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November 12, 2006
Diagnosis
The Healing Problem
By LISA SANDERS, M.D.
1. Symptoms
As Dr. Lisa Pastel, a resident in her second year of training, entered the brightly lighted cubicle, five faces turned to greet her. The patient, a pleasant-faced middle-aged man in a wheelchair, invited her in. His wife sat next to him, and their three children sprawled across the cool linoleum floor with schoolbooks opened before them. For this family, like so many caught up in the care of a chronically ill member, going to the hospital had become just another family routine.
The patient leaned forward to shake the doctors hand. His grip was firm and his hand warm, the doctor noted, but not hot or sweaty. He was tired and achy, he told her, and he had a fever he just couldnt shake. He had been well until a couple of days ago or at least as well as he could be, considering all his other health problems, he added, smiling through a bushy, gray-streaked beard. Because of this fever, he visited his doctor, who told him he had to go into the hospital. That would be excessive for most of us, but this patient had an impaired immune system, and close observation and strong antibiotics were necessary.
He was 47. Four years earlier, he had gastric bypass surgery. It worked, and he lost more then 100 pounds. Before the surgery, he had diabetes, high cholesterol and sleep apnea, but those diseases melted away along with the excess pounds.
About two years later, he developed a hernia, a common complication of abdominal surgery. He had an operation to fix it, and thats when the latest round of trouble began. After the operation, he developed a serious infection. He needed weeks of intravenous antibiotics, and he was still living with the consequences: the incision that the doctors made to repair the hernia never healed. It remained an open wound, and no one could figure out why. That wasnt the only mystery: six months ago, routine blood work showed that he had developed anemia (too few red blood cells) and neutropenia (too few infection-fighting white blood cells). He had a slew of tests, but no one could explain this newest complication either.
2. Investigation
The resident could find no obvious signs of infection when she examined the patient. The large wound on his abdomen was almost the length of her hand. The tissue lining his incision offered no clues about why it had not healed. His blood work showed that he had fewer than 2,000 white cells per microliter of blood less than half the number he should have had, even without an infection. The neutrophils the type of white blood cells that serve as the front line of the immune system, our bodys version of the Marine Corps were below 500 cells per microliter, an inadequate force to fight off even the most insignificant infection.
Pastel admitted the patient to the hospital, ordered a chest X-ray to look for pneumonia and blood and urine cultures to look for other infections and started broad-spectrum antibiotics. She might never find out where the infection was, but the antibiotics would shore up his tiny army of white cells and treat it.
Then the resident turned to examine the patients extensive chart. She was particularly curious about his neutropenia. She had taken care of many patients with neutropenic fever, but usually the cause of the white-cell loss was obvious. A person had undergone chemotherapy or taken immune-suppressing medicines for some other reason. But this patients neutropenia was described as idiopathic; after an extensive work-up, they still hadnt found the cause. He had been checked for hidden infections like hepatitis and H.I.V., for autoimmune disorders, for thyroid disease. Nothing stood out. A bone-marrow biopsy showed only that he wasnt making enough red or white cells. She began reading up on idiopathic neutropenia for some clue about what could be causing his bone marrow to fail. She knew she probably wouldnt be able to figure this out more experienced doctors had already been through all this. Still, she was interested and confident enough to try.
After reviewing the studies and his work-up, the resident could come up with only a couple of possible unexplored causes. The patient was on more than a dozen medications. Could any of these be connected to his problems? In addition, in a few cases, nutritional deficiencies after gastric surgery had been linked to neutropenia. But the patient had been tested for most of them: iron, vitamin B12, folate. He had not been tested for copper deficiency, but that was pretty rare. In about a third of all cases of idiopathic neutropenia, she read, no cause was ever found.
That evening, the patients wife approached the young doctor. She had gone home to get the list of vitamins he was taking. Please make sure he gets them, she said. He needs them. The resident looked over the list: iron, calcium and a multivitamin such a regimen was normal enough after gastric bypass because the removal of parts of the gastrointestinal tract limits the bodys ability to absorb certain nutrients. But then she noticed two supplements that she wasnt used to seeing: vitamin A and zinc. Could they have anything to do with his neutropenia?.
