What’s Wrong With Me?

A med­i­cal mys­tery re­solved.

Reader's Digest (Canada) - - Contents - SYD­NEY LONEY

THE PA­TIENT: Jiang, a 30-year-old kinder­garten teacher in Toronto THE SYMP­TOMS: Back pain and low-grade fever THE DOC­TOR: Dr. Khalil Siv­jee, med­i­cal di­rec­tor for the Cleve­land Clinic Canada

IN OC­TO­BER 2015, Jiang started to de­velop a sore back, which she at first at­trib­uted to long days sit­ting on the car­pet with her small pupils. How­ever, when the unusual pain per­sisted for two weeks, she went to her fam­ily doc­tor.

Jiang’s physi­cian pre­scribed over­the-counter pain med­i­ca­tion and mus­cle re­lax­ants. Al­though her back didn’t im­prove, it didn’t get worse, ei­ther, so Jiang en­dured the dis­com­fort. But by De­cem­ber, she be­came con­cerned again when she came down with a low-grade fever, lost her ap­petite and was los­ing weight.

This time, her doc­tor sent her to Sun­ny­brook Health Sciences Cen­tre for a CT scan, which showed le­sions on her spine and small nod­ules on the bot­tom of her lungs.

The physi­cians sus­pected she had ei­ther con­tracted tu­ber­cu­lo­sis (TB)— Jiang had re­cently vis­ited ex­tended fam­ily in China—or had a metastatic can­cer of un­known ori­gin. “When­ever you see stuff all over the body, you tend to won­der if the pri­mary cause is can­cer,” says Dr. Khalil

Siv­jee, who, as the hospi­tal’s head of respirol­ogy at the time, was asked to con­sult on the case.

Siv­jee or­dered a full CT scan of Jiang’s lungs, which re­vealed that the nod­ules were present through­out. It also showed en­larged me­di­asti­nal lymph nodes—glands lo­cated be­tween the ster­num and spinal col­umn. Since all th­ese symp­toms were con­sis­tent with TB, Jiang was placed

in iso­la­tion and put on sev­eral drugs that tar­get that dis­ease.

Mean­while, in or­der to de­ter­mine which TB bac­te­ria Jiang had been in­fected with, Siv­jee per­formed a bron­choscopy and lung biopsy to re­move fluid sam­ples for test­ing. Jiang was al­lowed to go home while she awaited the re­sults but couldn’t re­turn to work, as she might in­fect oth­ers. Af­ter al­most four weeks, the lab tests came back neg­a­tive for TB, but the biopsy re­vealed gran­u­lo­mas (small col­lec­tions of in­flam­ma­tory cells) in her tis­sue sam­ples.

As gran­u­lo­mas can be a sign of TB, Jiang re­mained on the med­i­ca­tion, but Siv­jee wasn’t con­vinced this was the an­swer—not only due to the test re­sults but be­cause his pa­tient wasn’t re­spond­ing to the treat­ment. He took a biopsy of her spine and dis­cov­ered that the cells at the cen­tre of her gran­u­lo­mas were alive, which is in­con­sis­tent with TB.

Siv­jee sus­pected sar­coido­sis, an im­mune sys­tem dis­or­der that of­ten man­i­fests in the lungs and af­fects about 10 to 20 peo­ple out of ev­ery 100,000. He checked Jiang’s an­giotensin-con­vert­ing en­zymes, which con­trol blood pres­sure, and found that they were el­e­vated, a nearly de­fin­i­tive sign of the con­di­tion.

“What hap­pened next re­quired a leap of faith,” Siv­jee says. The only treat­ment for sar­coido­sis is steroids, but if Jiang was ac­tu­ally suf­fer­ing from TB or an­other im­mune dis­or­der, steroids could be fa­tal. Both doc­tor and pa­tient agreed that the risk was worth tak­ing.

Thank­fully, Siv­jee’s con­clu­sion was cor­rect, and Jiang showed im­me­di­ate im­prove­ment. Her fever dis­ap­peared and within two weeks her ap­petite was back to nor­mal. Four weeks af­ter the treat­ment, the nod­ules were gone; within three months, she was pain-free and back in her classroom.

A biopsy showed that the cells at the cen­tre of Jiang’s gran­u­lo­mas were alive.

Al­though she felt nor­mal again, Jiang re­mained on steroids for a year. “The prob­lem with sar­coido­sis is that it’s a sys­temic dis­ease and we don’t know what causes it,” Siv­jee says. “It can be very ag­gres­sive and can in­vade sev­eral or­gans, in­clud­ing the heart, which can be fa­tal. And it can come back.”

He says there are no known life­style changes or long-term med­i­ca­tions to pre­vent a re­lapse. “Sar­coido­sis is an in­ter­est­ing, al­though lit­tle un­der­stood, con­di­tion, and there aren’t many new ther­a­pies be­ing stud­ied for treat­ing it,” Siv­jee says. “For­tu­nately this pa­tient has done very well.”

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