SCENE FROM A PRACTICE Second Opinion

SCENE FROM A PRACTICE Second Opinion

“HOW’D YOU LIKE TO SEE A PATIENT with Lyme disease?”

The questioner was Ivo White. 11 a surgeon friend of mine who knows how to tickle my interest. He knows that I like to see patients with unusual illnesses and disorders. The rare disease, I’m convinced, can be a great help in understanding the common malady. A difficult diagnostic puzzle challenges your problem-solving skills, keeps you thoughtful, and is more fun than any of the best mystery novels.

To have a diagnosis is to have a hook on certainty-sometimes. A diagnosis is a label that presupposes a cause and establishes familiarity, a comfort level. At least, someone else has seen the same thing and has put a name on it

But once a diagnosis and a patient are hooked together, it can be hard to twist them apart. Just the word “diagnosis” can be prejudicial because the clinician’s question changes from “What is wrong?” to “What should I do?” That’s why. when C.P. Wainwright came into my office, I was prepared to deal with a case of Lyme disease.

The disease, first studied in Lyme, Conn., in 1975, is now well-known and well-labeled. It’s caused by a microorganism called a spirochete, specifically Borrelia burgdorferi, which is carried by the deer tick, specifically Ixodes dammini. A peculiar rash may appear in about seven days following a bite by an infected tick. A victim feels generally unwell, with fever, malaise, and generalized aches and pains. Some will later develop joint pain and swelling or heart disease. Occasionally, even the brain and nervous system suffer.

Difficult diagnosis, easy therapy. So why did Ivo White pass this patient to me? Why was I seeing someone with this disease?



“HELLO, MR. WAINWRIGHT. HOW CAN I HELP YOU?” I asked.

“Got Lyme disease and I need a new doctor,” he answered.

“Had you been seeing Dr. White?” I asked.

“Oh no. I was doing some work for Dr. White and asked hi m who I should see. I’m a landscape architect and got to talking with Dr. White about my Lyme disease and how 1 needed a new doctor, and he said I should see you.”

“Well,” I said, “tell me about your illness and how you think I can help you.”

“It started about a year ago. I got some tick bites in my work-always seem to be getting tick bites. Then I got this rash and felt bad. Got a fever and sweats and felt awful. It lasted a couple of weeks, off and on, but I didn’t see anybody about it. Then my sister said she saw this TV program about Lyme disease and she said that must be what I have, so I went to my family doctor and he started to treat me.”

“What did the doctor do?” I asked.

“Well, he gave me some antibiotics and I felt much better,” Mr. Wainwright answered.

“Did he do some laboratory tests?”

“Oh yeah, he took some blood samples.”

“Did he say what he thought was wrong with you?”

“Well, yeah, he said I probably did have Lyme disease.”

“How are you now?” I asked, getting more curious about the reason for this visit.

“I’m OK now, but unless I take the antibiotics, I get sick again. Now my doctor says he’s not going to give me any more antibiotics because I should be all better. But I’m not. I think he just gave up on me!”

“Tell me more about your illness. Exactly what has been happening over the last year?”

“Well, here. I brought you a whole bunch of info on Lyme disease,” he said, handing over a stack of tom-out magazine articles, photocopied flyers, and a brochure from a Lyme organization, a group of patients and friends interested in the disease swapping notes, caution, and advice.

This wasn’t what I wanted. What Wain-wright was telling me was that he had all the preliminary material under control- he had a diagnosis-and now he just wanted to get to the treatment pan. He specifically pointed out to me that difficult cases require intravenous antibiotics and he wanted to know how soon we could get started since his supply of pills was going to run out soon. What I wanted was to start at the beginning, to have a conversation about his illness.

“OK, Mr. Wainwright. How about I lake a look at you and then we talk about where to go from here?”

“Whaddya mean? You want to examine me? What for?”

“Well, it will be helpful to me if I know where we are now so that I can see what progress we make with treatments.” I explained.

“Well. OK. But the rash is gone and you aren’t gonna find anything, cause I been taking the antibiotic and now 1 feel good.” he said resignedly.



