Fascinomas- Fascinating Medical Mysteries

by Clifton K Meador

  Kaminski suggested stopping the Metformin and substituting another oral medication for blood sugar control. Within three months, McKnight had a return of normal nerve function to his legs and feet. His vitamin B12 level also returned to normal.

  It’s a strange coincidence that a medicine aimed at preventing a complication of diabetes should, in fact, create the very complication it was designed to prevent.

  This toxic effect of Metformin is something not many doctors know. While the British navy may have known lime juice could prevent scurvy more than 160 years before it was required on all ships, one should hope critical medical information would spread a bit faster in the information age.

  *Case shared by:

  Paul Barnett, M.D.

  Associate Clinical Professor of Medicine

  Department of Medicine

  Vanderbilt University School of Medicine

  Chapter Thirteen

  Miss Information*

  Boston City Hospital had become so busy for the interns that they had to serve an extra night shift once a week; the “night float” had to be created. The night float intern came on duty at 10 p.m. and worked until 7 a.m., sometimes admitting as many as 10 new patients.

  One night, Paul Barnett and a fellow intern were returning from a Celtics basketball game at Boston Garden. They had just seen the great Bob Cousy play and were discussing some of his amazing moves.

  They got on the late train heading for Boston City Hospital, both returning for the night float rotation in the ER. The train that time of night was nearly empty. Across the aisle was an old woman who looked homeless. Her hair was unkempt. Her long, stained skirt dragged the floor. She huddled in a ragged coat reading a small book, clutched in filthy hands.

  Barnett nudged his friend, “Do you see what she’s reading?”

  The friend looked for a moment then whispered, “I can’t believe it. She’s reading a Merck manual.”

  Merck Manuals were small medical books distributed free to medical students by Merck Pharmaceutical. The book contained short descriptions of nearly all diseases. The idea of a Merck Manual in the hands of a homeless old woman sitting alone on a late night train was so odd, it stuck in Barnett’s mind.

  Barnett rushed to change into whites and get to the ER before 10 p.m. Just as he came on duty, the resident in charge called out for help with a patient vomiting blood. It was none other than the old woman from the train. The sight of her stopped him in his tracks.

  “Get your ass over here and help,” the resident yelled. “Don’t just stand there.”

  He watched the woman heaving blood onto the floor and all over her dress. Barnett moved in to help, explaining to the resident how just a few minutes ago he had seen her reading the Merck Manual on the train. The old woman heard him.

  Suddenly she stood up and bolted towards the door. As she ran from the emergency room, she spit out several tiny blood-covered balloons, obviously the source of her ”vomited” blood.

  The resident shouted for the police, ever-present in the ER. They detained her, but it was too late. She had already swallowed the Demerol she had conned out of doctors for her alleged abdominal “ulcer pain.”

  There simply are no limits to what malingering patients will do to get drugs. We can only wonder what new diseases this woman found in her Merck Manual to serve her devious purposes in subsequent ER visits.

  *Case shared by

  Paul Barnett, M.D.

  Associate Clinical Professor of Medicine

  Department of Medicine

  Vanderbilt University School of Medicine

  Chapter Fourteen

  An Uncommon Cure *

  Walter McKenzie was a patient of old Dr. Smithers for over 2 decades. When it was time for Smithers to retire, he referred McKenzie to Dr. Jim Jirjis, a young internist. By this time, McKenzie was 78 years old.

  On his first visit to see the new doctor, McKenzie brought a stack of his old medical charts several inches thick. The two met and talked for a few minutes, then Jirjis told McKenzie he would review the records and see him for a complete examination the following week. As was his practice, Jirjis read every page and reviewed all the lab work for the past 23 years that Dr. Smithers had cared for McKenzie.

