The 75-year-old man lay sprawled on the floor between the kitchen counter and the island, surrounded by a halo of pills. “What happened?” his wife asked as she hurried to his side, although she suspected she already knew.
He wasn’t sure, he told her. One minute he was standing at the counter, getting ready to take his morning medications; the next, just like that, he was on the floor. She helped him sit up. When he was able to, he slowly rose to his feet. It was the third time he fainted in the last 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 made his way into the house, he felt unsteady and braced himself on the wall. He made it to a chair but passed out a couple of times just sitting there. And when awake, he was confused. He was trying to read a text from his daughter but couldn’t remember how.
The next time, a couple of days later, he woke to go to the bathroom. He got up, then suddenly found himself on the floor. A sharp pain in his forehead told him he’d clipped the bedside table on his way down. His wife helped him up and to the bathroom. He found that he’d been incontinent. He was embarrassed, in front of his wife of 53 years. He called his doctor’s office the next morning and arranged to come in the following day. He hadn’t been feeling well for the past couple of weeks, he told the young physician assistant. He’d woken up drenched with sweat a few times recently, and his wife told him he rattled the bed with his shivering. He felt feverish. Tired. No appetite. No ambition. Foggy. One night he wasn’t even able to remember the prayer he always said before bed. And urinating was strangely uncomfortable.
After finishing her exam, the physician assistant sent him to the lab. This was probably a urinary-tract infection, she told him after reviewing his test results. These are not uncommon in older men, because an enlarging prostate can make it hard to urinate. She started him on an antibiotic often used to treat this kind of infection.
That was just two days before this most recent episode. The P.A. told him to go to the hospital if he felt any worse. He definitely felt worse.
A Highly Motivated Clinician
In the emergency department of the Yale New Haven Hospital, it was clear that the elderly man was sick. He had a fever of 101, his heart was racing and his blood pressure was abnormally low, even though he hadn’t taken his hypertension medications that morning. Lab results confirmed that first impression. His kidneys were failing — though they were fine just two days earlier. He was given IV fluids and started on broad-spectrum antibiotics. The drug he’d been taking for the past couple of days didn’t seem to be doing the job.
On the floor, the first clinician the patient met was Alan Lee, who was in his last year of med school and serving as an intern. Lee was excited to see this patient. Because the hospital was so crowded, thanks in part to the recent resurgence in Covid-19 cases, patients often spent hours, sometimes days, in the E.R. waiting for a bed. By the time they got onto a medical floor, they could already have a doctor assigned. This meant most of the thinking about the patient had been done, and the accepting physician usually just carried out the first doctor’s plan. This Sunday-morning admission came during a lull in the action, so Lee’s team would get the first crack at figuring out what was going on.
The doctors in the E.R. were focused on the man’s failing kidneys, but what injured 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 supervising resident, 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 in the past week or so because he felt too sick to eat or drink.
Once Lee finished his questions, Ying asked the patient if he had been bitten by a tick recently. Absolutely not, the man answered promptly. He often took his dog to wooded paths down by 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 could have caused the man’s urinary problems as well as the fever. Those symptoms could make the patient not want to eat or drink, allowing him to become dehydrated. That, in turn, could have caused him to faint and could have even damaged his kidneys. But a 10-pound weight loss was not a common finding in a urinary-tract infection. Neither was night sweats. Could this be a tick-borne illness like Lyme?
The Most Likely Diagnosis
Donroe agreed that these symptoms were atypical. It seemed likely the patient now had urosepsis — an infection that started in the urinary tract but then involved the entire body — and that the cause of his symptoms was a urinary infection. But because he was already on antibiotics, they probably wouldn’t see anything in the urine if they tested him now. Lee should call the patient’s primary-care doctor Monday morning to get the results of the tests done before he had started the antibiotics.
The next day, the patient was feeling a lot better. He’d gotten fluids and a good night’s sleep. No fever, no shaking chills. Maybe the antibiotics were working. Still, his kidneys were no better.
After rounds, Lee called the patient’s doctor. The urine culture hadn’t grown anything at all. The only abnormality was that the urine contained a lot of blood. Now what? Lee went to the attending with the news. Together Lee and Donroe went over the data one more time. 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 sick for nearly two weeks with fevers and chills, and he had something destroying his red blood cells. To Donroe that sounded like a tick-borne disease. Not 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 one for Lyme, ehrlichiosis and anaplasmosis — the most common tick-borne diseases in Connecticut.
It was late afternoon when the first result came back. Inside many of the patient’s red blood cells, the lab tech had seen a single tiny dark circle — a parasite. The patient had babesiosis.
A Circle or a Cross
Babesia is a protozoan, a single-celled parasitic organism, carried by the deer tick. This arachnid picks up the bug while feeding on a white-footed mouse and delivers it to the next mammal it bites. Once the organisms enter the circulation, they invade red blood cells, where they multiply. Under the microscope the organisms look like either a circle or a cross depending on where they are in maturation and reproduction. Then progenitor and offspring burst out of the cell, enter neighboring red blood cells and the process continues.
In the Northeast, the deer tick is best known as the carrier of Lyme disease. And in fact, up to 42 percent of ticks that carry Babesia also carry Lyme disease, according to a study from a Connecticut state lab. The following day, the team learned that it was true for the tick that bit this patient as well. He had both Lyme and babesiosis, and so needed to be treated with three medications — two for the Babesia and one for the Borrelia, the bacteria that cause Lyme disease. He would have to take them for about two weeks.
The patient could feel the difference the day after he started taking the medications. His appetite was back. So was his energy. Now that he is back home, he is considering how to deal with those ticks. He knows they’re not going anywhere, but neither are he and his wife. He already uses a spray to discourage their bites. Clearly he will just have to look a lot harder after his walks with the dog. He’s not going to let the arachnids win.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is ‘‘Diagnosis: Solving the Most Baffling Medical Mysteries.’’ If you have a solved case to share with Dr. Sanders, write her at Lisa.Sandersmd@gmail.com.
Source: NYT
