“Nonno says he doesn’t feel good,” the 8-year-old girl reported, handing her mother a digital thermometer. The woman looked at the readout — just under 102 degrees.
Her father, the child’s grandfather, had been sick for weeks. He was weak and exhausted and ran a fever accompanied by shaking chills every afternoon. He wasn’t eating and had lost nearly 20 pounds. It was late summer, and the tomato and eggplants in his garden were ripe, but he hadn’t been outside for days. Over the past two months she’d taken her 67-year-old father to doctor after doctor. They looked him over and gave him antibiotics and other medications, but so far nothing had helped.
“Tell Nonno that if he’s feeling sick, he’s got to go to the hospital.” The girl darted back to him with the message, then quickly returned. “He says he’s ready to go.”
The More Obvious Possibilities
The woman first took her father to his internist when she noticed his fever early that summer. The doctor thought the patient probably had Lyme disease. Though he didn’t have the rash that usually announced the presence of the disease, it was summertime, and Lyme was common where they lived in Connecticut. The doctor knew his patient spent most of his summer days in the garden behind the house where he lived with his wife, their daughter and her children. The patient took antibiotics for the presumed Lyme, but the fevers continued.
His stomach was bothering him a bit, he told his doctor when he went for a follow-up visit. So he was sent to a gastroenterologist. That doctor gave him a diagnosis of Helicobacter pylori — a bacterium that can survive the acid environment of the stomach, where it can cause pain and ulcers, though not usually fever. Still, for the next two weeks the man took the prescribed medications: three pills to kill the bug and one to neutralize the acids that can exacerbate the stomach distress. But the daily fever persisted.
A Dropping Blood-Cell Count
Then the man’s wife noticed he was coughing. His doctor gave him another antibiotic for possible pneumonia. He was still taking it when he agreed to go to the emergency room that summer afternoon.
Three generations — wife, daughter and grandchildren — of concerned family members got in the car with the patient and drove to Yale New Haven Hospital, in the next town over. The doctors there did a chest X-ray, which found no sign of pneumonia. They assumed the patient had a virus and sent him home.
The next day, the man felt no better. So after his daughter returned from work, the whole family got back in the car and drove to the Hospital of St. Raphael, a community hospital recently added to the Yale New Haven Health System. When the doctor arrived, the patient’s wife and daughter explained once again how sick he’d been, how tired. But when the doctor examined the older man, he could find nothing out of the ordinary — except the fever.
His blood tests were more revealing. At the hospital the day before, his red-blood-cell count was nearly normal. Now it was low, which was worrisome. There was also evidence of liver damage, so he was tested for viral hepatitis. He tested positive for hepatitis A and was admitted.
Looking for Patterns
Dr. Neil Gupta, the resident leading the team on call, heard about this patient the next morning on rounds. Seeing that he looked fairly well and hearing the relatively routine diagnosis of hepatitis A, Gupta turned his attention to patients who seemed sicker.
In puzzling over a possible diagnosis, doctors often rely on “illness scripts,” detailed mental images of what a particular disease looks like based on our knowledge of the disease’s characteristics along with our experiences with patients. That afternoon, when Gupta heard that the patient had developed a fever, he was surprised. That didn’t usually happen with hepatitis. He went back to see him. The older man was pleasant but didn’t say much. Perhaps there was a language barrier; the patient spoke with a thick Italian accent. Or perhaps he was one of those patients who don’t dwell on their suffering.
His wife and daughter, however, were keenly attuned to the changes in the patient’s health and behavior, and what they told Gupta at the bedside didn’t sound like hepatitis. Gupta wondered: Was this the right diagnosis?
A Story in the Details
Gupta sat down with the family in the lounge and asked to hear the patient’s story from the beginning. The man had been sick for several weeks. He’d had a fever every day. Before he became ill, he was never idle; these days he sat on the sofa for hours. Sometimes he had pain in his upper abdomen, but never any nausea. He had a cough.
Gupta returned to the patient and examined him, this time quite carefully, looking for the typical signs of hepatitis. The man’s skin was dark, but olive-hued, not yellow; his eyes showed no hint of the yellow of liver disease, either. His liver was neither enlarged nor tender. Yet he had tested positive for hepatitis A. Perhaps it was a false positive. But then what did he have?
A Symptom Log
Gupta and his team wrote a list of key symptoms: a fever that recurred every afternoon, an occasional cough and some upper abdominal pain. His liver showed signs of very mild injury — not consistent with hepatitis, which usually causes significant liver damage. He had an anemia that had worsened over the past three days.
That list suggested a different set of diseases, and Gupta began marking them down as well. Could he have a tick-borne illness other than Lyme? The cyclic fevers were suggestive of malaria — rare in this country, but still worth thinking about. Could this be mononucleosis? Or even H.I.V.? Those diseases can affect red blood cells and the liver. This new list required additional testing.