42. The Case Presenter

 

Colin Hunt had been a patient in Brooklyn Hospital since he was 17 years old. When I met him at the clinic, he was already 24. I was rotating in the gastroenterology clinic. Colin had been diagnosed with Ulcerative Colitis by my attending, Dr. Lane. She was such a great physician, it was fun to watch. She always wore this white coat with folded sleeves which made her look younger. Every patient in the waiting room absolutely loved her.

Colin was no different. I called him up on a Friday morning. A skinny white boy rose from a chair in the waiting room. I checked his age again on the chart I had in my hand. It was hard to believe he was 24. He didn’t look more than 18 to me. 

He smiled at me as he entered the room and sat on the chair. Just then, Dr. Lane passed by and saw us. 

‘Good morning, Colin!’ She said to him, who had already crossed his legs and looked like he owned the place.

‘Oh, hey, Maddie!’ He cracked a giant smile. By then I had already learned that most patients called Dr. Madeline Lane, one of the greatest gastroenterologists in America, Maddie. 

‘Don’t scare Dr. Lisa, okay?’

‘Oh, you know me. You have nothing to worry about.’ He winked at her.

Dr. Lane laughed. ‘You are going to love this one, Lisa.’ She turned to me. ‘Call me when you are done.’

‘Hi, Colin.’ I said as I sat in front of him. ‘It’s a pleasure to meet you. How have you been?’

‘Well, not so great, doc.’ He scratched his head. ‘But I’ll tell you all about that in a moment. Do you mind if I present my case first?’

I frowned. ‘Present?’

‘Yeah, you’ll see. I’ve been doing this for a while.’ Colin gave me a goofy smile.

‘Well, go ahead.’ I said suspiciously.

He straightened up in his chair. ‘Colin Hunt, 24 years old. Diagnosed with Ulcerative Colitis since the age of 17, after he spent a year with persistent bloody diarrhea. Since then he has had some complications of this condition, such as ankylosing spondylitis and uveitis. All of his previous symptoms are now in good control with medications. He has nothing of note in previous medical history. No family history either.’

I nodded for him to continue, already impressed.

‘Today Colin comes for a follow-up consult. He has no complaints related to… How do you say poop in a nice medical way?’

I laughed at that. ‘You can call it bowel function.’

‘Oh, right.’ He said snapping his fingers. ‘So, Colin comes to the consult with no complaints related to his bowel function. He has had a couple of brief episodes of diarrhea but nothing out of his usual. He has, however, a new complaint: itching.’

‘Pruritus you mean.’ I said getting into his game.

‘Precisely!’ Colin said smiling. 

‘I’m impressed.’ I said crossing my arms.

‘Thank you. I practice every time I come here.’ He sat more loosely. ‘Maddie helped me with it. Since I come here so often, it makes it more fun.’

‘Good for you, Colin.’ And I meant it. I had never seen something like it before, but it was nice to see. There are no rules for this, everybody copes with illness in a different way. I was happy Colin and Maddie, I mean, Dr. Lane had found a fun way to do it. ‘Now let’s start with the itching. What can you tell me about it?’

And then Colin Hunt became a patient again. He told me it had started 3 weeks before. It was a generalized itching without any trigger and it didn’t improve with a cream he had tried at home. I asked him a series of follow-up questions but he denied anything else besides the itching. 

‘Okay.’ I said when he finished. ‘You know the drill. Let’s get your physical now.’

I performed a full physical exam on Colin. Head to toes. He had no rash in his skin, although he had some scratch marks and abrasions from the itching. One thing caught my attention as I continued. I wasn’t sure I was imagining it or not, but his eyes seemed a bit yellowish. Cholestasis came to mind, it explained the pruritus and jaundice. To be sure, I asked him to examine his mouth next, and then I knew, his mucosa also had that yellowish tone. The rest of the exam was unremarkable.

I excused myself to find Dr. Lane. She smiled when she saw me coming.

‘So, how was it with Colin?’

‘Surprising.’ I said.

‘He is quite something, right?’ She said proudly. ‘Did he present his case well?’

‘Honestly? Better than me.’ Dr. Lane laughed loudly.

‘Good. And how is he doing?’

I told Madeline about Colin’s new symptoms, and that I thought he looked a bit jaundiced. She listened carefully to what I was saying with a sad expression.

‘So what do you think, Lisa?’ Dr. Lane asked me.

‘I think it’s related to his Ulcerative Colitis.’

‘You are right. But what?’

I stood silent. I knew I had studied that already, but just couldn’t remember the name. ‘I know it can be an inflammatory destruction of his bile ducts, that is causing the cholestasis and his symptoms. I’m thinking primary cholangitis but I’m pretty sure I’m missing some part of the name.’

She nodded. ‘Primary Sclerosing Cholangitis.’ I waited for her to continue. ‘You know, I’ve had some cases of PSC in this clinic. Colin has light symptoms of cholestasis now, like you suggested. But eventually he can have more symptoms of chronic stasis, like steatorrhea and even true episodes of cholangitis with fever and pain. If we confirm this, he has only one way to go.’

‘Transplant.’ I thought out loud.

‘Exactly. We can help him with some meds until then, such as ursodeoxycholic acid. But only transplant can cure Colin.’

After a couple of minutes of silence, Madeline continued. 'Let's go. We should tell him.’

‘It took you long, Maddie!’ Colin teased her as she walked in.

‘You know me, I may take time but I always show up.’ She winked. ‘Colin, we need to talk.’

For the next few minutes, I saw those 2 working together on Colin’s likely next diagnosis. Their connection was just incredible. Colin asked her several questions and Dr. Lane answered them all until, by the end, they were both determined to not lose hope. 

I saw Colin once again about 5 years later. He looked better, gained some weight, and immediately recognized me.

‘Hey, doc!’ He said lifting his shirt and showing his scar. ‘I’ve got a new liver now!’ He couldn’t hide his smile while he rode away on his bike.

…

Want to read more about Primary Sclerosing Cholangitis?

https://rarediseases.org/rare-diseases/primary-sclerosing-cholangitis/

Want to read a real case of Primary Sclerosing Cholangitis?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5453659/

Clinical Board

ERCP: Endoscopic Retrograde Cholangiopancreatography; Tt: treatment.

Bonus Board

 

This condition can be easily confused with another one with a similar name! Learn about this other disease below!

Ab: antibody; Bx: biopsy; Tt: treatment.

Remember: think BILIARY for WOMEN, and SCLEROSING for MEN.