37. The Burger


‘Johnny, I can’t believe you’re here!’

John Carter was one of my patients at the clinic. I was surprised to see him at the wards. He was in his sixties and such a nice guy. He was a retired cop who I treated for hypertension and asthma. I had a great relationship with him and his wife Hailey, they were the kindest people.

‘Oh, Liz, you know me. I was missing some whitecoats.’ He joked.

‘You? Missing whitecoats? I don’t buy it. You missed your last appointment.’

‘And that’s exactly why I missed you!’

I looked at Hailey and she rolled her eyes at him.

It turns out John was admitted the day before because of acute chest pain, which ended up being an acute coronary syndrome. His ECG was consistent with a Non-ST Segment Elevation Myocardial Infarction and was treated accordingly.

We chit-chatted for a while then I examined him. He was a strong guy, and very tall. He was wheezing a little more than usual and localized to the right lower lung lobe, so I made a mental note to check his chest x-ray. But what really caught my attention is that he had sort of a claw left hand.

‘Open this hand for me, John.’

He tried but failed. ‘I don’t know why but these last few weeks my hand is feeling weak. Not my hand actually, just these last two fingers.’ He was talking about his 4th and 5th fingers.

I thought this was weird, so I asked him if he had noticed anything different besides that.

‘I’m also having trouble standing on my tiptoes on my right leg, but I think that’s because of my plantar fasciitis.’

I decided to perform a neurological exam and he did seem to have two completely unrelated neuropathies - namely, mononeuritis multiplex, which wasn’t that common and really narrowed down his differential.

I wished him good luck at the coronary catheterization and told him we would see each other afterward.

‘I don’t get why I need this catheterization, Lisa. My heart is good and I can feel it. No way I have fatty coronaries. In fact, I bet you a fatty burger.’

‘This bet is not helping your case.’ I laughed. He was a healthy guy, but he did love burgers. He said it reminded him of his late rounds as a cop. He wasn’t sure of the procedure but his wife convinced him to agree with it.

‘We’ll see, John, we’ll see.’

Later that day we discussed his case and it was very intriguing. Not his chest pain, which seemed to be really settled as an MI. But what could possibly explain his peripheral neuropathies? We weren’t having any brilliant ideas.

And to make it even more confusing, his chest x-ray showed a pulmonary infiltrate, even though he didn’t have pneumonia symptoms. We were still clueless by then, although the diagnosis wasn’t that far away.

‘This seems to be too much information somehow, don’t you think?’ Dr. Collins asked us and we looked confused. ‘I know, I am always talking about how more information is always better.’ She started laughing. ‘But I am trying to teach a point, so go along please.’

‘Okay. It does seem like too much.’ Peter said with a smile.

‘Doesn’t it?’ Lucy stared at him. ‘When that’s the case, what do you think the best approach is?’ We both had no idea, so we just waited for her to go on. ‘We have two options: we either analyze the most specific symptom he has, which would probably be mononeuropathy multiplex, or we analyze the whole picture. That depends on the case.’

We still seemed a little lost.

‘So what do we do in this case?’ I asked.

‘You tell me.’ She smiled. ‘I have a theory, but let’s wait for his catheterization. In the meantime, try to figure out what I mean.’ Looking back now, it seems so clear. But as everyone says, making a retrospective diagnosis is always easier.

So Peter and I were shocked by his perfect clean coronaries. Everyone was actually, except John, of course, and Lucy.

‘I hate to brag, but can you smell the burning steak already?’

Hailey and I laughed. I was honestly surprised by the result.

‘Actually, I can! And I am very happy you were right, John!’ I smiled. ‘But now we have to figure out what is going on with your heart.’

‘Oh, I am sure you’ll figure it out, Liz. And my burger can wait.’

‘He’s loving the fact that he won the bet.’ Hailey said. ‘He’s just impossible when he’s right.’

I decided to review what else we knew about him and started reading his chart. He had a history of hypertension and asthma, which didn’t help a lot with his “non-fatty” NSTEMI. Besides, he had a new pulmonary infiltrate and mononeuropathy multiplex.

‘That is too many symptoms without a diagnosis.’ Peter said to me.

‘You’re right.’ I said with a hint of surprise. ‘Damn, Peter, you’re right!’ I started rapidly skimming through his labs looking for a very specific one.

‘I’m all ears to your apparently brilliant eureka moment, Dr. Diaz.’ He smirked at me.

‘I was too stuck on his MI. The truth is that all his symptoms make a syndrome. A-ha! Here it is!’ I handed him his CBC. John’s eosinophils were 23%.

‘Churg-Strauss?’ Peter raised an eyebrow. ‘Not bad, Dr. Diaz!’ Peter said with a sarcastic smile.

‘You know that the right name now is Eosinophilic Granulomatosis with Polyangiitis, right?’

‘Don’t be such a smartass. Go put him on some steroids.’

‘Will do, Allen.’

Dr. Collins arrived at our discussion just in time.

‘So?’ She asked.

‘It’s a syndrome in this case.’ I smiled. ‘You were right. His coronary catheterization was clean, he has asthma, neuropathy, pulmonary infiltrates, and eosinophilia. He fills the criteria, and the vasculitis could explain his MI.’

‘Syndrome it is.’ She repeated. 


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Clinical Board
Pulm: pulmonary; Bx: biopsy; Eosin: eosinophils; yo: years-old; Tt: treatment.

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