeon, known both for his surgical skill and his ability to sort through difficult cases.

  Mrs. Settler had been referred to Stoney by a family physician in Arkansas. Despite all of his diagnostic efforts, he couldn’t find the cause for the bloody sputum.

  Mrs. Settler described her coughing up blood as intermittent and unpredictable. Sometimes she would go for over a month and then cough up blood daily for a week or more. She had no fever and her general health was excellent.

  She had married her high school sweetheart, an outstanding halfback on the local team with all-state honors. Randy Settler went on to the University of Arkansas, where he and Veronica got married. The year was 1978, about the same time she began coughing up blood. Mrs. Settler was 23 years old at the time.

  Dr. Stoney admitted Mrs. Settler and began to repeat all the tests that might identify the cause for bleeding somewhere in her lungs and bronchial tubes. He even considered vicarious menstruation and sought a gynecological consultation. Vicarious menstruation occurs when uterine tissue somehow gets implanted in the nose or bronchus. At the time of monthly menstruation, the aberrant tissues also bleed, giving a puzzling periodic bleeding. Mrs. Settler, herself, had wondered if the bloody sputum might be close to her monthly menstrual periods. But the sputum was examined microscopically and no uterine or other aberrant tissue was found – another blind diagnostic alley.

  Mrs. Settler’s chest x-ray showed a large calcified lymph node sitting next to the trachea and right bronchial tube. These were the days before CT scans or MRIs, so a bronchoscope was the best tool. But repeated looks down the bronchoscope by several doctors revealed nothing that looked like a tumor or a bleeding site on the inside of the trachea or right bronchus.

  Stoney had several colleagues review the chest x-rays with him. The consensus of the consultants was that it would make sense to remove the calcified node, since it could represent an active fungus infection such as histoplasmosis, a prevalent fungus in Arkansas and the Ohio and Mississippi Valleys. Some thought it could even be a low-grade malignant tumor or a tumor of the lymph nodes. Whatever it was, its close proximity to the airways could conceivably lead to periodic erosions and bleeding.

  Dr. Stoney met with Mrs. Settler and her husband and offered to do an exploratory thoracotomy (open chest operation) to remove the large node or mass. The couple wanted time to think it over and asked to be discharged from the hospital.

  A month later, Mrs. Settler was admitted and had the thoracotomy done by Dr. Stoney. The node was easily removed. Tissue examination showed what appeared to be an old and healed fungus infection with histoplasmosis. There was no evidence at surgery for active invasion of the air tubes by the lymph node. The operation did not uncover the cause for the bloody sputum. Mrs. Settler went home on the 8th post-op day.

  Three weeks after the operation, Mrs. Settler called Dr. Stoney to tell him she had been coughing up blood for over a week, this time in large quantities. She was worried about the amount of blood she was losing in her sputum. Stoney insisted she come immediately to the hospital for admission. He was at a complete loss as to what he would do. In his wildest thoughts, he would do a complete clotting workup. Maybe he had missed some weird hemophilia bleeding disorder? But that didn’t make much sense since there was no bleeding problem from the thoracotomy.

  Mrs. Settler was admitted to the hospital, still spitting up almost pure blood in her sputum. In the 1970s, there were still four-bed units in many hospitals, called “semiprivate beds.” Mrs. Settler was admitted to such a unit. Each bed had its own curtain to pull around and provide some privacy.

  When Dr. Stoney made his morning rounds the next day, he saw out of the corner of his eye the woman in the adjacent bed making signs by nodding her head, indicating she wanted to speak with Stoney privately. The woman got out of her bed and walked into the hallway, waiting for him to finish with Mrs. Settler. When he exited, she grabbed his arm and whispered into his ear, “She’s sticking her gums with needles to make them bleed.” She turned abruptly and went back to her bed.

  Stoney examined Mrs. Settler’s mouth and found multiple small cuts in the far reaches of her gums behind the back molars, some still bleeding. It became clear she had self-inflicted the wounds and made up the entire story, submitting herself to an unnecessary and life-threatening operation. She was continuing to make needle cuts to get medical and other attention.

  Stoney was not sure of his next move. He called for her husband to join him and Mrs. Settler in the small consultation room off of the lobby. He had a nurse attend the meeting as a witness.

  Dr. Stony then told in detail all that he had done to find the cause for the bloody sputum and his reasons for doing the chest surgery. Then he told them what Mrs. Settler had done to fool and mislead the efforts by self-inflicting the bleeding. He let them know in detail that he knew about the needles and the dangers of what Mrs. Settler had done. He waited a few moments for Mr. or Mrs. Settler to respond. Neither said a word. Both sat there with blank expressions. Stoney pressed for comments. Both only shook their heads. Neither responded.