  Jirjis was impressed with the meticulous notes old Dr. Smithers kept. He easily followed the life history and clinical course of first a man in robust health, then married, having two sons and finally moving on through the middle years to his current senior age. Many years ago, McKenzie had developed Type 2 Diabetes. Dr. Smithers’s notes describe a slow progression of various unrelated illnesses: pneumonia with flu, an inguinal hernia operation and a fracture of the wrist from a fall. The diabetes, as is common, worsened over the years, requiring diet, exercise, oral diabetes pills and, ultimately, when the pills were maximized and no longer sufficient, the addition of insulin.

  As unremarkable as the charts’ information was overall, one thing caught Dr. Jirjis’ attention: He began to notice in the chart a slow and gradual trend of the fasting blood sugar levels decreasing over the years. In the early years, the levels seemed to average nearly 250 mgm%. In those days, a normal blood sugar was considered to be less than 140.

  When the test for hemoglobin A1C levels became available, McKenzie’s were also quite high. Hemoglobin A1C levels measure blood sugars attached to hemoglobin and give a measure of the average blood sugar levels for the previous several months. It is now the gold-standard measurement of diabetic control.

  Despite these high numbers early on, Dr. Jirjis noted on McKenzie’s first visit with him that the patient was off all of his medications, including the pills and the insulin. Yet, inexplicably, his blood sugars were completely normal at around 100. The hemoglobin A1C level was also normal at 6.5%.

  What had at one point been severe, advanced diabetes had gradually gone away without a trace and while receiving no medication or insulin.

  When Dr. Jirjis asked McKenzie about this dramatic turn of events, he simply said, “Old Doc Smithers, I guess, cured my diabetes.”

  At first Jirjis couldn’t believe he had witnessed a complete cure of diabetes. No colleague had ever seen such a case. Dr. Jirjis was totally perplexed.

  In the months after that initial enigmatic meeting with Dr. Jirjis, McKenzie began to have episodes of emotional irritation, becoming very irritable with no cause. Later the episodes were followed by loss of consciousness. The first time occurred in church when he fell to the floor in the middle of a hymn. These symptoms were all consistent with low blood sugar.

  Jirjis immediately knew there was only one possibility: McKenzie’s body was somehow being exposed to insulin. The patient was either injecting himself with insulin and not telling anyone, or he was making insulin from his pancreas.

  He quickly ruled out surreptitious insulin and honed in on the pancreas. How could a pancreas that made too little insulin suddenly switch to making too much?

  Dr. Jirjis ordered tests, among them a CT scan of McKenzie’s abdomen. It revealed the answer: a malignant tumor of the pancreas known as an insulinoma. The cancer had already spread to the liver. McKenzie lived only a few more months, dying in protracted hypoglycemia and coma from the malignant insulinoma of his pancreas.

  How strange can nature get? Tissues once deficient in producing insulin became malignant, secreting excessive amounts – a weird irony of biology.

  Malignant pancreatic tumors secreting insulin are quite rare, occurring in about four per million person years. Even more rare is the coexistence of an insulinoma occurring in a patient with diabetes mellitus. Only a few cases have been reported. (See Chapter notes.)

  Further compounding the uniqueness of this amazing case is the fact that Dr. Jirjis’s first meeting with McKenzie happened to perfectly coincide with his pancreas making exactly the right amount of insulin to “treat” his diabetes. The coincidence is remarkable.

  *Case shared by:

  Jim Jirjis, M.D., MBA

  Assistant Chief Med
ical Officer for Vanderbilt Medical Group

  Assistant Professor of Medicine

  Department of Medicine

  Vanderbilt University School of Medicine.

  Chapter Fifteen

  Shining a Light on the Problem *

  The hospital was nothing new to Gertrude Amarill. She had been an emergency room nurse for seven years. Being a patient, however, was something that had become all too common recently. On this day, she, a 32-year-old woman, was being admitted to the Regional Medical Center for recurring breast masses. This was her 13th admission.

  Peter Seinfold was the admitting surgical resident. In his admission history and physical exam write-up of Ms. Amarill, Dr. Seinfold recorded the recurring admissions and failures of therapy. The exact nature of the recurring left breast masses had not been consistently defined. Numerous biopsies had been taken. Most were read as “nonspecific inflammatory reaction. Rule out deep fungus infection.” Several were read as “suspicious of unusual form of breast cancer.” Still others were read as “multiple breast abscesses, infecting organism unknown.”