HE WAS RIGHT-ALMOST. THE EXAMINATION really was quite norma! except that following the rectal examination, there was a very faint blush of blue on the Hemoccult card. This is a very simple chemical test for blood in the stool. Sometimes the blush is simply the result of disturbing a hemorrhoid or fissure with the digital exam, but, of course, it could signify trouble anywhere in the gastrointestinal tract.

I told Mr. Wainwright about the exam, including the trace of blood in his stool, and asked him about symptoms of ulcer disease. He had none.

“How about your bowels, Mr. Wainwright?”

“Well, they haven’t been too good ’cause of all the antibiotics. I tend to have constipation and have to take lots of laxatives to keep ’em moving,” he said.

“Ever see any blood in your bowel movements?”

“Yeah, but my doc said I had hemorrhoids.”

“Well, I didn’t see any, but perhaps you have some internal hemorrhoids.”

“Doc.”hesaid,gettinga little upset, “this isn’t what I came to see you about. I don’t want to miss any more work, and I’m gel-ting tired of feeling bad and taking pills!”

Time to make a deal, I thought. I’ve been here before: How do you get your job done and keep everyone happy? The art of negotiating can be just as important in the doctor’s office as in the corporate board room.

“OK. Mr. Wainwright. Here’s what I suggest we do. Let me run a few blood tests on you today and I’ll give you some more antibiotics next week. I promise. In the meantime, I want to gel the results of your tests so we can put all this information together and solve your problem. How’s that sound?”

I also asked him to take along a few stool test cards and bring them back to me the next week.



THAT WEEK WAS FULL OF PHONE WORK. I called his doctor and found he had a slightly elevated antibody titer to the Lyme spirochete about nine months earlier, but it had not been repeated. Mr. Wainwright’s sisters each called me with their own advice about how to treat Lyme disease. His wife called to find out if I thought treatment for Lyme disease would be covered under worker’s compensation and wasn’t there some kind of legislation to control this disease? She-and the sisters-all knew of some experts in Lyme disease and wondered if Wainwright should go see them. And I called our lab to find that his test for Lyme was now negative.

When Mr. Wainwright returned, he reported that he was feeling well. Couldn’t we get on with the business at hand and start intravenous antibiotics? The problem was, all the stool cards he brought back showed blood.

Mr. Wainwright agreed to a barium enema to find the cause of the bleeding, only if we would then “get on with” his treatment for Lyme disease.



IT WAS A TYPICAL PICTURE OF CANCER OF THE colon.

The X-ray showed a large apple core lesion-so-called because it looks like an apple that’s been chewed almost to the center-located in his lower colon. There was also a small tract of barium that filled an adjacent abscess. Mr. Wainwright’s illness now made sense. The antibiotics concealed the presence of the pus pocket and made him feel well enough to tolerate the inexorable growth of the tumor.

Sooner or later, of course, he would have obstructed his colon and would have shown the weight loss for which this cancer is well-known. The question now was, how much later were we? At least nine months of symptoms had passed. Nine months of chances for the cancer cells to break free from the tumor and slip through his blood stream to nest in faraway organs.

After passing a cup of chagrin all around, there was a general truce in the conversations until the day of surgery. The surgery was difficult since the abscess had caused dense adhesions around the area of the tumor. It was removed along with a generous wedge of the mesentery, its supporting membrane, and as many lymph nodes as could be dissected along the root of the mesentery and the aorta.

But fools have great luck. And so it was that two days later, we were told by the pathology department that all the lymph nodes were free of disease and that the tumor seemed to be contained. And it turned out that the abscess was not a tumor abscess but an adjacent diverticular abscess. In other words. Mr. Wainwright has probably been cured of his disease.

I rejoiced with the family. It’s a thrill to see enthusiasm for the routine come upon those who have had a close call. It’s like someone just turned up the intensity of the light: You notice and relish small things, food tastes better, courtesies are extended easily, the newspaper is more interesting, and talk is more refreshing.

However, my own vicarious joy was dulled just a bit on the day Mr. Wainwright was discharged from the hospital. Mrs. Wainwright took me aside and asked me, “Doctor, what are we going to do now about his Lyme disease?”