  In order to bring some closure to his own frustrations, Stoney had a novel solution. He had brought a pint of a cough syrup with him. He told Mrs. Settler to take a teaspoon of the cough syrup each morning until she finished the entire bottle. “If you do this, then the bloody sputum will go away,” he told her in his most serious voice. He estimated the syrup would last about six months. Stoney, lacking any real cure, thought the use of the cough syrup would give Mrs. Settler an out, an excuse or reason to stop her self- infliction. Stoney then left the room and never saw Mrs. Settler again.

  The story of Mrs. Settler went all
over the doctors’ lounge for weeks. Every one wondered if Stoney’s almost hypnotic suggestion would work.

  Almost six months to the day, Stoney got a call from a doctor in Melbourne, Arkansas. He said that he was now Mrs. Settler’s family doctor. She had told him about the chest operation and her history of coughing up blood. He wanted any clinical details Stoney had to share. Stoney told him the entire story.

  As an afterthought, Stoney asked, “What is she seeing you about?”

  The local doctor hesitated a moment, then said, “Your information has been helpful, but I’m not sure what I will do with it. She’s been urinating bloody urine for several weeks but with no demonstrable lesion in her bladder or kidneys.”

  Stoney only shook his head, wondering what drove Mrs. Settler and all like her to do what they do to themselves.

  The most puzzling problems faced by physicians are those that are self-inflicted or feigned. According to Marc Feldman, M.D., a recognized international expert, there are four types of self-harm: Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder.

  Munchausen Syndrome was named after Baron von Munchausen, an 18th century German aristocrat known for his tall, elaborate tales. Munchausen himself was not sick. Patients with Munchausen Syndrome inflict real harm by injecting feces, bleeding themselves, injecting insulin, taking anticoagulants or feigning serious neurological symptoms. The list of self-inflictions is long. These patients are quite dramatic and move from one emergency room to another and from town to town fooling one doctor after another. They do what they do to get attention not available from normal social encounters. The condition is considered to be a psychiatric disorder. Mrs. Settler was very private in her self-induced bleeding; she would not be considered to have Munchausen Syndrome.

  Munchausen by Proxy is when one person inflicts harm on another person. Most often it’s a mother inflicting harm on one of her children. This is a crime and should be reported to police.

  Malingering is conscious infliction or feigning of an illness for drugs or monetary or other tangible gain. Malingering often co-exists with a borderline or antisocial personality. Mrs. Settler was not seeking any tangible gain.

  The fourth type of self-harm is called a Factitious Disorder. Patients with this disorder do not move from place to place and they are not dramatic in their presentation. Many lead quiet and, to some extent, productive lives. They are seeking some sort of attention otherwise not available in their daily lives. Mrs. Settler was a typical example of a Factitious Disorder. Most of these people are incurable.

  All of these disorders are difficult and usually impossible to manage. One essential feature of the doctor-patient relationship is the requirement for trust. When trust is consciously violated, there can be no successful encounter with a physician. These patients, once discovered, will move immediately to another physician. Such was the case with Mrs. Settler.

  *Case shared by:

  William Stoney, M.D.

  Professor of Cardiac and Thoracic Surgery, Emeritus

  Vanderbilt University School of Medicine

  Chapter Four

  Seasonal Disorder *

  Fred Altman was a happy-go-lucky traveling salesman with a lovely wife, two young boys he adored and overall good health — except twice this month he had been admitted to the University Hospital with severe headaches.

  “This was the worst headache I ever had in my whole life,” Altman said. “Not like the kind of headache you get from driving all day with the sun in your eyes. I’ve had those, too. But this was something different — much, much worse.”

  With the headaches came nausea and vomiting. On both occasions when the pain started, Fred became dizzy and confused. It was November and he was looking forward to traveling during the holidays, but he worried that one of these awful headaches might hit him again with his family in the car.

  A careful medical history revealed Altman had also experienced these same symptoms in late March of the same year, but these were much milder and lasted only an hour. He didn’t seek medical attention, chalking it up to perhaps a few too many cocktails the previous weekends. He had experienced no recurrences of the headache or other symptoms until the two hospital admissions, the first on November 21st and the second on November 30th.

  On both admissions, Altman underwent extensive diagnostic workups. The careful and thorough physical examinations proved normal. Neither his blood pressure nor other vital signs fluctuated throughout his stays. Head and spine CT scans were also normal on the first admission, and an MRI of his brain was normal on the second admission. All routine blood chemistry tests were normal. Furthermore, within 24 hours of being admitted to the hospital both times, Altman was symptom free.

