30. The Waters
I met May Waters at the outpatient clinic. She was 55 years old and an incredibly elegant lawyer.
‘Hi, Mrs. Waters. I am Lisa Diaz. How can I help you today?’
‘I’ve been feeling out of breath. It doesn’t limit my activities overall, but it bothers me. I’ve been meaning to come here for a while, but my job keeps me too busy sometimes.’
‘How long since you started feeling this way?’
‘About 3 months, I think.’
She then told me her symptoms were first triggered by taking the stairs at her office. But after a while she began feeling a little breathless by walking just a couple of blocks. She denied any other symptoms, you name it: cough, fever, feet swelling, anything.
‘Did you look for medical care during this time?’
‘Yes, I went to an ER about a week ago, when I was feeling really tired. They ordered an x-ray for me and after a couple of hours of observation they discharged me and said I should schedule an outpatient appointment.’
‘I see. Do you have this x-ray with you, Mrs. Waters?’
‘Yes.’ She gave me a CD. ‘They gave me this when I left the hospital.’
‘Alright, I’ll take a look at it after we finish here.’
I asked her some other questions, but the only thing she mentioned was that she gained a little weight in the past months, about 5 pounds, but she was still in pretty good shape.
‘I try to live a healthy life.’ she told me. ‘I exercise 4 times a week and eat healthy most of the days.’
‘That’s good to hear. What about smoking?’
‘Never. Never smoked. I drink a glass of wine at parties, but that’s it.’
She also didn’t have any past medical history. She hadn’t had any health problems that needed the care of a physician since she was a teenager.
‘When I was a kid my mother took me to the doctor a couple of times for a cold or something, but nothing memorable.’
While talking to her, I counted her respiratory rate: 24 . Higher than expected for a woman like her. Her breathing was also a little shallow. After the interview I performed a complete physical exam. Her breath sounds seemed diminished at the lung bases, but besides that it was completely unremarkable.
It occurred to me that maybe she could be having some anxiety related disorder that was leading to her discomfort. I decided to talk to her about her mood, her life and worries. Honestly, she had a busy life but her mood seemed completely in tune with it, good coping mechanisms and nothing that pointed me towards anxiety.
‘I’ll find a computer that runs this CD to look at your exam and will be right back, okay?’
Her chest x-ray had bilateral pleural effusions, bigger on the right side. Not massive, but considerable. The rest was normal, her heart seemed to have a proper size, her lung fields were also clear. Interesting. I discussed her case with the attending in the clinic that day, Dr. Fitz, and he suggested a pleural fluid analysis.
‘She doesn’t have any signs of heart failure. It’s not a minimal effusion, and it seems to be causing her dyspnea. Now we should take a look at this fluid, this will tell us where to go next.’ Dr. Fitz told me.
I went back to talk to May. I explained what we had seen in her x-ray and what would be our next steps.
‘We don’t know yet why you have this liquid around your lungs, but this test I told you about can help us figure it out. Do you have any questions, Mrs. Waters?’
‘Do I need to stay in the hospital for this procedure?’
‘Not necessarily. We can schedule a date this week, you come here and if everything goes well you can go home in the same day.’
‘Good. I have no more questions for now.’
Two days later she was back at Brooklyn’s Hospital for her thoracentesis. Everything went well and she went home afterwards. Her results came back the next day: it was a transudate. Nothing that suggested infection.
‘So that leaves us with heart, liver or kidneys.’ Dr. Fitz said. ‘Figure it out and let me know.’ He smiled. ‘I am intrigued.’
I talked to May and explained our next steps. We would order some blood tests for her kidney and liver functions, an echocardiogram and an abdominal ultrasound.
‘Ok.’ She said. ‘Let’s do this.’
She came back with the results the following week. I had discussed her case with Peter, since I had to get back to inpatient service and he would be the one at the clinic in her follow-up.
‘So, how was it?’ I asked him when he called me later that day.
‘Well, her liver is super. Her kidneys and heart too. But hear this: her belly also has water. The ultrasound showed ascites.’
‘Damn. What is wrong with this woman?’
‘Yeah… Did she tell you any other symptoms?’
‘None.’
‘Me either.’ Peter paused. ‘I’m thinking here. Does she have any gynecological history? An ovarian cyst or mass?’
‘I don’t think so. She is post-menopausal. Why?’
‘It’s really rare, so it’s probably not it. But do you know Meigs Syndrome?’
‘Something with ovarian mass?’ I tried.
‘Exactly. An ovarian fibroma that can cause hydrothorax and ascites.’ Peter explained.
‘Sounds great to me. Discuss this with Fitz, he can give us his insight.’
‘Deal.’
When I got home I read everything I could find about Meigs Syndrome and it was exactly what Peter said. May Waters really fit the profile, she could have this ovarian fibroma. It’s a benign condition. After surgical removal her pleural effusion and ascites would go away, then she could go back to her healthy self.
A month later, I ran into May at Brooklyn’s Hospital. She was radiant. Her workup had shown an ovarian mass and after surgery Peter’s diagnosis was confirmed.
‘Thank you for everything, Dr. Diaz. Please thank Dr. Allen for me too.’ She smiled. ‘I hope I don’t need you again anytime soon.’
I laughed at that. ‘I hope so too.’
…
Want to read more about Meigs Syndrome?
https://www.ncbi.nlm.nih.gov/books/NBK559322/
Want to read a real case of Meigs Syndrome?
https://www.contemporaryobgyn.net/view/meigs-syndrome-case-presentation-and-revision-literature
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