The 75-year-old man was sprawled on the floor between the kitchen counter and the island, surrounded by a halo of pills. “What happened?” his wife asked as she hurried to his side, although she suspected she already knew.
He wasn’t sure, he told her. He stood at the counter for a minute, getting ready to take his morning medication; the next he was just lying on the floor. She helped him stand up. When he was able to do so, he slowly rose. It was the third time he passed out in the past week and a half. The first spell came when his wife was out of town. He dozed on the terrace and woke up hot and sweaty. When he entered the house, he felt unsafe and leaned against the wall. He made it to a chair but passed out a few times just sitting there. And when he was awake he was confused. He tried to read a text from his daughter but couldn’t remember how.
The next time, a few days later, he woke up to go to the bathroom. He got up and suddenly found himself on the floor. A sharp pain in his forehead told him he’d unclipped the bedside table on the way down. His wife helped him to the bathroom. He found that he was incontinent. He was embarrassed in front of his 53-year-old wife. The next morning he called his doctor’s office and made an appointment for the next day. He told the young doctor’s assistant that he hadn’t felt well in the past few weeks. He had woken up a couple of times lately, and his wife told him that his tremors rocked the bed. He had a fever. Tired. No appetite. No ambition. Foggy. One night he couldn’t even remember the prayer he always said before going to bed. And urinating was strangely uncomfortable.
After completing her examination, the nurse sent him to the laboratory. This was likely a urinary tract infection, she told him after reviewing his test results. These are not uncommon in older men, as an enlarged prostate can make urination difficult. She gave him an antibiotic, which is often used to treat this type of infection.
That was just two days before that last episode. The PA told him to go to the hospital if he was worse. He definitely felt worse.
A highly motivated clinician
In the emergency room at Yale New Haven Hospital, it was clear that the elderly man was ill. He had a fever, his heart was racing, and his blood pressure was abnormally low despite not taking his high blood pressure medication that morning. Laboratory results confirmed this first impression. His kidneys were failing – although they were fine two days earlier. He was given IV fluids and started on broad spectrum antibiotics. The drug he had been taking for the past few days did not seem to be working.
On the floor was the first doctor the patient met, Alan Lee, who was in his senior year in medical school and was an intern. Lee was excited to see this patient. With the hospital so crowded, thanks in part to the recent resurgence of Covid-19 cases, patients often spent hours, sometimes days, in the emergency room waiting for bed. By the time they got to a medical floor, they could already have a doctor assigned. This meant that most of the thought was done about the patient and the accepting doctor usually only carried out the first doctor plan. This Sunday morning recording was made during a rest period, so Lee’s team got their first attempt to figure out what was going on.
Doctors in the emergency room focused on the man’s failing kidneys, but what hurt those kidneys? What caused the fever? These were the questions Lee had to answer for himself and for the patient. The young man, accompanied by his caring resident Dr. Roger Ying the room. They introduced themselves and Lee started asking questions. The patient shared the story of his three fainting spells, how he felt feverish and sick, and how he lost about 10 pounds in the past week from feeling too sick to eat or drink.
When Lee finished his questions, Ying asked the patient if he had recently been bitten by a tick. Absolutely not, the man replied promptly. He often took his dog on wooded trails on the Connecticut River, but when he got home he carefully checked his body for ticks.
Dr. Joseph Donroe, the attending physician, joined the trainees at the bedside. Lee admitted that a urinary tract infection could have caused both the man’s urinary problems and the fever. These symptoms could make the patient unwilling to eat or drink and become dehydrated. That in turn could have fainted and even damaged his kidneys. But a 10 pound weight loss wasn’t a common finding with a urinary tract infection. Neither do night sweats. Could this be a tick-borne disease like Lyme?
The most likely diagnosis
Donroe agreed that these symptoms were atypical. It seemed likely that the patient now had urosepsis – an infection that started in the urinary tract but then spread throughout the body – and that the cause of his symptoms was a urinary tract infection. But because he was already on antibiotics, they probably wouldn’t see anything in the urine if they tested him now. Lee was supposed to call the patient’s GP on Monday morning to get the results of the tests done before the antibiotics started.
The next day the patient was much better. He’d gotten fluids and slept well. No fever, no chills. Maybe the antibiotics worked. Even so, his kidneys were not doing any better.
After the rounds, Lee called the patient’s doctor. The urine culture had grown nothing at all. The only abnormality was that the urine contained a lot of blood. What now? Lee went over to those present with the news. Together, Lee and Donroe went through the data again. One of the laboratories ordered indicated that red blood cells were being destroyed somewhere in the body. Suddenly it all made sense.
The man had been sick with a fever and chills for almost two weeks and had something that was killing his red blood cells. To Donroe, it sounded like a tick-borne disease. Not Lyme, but another disease carried by the same type of tick: a disease called babesiosis. You should order a test for Babesia as well as one for Lyme, Ehrlichiosis, and Anaplasmosis – the most common tick-borne diseases in Connecticut.
It was late afternoon when the first result came back. In many of the patient’s red blood cells, the lab technician had seen a single tiny dark circle – a parasite. The patient had babesiosis.
A circle or a cross
Babesia is a protozoon, a unicellular parasitic organism carried by the deer tick. This arachnid ingests the beetle while it feeds on a white-footed mouse and gives it to the next mammal that bites it. As soon as the organisms enter the circulation, they invade the red blood cells, where they multiply. Under the microscope, the organisms either look like a circle or a cross, depending on where they are in the process of maturation and reproduction. Then precursors and offspring break out of the cell, invade neighboring red blood cells, and the process continues.
In the northeast, the deer tick is primarily known as a carrier of borreliosis. In fact, up to 42 percent of ticks that carry Babesia also carry Lyme disease, according to a study by a Connecticut state laboratory. The next day, the team learned that this also applies to the tick that bit this patient. He had both Lyme and babesiosis, so he had to be treated with three drugs – two for babesia and one for borrelia, the bacteria that cause Lyme disease. He would have to take it for about two weeks.
The patient could feel the difference the day after starting the medication. His appetite was back. Likewise his energy. Now that he’s back home, he’s wondering how to deal with these ticks. He knows they are not going anywhere, but neither are he and his wife. He’s already using a spray to discourage her bites. Of course, he’ll just have to take a closer look after his walks with the dog. He won’t let the arachnids win.
Lisa Sanders, MD is a contributing writer for the magazine. Her latest book is Diagnosis: Solving the Most Baffling Medical Mysteries. If you have a resolved case with Dr. Sanders want to share, write to her at Lisa.Sandersmd@gmail.com.