  Other than his history of symptoms, there was no objective abnormal finding by any means. Several members of the residency team were beginning to wonder about psychological or stress causes for the headaches. But Altman and his wife insisted life was good in every way. He loved his job and family and couldn’t point to anything extraordinary or stressful.

  Walker Evans, the chief medical resident, called in Simpkins Jackson, a consultant in Neurology. Dr. Jackson was well known for taking very careful medical histories and solving complex cases.

  After spending more than an hour with Altman Dr. Jackson said, “Here is all I know about Fred’s recurring illness: He had one severe episode in March and a couple of minor ones in early April, then no more until these two admissions in November. All summer long he enjoyed vigorous good health, swimming and golfing, shooting to a handicap of seven, as a matter of fact.

  “Whatever this is, it does not occur in the summer. It is some kind of early spring and fall recurring illness. I asked him every known pollen-grass-seed-dust-pollution question I could think of. He is a traveling salesmen delivering and taking orders from small grocery stores and gas stations, selling candies, crackers, and small edible items. Stops every few miles across the country roads out from towns. I even asked him if he ate different candies before the episodes, trying to get something to correlate with the seasonal headaches. Nothing so far. By the way, all the headaches came on late in the afternoon.”

  Just one week after Altman was discharged from the last November hospital stay, he was back. This time, he arrived by ambulance. He was unconscious and unresponsive to painful stimulation, with very shallow breathing.

  After several hours of ventilation on 100 percent oxygen, however, the patient woke. Remarkably, he wasn’t groggy or confused, but fully conscious and completely oriented. Yet he had no memory of what happened to him. “All I remember is that I was driving my car back toward town,” Altman said. “The next thing I knew, I was waking up here.”

  The EMT team said they were called to the scene of a one-car accident where Altman’s car had run off the road into a ditch. The windshield was broken out, and he was slumped over the steering wheel unconscious.

  “Well, we finally know the cause of your illness. Your blood carboxyhemoglobin level is one of the highest the lab has ever seen. You’ve got carbon monoxide poisoning.”

  “But why only in the fall and spring?” the chief medical resident wondered aloud. “And why only late in the afternoon?”

  The doctors explained their diagnosis, as well as likely sources of carbon monoxide to Altman. They asked him to think back over his daily habits, trying to connect how he might have come in contact with the deadly poison.

  He said he bought a used car in March, but hadn’t noticed any odors or problems. Typically, he drove with the windows closed when it was cold and open in warm weather. Because he makes so many stops every day, he said he’s not really in the car for any length of time until his drive home in the afternoon.

  It was those last words that unraveled the mystery. Since Altman’s headaches began in March and only occurred in cold weather in the late afternoon, riding for a sustained time with the windows up in a faulty car was the culprit.

  Carbon monoxide (CO) is
a close chemical gaseous cousin of carbon dioxide (CO2). It is a tasteless and odorless gas and very poisonous. There are thousands of ER visits each year from CO poisoning and several hundred deaths in the U. S. The gas is formed in any heating system where the combustion is partial or incomplete. Home stoves or heating systems not well vented are the most common sources, as are automobiles with improper exhausts or poorly vented engine gases. Home heating systems with no vents are notorious. Charcoal fires inside homes are also sources of fatal carbon monoxide poisoning.

  When breathed into the lungs, carbon monoxide quickly combines with hemoglobin and displaces oxygen. As carbon monoxide levels increase, oxygen levels fall. The victim becomes more and more anoxic and, if not removed from the source of the gas, soon dies. Oxygen administration speeds removal of carbon monoxide from its attachment to hemoglobin. Death from the gas is actually an internal asphyxiation, the same as being choked to death.

  The fire department was dispatched to find Altman’s car. When they tested it for carbon monoxide emissions, they found the levels to be quite high.

  Altman had been only minutes away from death, probably saved by the broken windshield that let in fresh air.

  Altman had the car repaired and resumed his rounds selling candy and crackers along the back roads. With the exhaust system fixed, he had no recurrence of the poisoning. The case reminds us not only of how dangerous and sneaky carbon monoxide can be, but also that not all seasonal illnesses can be blamed on allergies.

  *This case was shared by Dr. Jim Jirjis, M.D., M.B.A.

  Assistant Chief Medical Officer for Vanderbilt Medical Group

  Assistant Professor of Medicine, Vanderbilt University School of Medicine

  Chapter Five

  Snakes on a Porch *

  Dewayne Childs and his wife Edwena bought an old log cabin on the western bank of the Buffalo River. The cabin, built in 1858, was in shambles. But that didn’t bother these two. Newly married, young and full of energy, they were excited about restoring it for their first home.