Saturday , October 23 2021

Heart under water – an enigmatic patient


The 44-year-old man was not well for some time when he was taken to Massachusetts General Hospital in Boston. Ten months ago, her shoulder joints began to ache. A rheumatologist examined him and injected an anti-inflammatory agent into his shoulders.

In the months that followed, the patient's finger and knee joints also began to ache. The rheumatologist diagnosed fibromyalgia, prescribed painkillers and again injected syringes into his shoulders.

But the man is getting sicker and sicker. He does not like to eat more, his stomach hurts. In addition, a shooting pain in the chest, which increases when he is lying on his back, torments him. He sleeps badly, coughs. Sometimes he is too exhausted to get out of bed. Overall, he will lose about 18 pounds in the ten months without wishing to do so.

Because she cares about him, her sister finally brings the man to the emergency room. There, a blood test reveals that the number of white blood cells is very low.

Fluid in the lungs – and in the pericardium

An X-ray of your rib cage reveals a mild pulmonary edema, which is an accumulation of fluid in the organ. Also, between the lungs and the ribs, doctors sift more fluids, so there must be – medical people call this pleural effusion.

The patient is transferred to the Massachusetts General Hospital. There, doctors record their medical history exactly, as the team around Sheila Arvikar in a case report in the journal "NEJM" records.

The man suffers from a depression, against which he takes a drug. He comes from an African country south of the Sahara and immigrated to the US 18 years ago. He has not left the country for 15 years. In his own words, he drank a lot of beer for several years, but stopped for about 20 years. He has not smoked in 15 years. There are no cases of heart disease, tuberculosis, HIV, autoimmune diseases or cancer in your family.

Tests for influenza, HIV and Borrelia virus

The man's heart beats too fast. Your knees and shoulders are hot and hurt when they are turned. Its temperature is slightly elevated to 37.7 degrees Celsius.

Does an infection cause the symptoms? Tests for influenza, HIV and Borrelia virus are negative. However, a test for cytomegalovirus suggests that they can trigger serious diseases, especially in people with weakened immune systems.

Additional exams of the heart show that excess fluid has accumulated in the pericardium surrounding the organ. Such a pericardial effusion can be fatal. After a certain amount, the fluid ensures that the heart can no longer fill with blood. Consequently, it can no longer sufficiently supply the body with vital oxygen.

Doctors transfer the patient to cardiology. The next day its temperature rises to 39.1 degrees Celsius. Your heart keeps running.

Tuberculosis, cancer, autoimmune disease?

Doctors suck the pericardium well into a pint of bloody fluid so the organ can function properly again. They then examine the fluid to find out what triggered the pericardial effusion. Possible causes include tuberculosis, cancer and autoimmune diseases.

A test for cancer cells is negative, and the previous imaging methods did not provide any indication of a tumor. Therefore, doctors consider the cancer unlikely.

Fever and unwanted weight loss may indicate tuberculosis. But the test results speak against it, and the disease does not fit.

Doctors go through various rheumatic diseases. After all, unfortunately the man close to the heart problem also pain in the joints of the shoulder and knee, which is typical, for example, of rheumatoid arthritis. However, even these possible diagnoses seem unlikely: the values ​​of your white blood cells do not fit the picture here.

A disease that mainly affects women

Doctors finally come to a new suspicion: the man is suffering from one called lupus erythematosus? This autoimmune disease, in which the body's defense attacks its own tissue, affects 90% of women and therefore is not necessarily the first suspicion in a male patient.

But lupus could explain all the symptoms: joint pain, fever, reduced numbers of white blood cells – and pericardial effusion. Because of a lupus, the pericardium can ignite, which, in turn, leads to dangerous spillage. Other tests confirm the diagnosis.

The patient receives two drugs that fight the autoimmune disease. A day later he is noticeably better. After his discharge from the clinic, he will continue to be seen in the rheumatology clinic. In the next year and a half, he will stop one of the medications without medical guidance and decrease the dose of the other. For a few years he lives well with this until he seeks help again with chest pain and joint pain in the emergency department.

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