What was The Diagnosis?
14 Sep 2009
This week, how about letting me relax, and you play doctor? I’ll just pass along pertinent facts about a patient. Then you can see how smart you are in making a diagnosis. First, a couple of clues. The final diagnosis was made by common sense, not by fancy hospital tests. And it’s also possible that any of us could arrive home from vacation with this distressful problem.
Drs. Jane Pritchard and Stephen Hwang report in The Canadian Medical Association Journal the interesting case of a 62 year old man who complained of generalized fatigue. It was apparent from looking at this man’s medical history that you didn’t have to be a graduate of The Harvard Medical School to know there were many reasons for his lethargy.
For years he had been treated for Type 2 diabetes due to obesity. His blood cholesterol was high and he suffered from reflux esophagitis (inflammation of the lower end of the food pipe). He was also depressed, and on a number of medications, that can cause fatigue. And to add insult to injury he had abused alcohol in the past, used crack cocaine, and admitted he skipped meals while using cocaine.
Four months earlier he had not been anemic. Now, blood studies showed he had lost a considerable amount of blood. Physical examination revealed reddened papules and welts on his scalp and arms. So how had be become so anemic?
Doctors always worry that blood loss of this extent could result from a bleeding peptic ulcer or a malignancy of the large bowel. But these problems were ruled out by colonoscopy and gastroscopy where a lighted instrument is passed into the stomach.
The patient was treated with oral iron medication, folic acid and injection of vitamin B12. Four weeks later his family doctor noted he was very pale, but could find no evidence of how or why he was losing blood. He was admitted to hospital where studies revealed his blood was even lower than before. This time he was given two blood transfusions and sent home. Three weeks later his blood had hit a new low requiring three blood transfusions.
Don’t feel bad if at this point you haven’t figured out the diagnosis. Several different specialists had also seen this patient to no avail. So the patient was sent home with the diagnosis, "iron deficiency anemia without any known cause".
Give up? Well you could have made the diagnosis if you had done what his family doctor decided to do next. Once again this case shows how important it is to have a family doctor who has common sense and who has known you for several years. His doctor decided to make a home visit. Then the diagnosis was as easy as rolling off a log.
This man lived alone in an apartment. The doctor found on inspection thousands of bedbugs all over it. He found bedbugs crawling on walls. The bed mattress contained another thousand and some were on the patient. Night after night they had been sapping blood from this man. The apartment was treated by a pest control operator and six months later the man’s anemia was resolved.
Many years ago bed bug infestation was so common that the phrase "Don’t let the bed bugs bite you" was a frequent farewell. But bed bugs were nearly eradicated years ago by the insecticide DDT which killed most insects. Then when DDT was banned due to human toxicity, bed bugs made a comeback. Today, what may kill a cockroach may not kill this reddish-brown creature that measures a mere 0.5 centimeters (0.2 inches) long.
Today with increased international travel there’s always the chance you may return home with bed bugs in your bag or clothes. So do a thorough check when unpacking. And if you see blood stains on sheets think bed bugs. Luckily, bed bugs are not believed to transit disease to humans, but they can remove considerable amounts of blood.
Congratulations if you made the diagnosis. I hope this column has not made too many of you itch. But it’s worth remembering this crawling creature is making a comeback.