First she looked into vitamin A. She knew it could be toxic at high doses, and he was taking more than 10 times the recommended amount. A quick search, however, turned up nothing. What about zinc? She didnt know much about that mineral, but he was taking 15 times the usual dose. She did another search, and bingo! A half-dozen reports appeared on the screen describing cases in which high zinc intake had caused neutropenia, and sometimes anemia. She read on, fascinated. Zinc itself didnt cause the problem; it was that zinc and copper were absorbed by the body through the same cellular doorway. If you consumed too much zinc, you absorbed too little copper. And that mineral was essential to making blood and tissue. Maybe he had a copper deficiency after all, she thought triumphantly.
3. Resolution
She directed the patient to stop taking all his vitamins and sent off blood for a copper-level test. Even before the results came back, the effect was visible. Within days, his white-cell count was in the normal range. He was sent home with a prescription for copper and told to take it for the next six months. When the copper test finally came back, it confirmed the deficiency. Over the next couple of months, the anemia resolved too, and the wound finally healed.
Why was the patient on such high doses of vitamins? His surgeons had started them after the hernia surgery to promote wound healing; there is evidence that this can be helpful, especially early on. But the wound hadnt healed, and the patient continued to take the supplements. He had been in and out of the hospital several times since then. Each time he was admitted, hospital doctors had continued his vitamins with neither the patient nor the doctors seemingly aware of the possible complications.
It is a truism in medicine that the difficult diagnoses are most likely to be made by the oldest or the newest physicians. The oldest because they have seen so much, know what its not and also know, like Sherlock Holmes, that when everything else has been ruled out, what is left, no matter how unlikely, is probably the answer. The newest because they are fresh from the books and can follow the clues without a sense of just how unlikely the destination may be.
It seems somehow unfair, Pastel reflected when I spoke with her not long ago. Heres this guy doing everything he can to get better, but what he was doing what he was told to do was making him worse. We just dont think of vitamins as something that can be harmful.
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November 12, 2006
Diagnosis
The Healing Problem
By LISA SANDERS, M.D.
1. Symptoms
As Dr. Lisa Pastel, a resident in her second year of training, entered the brightly lighted cubicle, five faces turned to greet her. The patient, a pleasant-faced middle-aged man in a wheelchair, invited her in. His wife sat next to him, and their three children sprawled across the cool linoleum floor with schoolbooks opened before them. For this family, like so many caught up in the care of a chronically ill member, going to the hospital had become just another family routine.
The patient leaned forward to shake the doctors hand. His grip was firm and his hand warm, the doctor noted, but not hot or sweaty. He was tired and achy, he told her, and he had a fever he just couldnt shake. He had been well until a couple of days ago or at least as well as he could be, considering all his other health problems, he added, smiling through a bushy, gray-streaked beard. Because of this fever, he visited his doctor, who told him he had to go into the hospital. That would be excessive for most of us, but this patient had an impaired immune system, and close observation and strong antibiotics were necessary.
He was 47. Four years earlier, he had gastric bypass surgery. It worked, and he lost more then 100 pounds. Before the surgery, he had diabetes, high cholesterol and sleep apnea, but those diseases melted away along with the excess pounds.
About two years later, he developed a hernia, a common complication of abdominal surgery. He had an operation to fix it, and thats when the latest round of trouble began. After the operation, he developed a serious infection. He needed weeks of intravenous antibiotics, and he was still living with the consequences: the incision that the doctors made to repair the hernia never healed. It remained an open wound, and no one could figure out why. That wasnt the only mystery: six months ago, routine blood work showed that he had developed anemia (too few red blood cells) and neutropenia (too few infection-fighting white blood cells). He had a slew of tests, but no one could explain this newest complication either.
2. Investigation
The resident could find no obvious signs of infection when she examined the patient. The large wound on his abdomen was almost the length of her hand. The tissue lining his incision offered no clues about why it had not healed. His blood work showed that he had fewer than 2,000 white cells per microliter of blood less than half the number he should have had, even without an infection. The neutrophils the type of white blood cells that serve as the front line of the immune system, our bodys version of the Marine Corps were below 500 cells per microliter, an inadequate force to fight off even the most insignificant infection.
