May 9, 2011

USA: The Weakness That Wouldn't Go Away

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NEW YORK / The New York Times / Magazine / May 8, 2011

DIAGNOSIS
The Weakness That Wouldn’t Go Away
By Lisa Sanders, M.D.

SYMPTOMS
A fiercely independent and active 76-year-old woman spent the past decade caring for her aged mother, who died at 99. Weeks after her mother’s death, the woman collapsed at home. She was found to have bleeding from a collection of abnormal blood vessels (known as AVMs, or arteriovenous malformations) in her colon. In the months after, the patient’s red-blood-cell count returned to normal, but she never regained her old energy and strength. She told her daughters that she was weaker and more tired than she had ever been in her life.

THE EXAM

Dr. Susan Wiskowski, a family physician in Hartford, was the woman’s doctor. Until recently, the patient was in good health for her age, with only a few medical problems: high blood pressure, which was controlled with one medication; hypothyroidism, treated with Synthroid; and cataracts, which had been surgically repaired. Now, out of the blue, she was experiencing rapid weight gain, swelling and weakness in her legs, which made it hard to walk.

Possible Diagnoses: Heart disease can manifest as weakness and fatigue, particularly in the elderly. The patient was referred to a cardiologist. An elevated white-blood-cell count was detected during the bleeding episode. She was sent to a hematologist.

RESULTS
The hematologist’s report was unrevealing. The cardiologist found no coronary-artery disease but noted a partly obstructed heart valve, which, though longstanding, might be contributing to the patient’s fatigue.

ANOTHER SYMPTOM
A couple of weeks after the cardiac work-up, the patient’s behavior became erratic and strange. Despite her complaints of weakness, she veered between bursts of activity — endlessly cleaning her house, giving large dinner parties — and days of isolation and fatigue. She was sometimes elated, telling her four daughters that she’d found where heaven was located. She began to talk about giving away her possessions. One afternoon she seemed completely out of control. A neighbor called 911, and the patient was rushed by ambulance to St. Francis Hospital in Hartford.

IN THE HOSPITAL
In the emergency room, doctors discovered an extensive hematoma on the patient’s right groin and leg, which developed after a cardiac catheterization she had as part of her work-up. She was admitted to the hospital.

A psychiatrist diagnosed hypomania and started the patient on several medications to stabilize her mood.

The patient complained of severe weakness, which made minor chores difficult. A neurologist performed nerve-conduction tests, which revealed damage in the region where the nerves meet the muscle. He suggested that the injury might be a postviral neuropathy, an unusual reaction to a recent infection. He told her it should improve with time. The specialist sent her to physical therapy, but the weakness persisted.

ADDITIONAL SYMPTOMS
Walking became extremely painful, and within weeks she needed a wheelchair to get around. Dark purple lesions appeared on the back of the patient’s hand and arms. A daughter took pictures of the lesions and showed them to the patient’s doctor. After seeing the images, Wiskowski recommended that she take her mother to the emergency room right away.

© 2011 The New York Times Company