Well: Think Like a Doctor: A Green Heart

The Challenge: Can you figure out why an increasingly sick 76-year-old man has a heart that is turning green?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic mystery. Here's another chance to play medical detective.

Below you'll find a summary of a case that stumped a couple of internists, a cardiologist, a gastroenterologist, a pulmonologist and an orthopedic surgeon. Each doctor had the chance to put a story together to figure out a single cause of this man's many and apparently unrelated symptoms. The first reader to solve it gets a signed copy of my book, "Every Patient Tells a Story," along with the satisfaction of knowing you could outdiagnose Dr. Gregory House. Let's get started.

The Patient's Story:

"Wow, would you look at this!" Dr. Stephen Lahey, the chief of cardiac surgery at the University of Connecticut, broke the soothing rhythm of the Beatles song playing in the background of the operating room. He looked up at the anesthesiologist and his surgical assistant. "This guy's heart – it's green."

The two masked faces moved closer as Dr. Lahey pointed his forceps at a triangular bulge — an appendage of the heart's right atrium, situated near the top of the heart. He didn't need to point. The greenish sheen of that area stood out distinctly against the deep red of the surrounding heart muscle.

"What is that?" asked his assistant.

"I have no idea," Dr. Lahey replied, shaking his head.

The Patient's History:

The patient on the table was there to get bypass surgery for three clogged vessels in his heart. The operation, he'd told the surgeon when they'd met three weeks earlier, would be only the most recent of his many medical misadventures over the past few years. His whole life he had always considered himself pretty healthy — until three years ago, when he turned 74, and he started going downhill.

Sure, when he was younger, he had high blood pressure and diabetes, but they were both well controlled with medications. And his cholesterol was a little high; he had to take a pill for that, too. But he'd always felt pretty well. Then at some point a few years ago — he couldn't name a day — he started to feel old and sick and tired.

The first thing he noticed was that his fingertips started to bruise. Out of nowhere, suddenly he'd be doing something and, boom, his fingers would get all tender and painful. The next day he'd have bruises – on his fingertips. It was strange. His internist didn't know what to make of it, and neither did he.

A Cascade of Symptoms:

Then, about a year prior to the surgery, just before he and his wife set off to Las Vegas to celebrate their 50th wedding anniversary, he was afflicted with terrible diarrhea. He went to his doctor just before leaving on his trip. It was probably an infection called clostridium difficile, his doctor told him, and gave him some antibiotics. They didn't seem to do much good; he spent his anniversary week very close to his hotel room. He was making too many hasty trips to the bathroom to venture much past the doorway.

He spent weeks on one antibiotic, then another and another. Nothing helped. At the same time he got wicked heartburn, something else he'd never had before.

Finally he went to see a gastroenterologist. That doctor examined him "stem to stern, inside and out" and gave him a strong anti-acid medication. Between that and some Pepto-Bismol, he was finally able to get both the heartburn and diarrhea under control. It took months; and during that time he lost nearly 70 pounds. He'd been on the heavy side so was glad for the weight loss, but not for the way he lost it.

When the stomach problems finally settled down, he decided it was time to deal with his carpal tunnel syndrome. He'd had it for years, but it was getting worse. Now his hands were constantly pricked by invisible pins and needles that sometimes woke him up at night. And recently he'd started dropping things. They'd just slide out of his hands and end up shattered on the floor before he knew there was a problem.

It was while getting his pre-op exam for that surgery that the whole heart business got started. His doctor noticed a change in his EKG. He'd had a heart attack, the doctor told him. After a bunch of tests on his heart he ended up at John Dempsey Hospital in Farmington, Conn., talking to Dr. Lahey, who was going to fix his heart.

Another Day in the Heart Business:

From Dr. Lahey's perspective, this was just another nice guy with diabetes, high blood pressure and high cholesterol – the usual cardiac risk factors – with clogged arteries that needed to be fixed. He had a distant history of smoking but quit 50 years ago when he married the woman who loved him but hated his smoking.

The patient rarely drank and, since retiring, spent much of his time working in his big, beautiful yard. He had no complaints, he told the surgeon, but recently he noticed that he was getting out of breath when he walked even a short distance.

One other thing, his wife added. She didn't know if this was important, but sometimes when her husband spoke, his words sounded a little slurred. Not all the time. But every now and then, and lately even more.

On exam, his blood pressure was well controlled. His heart beat was regular and his lungs were clear. His legs were quite swollen – his socks sank deeply into the flesh of his calves. But his feet were warm and pink, and the pulses in his feet easily felt.

Getting Ready for Surgery:

Three weeks later, when Dr. Lahey next saw the patient, he was lying on the transport gurney, being prepared for surgery. An IV had been started, and the blood pressure and heart monitors hooked up.

Dr. Lahey greeted the man and his wife warmly. He outlined the schedule – the surgery would last about five hours. After the operation, the patient would be sent first to the PACU (post-anesthesia care unit), where they'd watch him as the anesthesia wore off, and then to the I.C.U. (intensive care unit) for close monitoring for a couple of days.

Dr. Lahey answered a few last minute questions, then set off to get ready for the surgery.

In the Operating Room:

The anesthesiologist was preparing to put the patient on a breathing machine before starting the medications that would keep him unaware throughout the surgery. He put the metal brace known as a laryngoscope into the elderly man's mouth to pull the tongue out of the way and expose the opening of the trachea so that he could put the breathing tube directly into the lungs.

The man's tongue was so large it was hard to see the back of his throat, much less the opening into the trachea. Finally the doctor had to do it without even seeing where the tube was going. He put his stethoscope to each side of the chest as the ventilator blew air through the tube into his lungs. He heard breath sounds on each side and breathed his own sigh of relief.

Dr. Lahey was right on schedule when he opened the older man's chest. He quickly opened the pericardium, the sack that contains the heart, to reveal the beating muscle below. It was once the heart was fully exposed that Dr. Lahey noticed the odd green hue of the upper right section of the heart.

Other than the color, the heart looked completely normal. It wasn't a bright green. That part of the heart was just a darker shade of a red that somehow had a greenish tinge to it. Dr. Lahey had been operating on hearts for 25 years, but he'd never seen anything like this before.

After the surgery, Dr. Lahey found the patient's wife in the waiting room. The operation went well, he told her. Her husband's heart was going to work a lot better now that it was getting good blood flow. He also told her about the strange colored muscle he'd seen.

You can see the surgeon's note about the operation and the nurse's post-op note here.

Solving the Mystery:

Can you figure out what was making this gentleman's heart turn green? And how did the surgeon figure it out?

Post your responses in the comments section. I'll post the answer on Friday.

Rules and Regulations: Post your questions and diagnosis in the comments section. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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