Pastel admitted the patient to the hospital, ordered a chest X-ray to look for pneumonia and blood and urine cultures to look for other infections and started broad-spectrum antibiotics. She might never find out where the infection was, but the antibiotics would shore up his tiny army of white cells and treat it.
Then the resident turned to examine the patients extensive chart. She was particularly curious about his neutropenia. She had taken care of many patients with neutropenic fever, but usually the cause of the white-cell loss was obvious. A person had undergone chemotherapy or taken immune-suppressing medicines for some other reason. But this patients neutropenia was described as idiopathic; after an extensive work-up, they still hadnt found the cause. He had been checked for hidden infections like hepatitis and H.I.V., for autoimmune disorders, for thyroid disease. Nothing stood out. A bone-marrow biopsy showed only that he wasnt making enough red or white cells. She began reading up on idiopathic neutropenia for some clue about what could be causing his bone marrow to fail. She knew she probably wouldnt be able to figure this out more experienced doctors had already been through all this. Still, she was interested and confident enough to try.
After reviewing the studies and his work-up, the resident could come up with only a couple of possible unexplored causes. The patient was on more than a dozen medications. Could any of these be connected to his problems? In addition, in a few cases, nutritional deficiencies after gastric surgery had been linked to neutropenia. But the patient had been tested for most of them: iron, vitamin B12, folate. He had not been tested for copper deficiency, but that was pretty rare. In about a third of all cases of idiopathic neutropenia, she read, no cause was ever found.
That evening, the patients wife approached the young doctor. She had gone home to get the list of vitamins he was taking. Please make sure he gets them, she said. He needs them. The resident looked over the list: iron, calcium and a multivitamin such a regimen was normal enough after gastric bypass because the removal of parts of the gastrointestinal tract limits the bodys ability to absorb certain nutrients. But then she noticed two supplements that she wasnt used to seeing: vitamin A and zinc. Could they have anything to do with his neutropenia?.
First she looked into vitamin A. She knew it could be toxic at high doses, and he was taking more than 10 times the recommended amount. A quick search, however, turned up nothing. What about zinc? She didnt know much about that mineral, but he was taking 15 times the usual dose. She did another search, and bingo! A half-dozen reports appeared on the screen describing cases in which high zinc intake had caused neutropenia, and sometimes anemia. She read on, fascinated. Zinc itself didnt cause the problem; it was that zinc and copper were absorbed by the body through the same cellular doorway. If you consumed too much zinc, you absorbed too little copper. And that mineral was essential to making blood and tissue. Maybe he had a copper deficiency after all, she thought triumphantly.
3. Resolution
She directed the patient to stop taking all his vitamins and sent off blood for a copper-level test. Even before the results came back, the effect was visible. Within days, his white-cell count was in the normal range. He was sent home with a prescription for copper and told to take it for the next six months. When the copper test finally came back, it confirmed the deficiency. Over the next couple of months, the anemia resolved too, and the wound finally healed.
Why was the patient on such high doses of vitamins? His surgeons had started them after the hernia surgery to promote wound healing; there is evidence that this can be helpful, especially early on. But the wound hadnt healed, and the patient continued to take the supplements. He had been in and out of the hospital several times since then. Each time he was admitted, hospital doctors had continued his vitamins with neither the patient nor the doctors seemingly aware of the possible complications.
It is a truism in medicine that the difficult diagnoses are most likely to be made by the oldest or the newest physicians. The oldest because they have seen so much, know what its not and also know, like Sherlock Holmes, that when everything else has been ruled out, what is left, no matter how unlikely, is probably the answer. The newest because they are fresh from the books and can follow the clues without a sense of just how unlikely the destination may be.
It seems somehow unfair, Pastel reflected when I spoke with her not long ago. Heres this guy doing everything he can to get better, but what he was doing what he was told to do was making him worse. We just dont think of vitamins as something that can be harmful.
Home
World U.S. N.Y. / Region Business Technology Science Health Sports Opinion Arts Style Travel Job Market Real Estate Automobiles Back to Top
Copyright 2006 The New York Times Company
Privacy Policy Search Corrections RSS First Look Help Contact Us Work for Us Site Map