  On her last admission, a partial resection of the left breast was performed. Several areas of chronic inflammation were seen microscopically. In addition, there were two small acute abscesses. Cultures revealed two infecting bacterial organisms: staph aureus and E. Coli, suspicious of fecal or other contamination. Examination of the breast prior to surgery revealed extensive scarring and depressed areas. The overall size of the affected left breast was at least half the size of the healthy right breast.

  Repeated questions to Ms. Amarill revealed no clues. She denied all forms of digital or oral manipulation by herself or other people. She also denied traveling anywhere out of the ordinary or having contact with unusual animals. She kept no pets in her apartment.

  Most physicians who saw her suspected some sort of self-infliction or infliction by someone else. She denied all these accusations. She insisted the lesions occurred spontaneously every month or so. There was no seasonal pattern to their appearance; she had been admitted in as many summer months as winter months.

  Dr. Seinfold was determined to pin down an etiology for the breast lesions, which he strongly suspected were self-inflicted. He developed the idea of applying a tracer solution to the surgical dressing. He soaked a new dressing in the tracer solution and applied it to the left breast.

  After some research, Seinfold had decided on fluorescein which shows up under ultraviolet (UV) light. It’s used in ophthalmology to scan the cornea for abrasions. It’s also used in lifeboats and life vests to help find those lost at sea. The fluorescein is released into the water and the fluorescence can then be seen from the air by search planes. The attending surgeon agreed to the fluorescein test.

  Dr. Seinfold applied the harmless chemical to the dressing and skin of Ms. Amarill’s left breast without telling her. All along, she insisted she had not, nor would she ever, touch the dressing or any area of the breast. Whether or not she was telling the truth would be revealed.

  On her next clinic visit, an UV light was shone on her hands. Both glowed brightly fluorescent. Despite continuing to deny the obvious, she was persuaded to admit herself to the psychiatric inpatient unit for an extended stay.

  Under psychiatric care, Ms. Amarill finally admitted to harming her breast. She had used her own fecal material as the infecting agent. No reason or motivation was ever uncovered, and after a month’s stay in the unit she was released. She eventually moved to another town. There was no way to determine the eventual outcome of her breast lesions.

  As noted in Chapter 3. (the woman who cut her gums to produce a bloody sputum), there are four general forms of self-harm: Munchausen Syndrome where the patient moves from hospital to hospital with the intent of being dramatic with self-inflicted disorders; Munchausen by proxy where another person secretly inflicts harm on another person, usually a mother on a child; self-harm for a tangible gain, such as getting illicit drugs or work compensation; and self-harm with no tangible gain, apparently for some unmet personal gain. This is called a factitious disorder

  Gertrude Amarill fit the last category. She had no tangible gain from her abscesses. Some unknown, deep psychiatric disturbance drove her to do what she did to herself. As is the case for many such patients, she was lost to follow-up, but hopefully not to further psychiatric care.

  *This case was shared by a colleague who wishes to remain anonymous.

  Chapter Sixteen

  What You Don’t Know Can Kill You *

  Matt Graton was a cotton farmer in West Tennessee, living on the banks of the Tennessee River about a hundred miles from Nashville. Graton had turned 56 in late August, just before cotton picking time.

  Graton had enjoyed unusually good health with no serious illnesses. That’s why he was surprised to wake one morning with severe shaking chills. His wife, Mabice, took his temperature: 104 degrees. This was serious, so they headed for the hospital in Nashville. By the time they arrived, a red rash covered his arms and legs.

  After Graton’s admission to the hospital, the medical housestaff began the workup to identify the cause for the fever. Under the supervision of Dr. Robert Latham, blood and urine cultures were collected, along with complete blood count and chemistry screening tests. All tests were normal, except for a very low platelet count. Platelets are essential for clotting, seen as small particles circulating in the blood. Bleeding occurs when the platelet count is low, explaining the hemorrhagic rash seen on Graton.

  Anyone with sudden fever and rash coming in the summer in Tennessee should be suspected of having one of the tick-transmitted infections. The most common one in Tennessee is Rocky Mountain spotted fever, caused by ticks that attach to deer, possums and other wild animals.

  When asked if he had gotten any tick bites, Graton answered, “Why, hell yes I get ticks. You can’t farm and not get some ticks.”

  That answer was enough for Latham to begin full antibiotic coverage for Rocky Mountain spotted fever. Within three days, Graton’s temperature and platelet count returned to normal and he was pleading to get home for cotton picking. He was discharged to finish a full two weeks of Doxycycline antibiotic.

  A few days after Graton went home, test results on the blood mailed off to a special lab for tick testing showed no antibodies for any of the tick-borne diseases. Dr. Latham scratched his head. Graton had all of the symptoms of Rocky Mountain spotted fever; he had recent tick bites; summer was the right time of year for ticks; and the fever and platelets returned to normal with antibiotic treatment. If Graton didn’t have Rocky Mountain spotted fever, he must have something very much like it. Latham filed the case in his mental file of strange and puzzling patients.

  In late November, Dr. Latham got a long distance call from Matt Graton. Graton said he woke with severe chills and fever and, again, a slight rash.

  “Can’t be no ticks this time,” Graton said. “We’ve had some hard freezes and I been inside for about a week. I’m heading your way for treatment.”

  Again Graton was admitted to the hospital and again the workup was negative except for the low platelet count and fever. Despite the highly unlikely possibility of a tick being the culprit, Graton’s blood was sent for study of Rocky Mountain spotted fever and all the other tick-borne infections. In addition, blood was frozen and held for future studies if needed. All the antibiotics given on the August admission were again used. In a few days, the fever and platelet count returned to normal and Graton was discharged to home.

  As expected, the test results for tick-borne infections again returned as negative. Latham was even more puzzled and this time signed out Graton as “fever and thrombocytopenia (low platelets) of unknown origin.”

  In early January, Graton was admitted again with the identical story and findings: high fever and low platelets. Latham was convinced they were missing something obvious. He spent several hours with Graton and his wife tracing a full day in their lives: where they went, where they shopped, what they ate an
d drank, what pets lived in the house and the state of those pets’ health, and on and on down a long list of environmental exposures and possible toxins. Nothing seemed to explain the recurring illness. As before, the antibiotics appeared to work and Graton went back home.

  Two months later, Graton showed up in the emergency room, having called Dr. Latham to say he was on his way with the same symptoms. When Latham arrived in the ER and found Graton’s exam room, the patient had some news.

  “You know, Doc,” he said, “I think I may have the answer.”

  Graton went on to explain how he sometimes got severe leg cramps at night. He kept a bottle of Quinine capsules on his bedside table and took a capsule whenever these cramps occurred. He had been using it safely for years.

  “But you got me to thinking with all those questions last time,” he continued. “I thought back over the time in August, and then in November, then in January when I got sick. And then I recalled that those are the only times I had to take my quinine for cramps. I had bad cramps last night and took my quinine and here I am sick again.”

  Latham nodded knowingly, relieved to finally have an answer to the mysterious fever and rash.

  Reactions to quinine are many and varied, including renal failure, severe clotting, liver toxicity and neurological damage, in addition to fever and low platelets.(1) Since quinine for leg cramps is usually taken infrequently, it can be difficult to associate with an acute illness. Because Graton had taken it safely for so long, he had no reason to consider it toxic. But over time, he had developed a dangerous sensitivity.

  This case shows how vital information can sometimes be buried in our memory, unavailable to recall. It was only on the fourth episode of chills, fever and low platelets that Graton thought of the quinine. The extensive questioning by Dr. Latham had prompted Graton to think of all possible causes, finally surfacing the quinine from deep memory.