Well: Think Like a Doctor: Arachnophobia

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

The Challenge: Can you solve the medical mystery of a woman who develops a sore on her leg and then fever, nausea and chest pain?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a 36-year-old stay-at-home mom with a sore on the back of her knee who also develops a fever, night sweats, diarrhea and chest pain. I have provided the only information that was available to the doctor when she was finally able to make the diagnosis.

The first reader to offer the correct diagnosis gets a signed copy of my book, "Every Patient Tells a Story," and the satisfaction of solving a difficult but really cool case.

The Patient's Story

"She thinks I have some kind of cancer," the 36-year-old woman said to her husband as she hung up the phone. She looked pale, and her eyes were shiny with tears.

Her primary-care doctor had just called to say that the CT scan the woman had had the day before showed something worrisome — so worrisome that she needed to go to the local cancer center the next day.

I don't know what's wrong with me, she told her husband, but I know it's not cancer. It can't be. It just doesn't make any sense.

A Funny Bump

Two weeks earlier, the woman had noticed a strange bump on the back of her knee. About the size of a nickel, it was red, firm and a little tender. She didn't give it much thought.

With a year-old toddler to care for, the woman didn't have time to worry about little things. But late that afternoon she started feeling ill. Her body ached, and there was a strange throbbing behind her eyes. By dinnertime she was shivering, with a chill that didn't make sense given the mild summer day. She took her temperature: it was 102.5. Her husband brought her some Tylenol and sent her to bed.

The next morning her fever was even higher. It wasn't flu season, but it felt like the flu. Her entire body ached. Her stomach warned her against eating. And she was so tired she could barely get out of bed.

Her husband stayed home from work to take care of their child, and she spent the day in bed. She felt miserable, sometimes drenched with sweat, other times shaking with violent chills. The lump on the back of her leg was dark red, and red streaks climbed up from the wound. When she was no better the next morning, she called her doctor.

Visiting Her Doctor

That afternoon she was seen by one of the nurse-practitioners in her doctor's office. Could this be a spider bite, the patient asked?

The nurse wasn't sure about that, but was pretty sure that antibiotics would help. The patient took the pills for the next three days but felt no better.

She went back to the doctor's office, saw another nurse-practitioner, and got another type of antibiotic.

That didn't help either. She still had high fevers every day. She also had terrible diarrhea. She lost over 10 pounds. The wound on her leg had become worse; it throbbed and exuded a hideous yellow pus. She was so tired that just getting out of bed seemed an insurmountable task.

Then her chest started to hurt whenever she took a breath. Any exertion caused a stabbing, aching pain on the left side of her chest. Coughing just about killed her. That's when she went to the emergency room of her local hospital in Frederick, Md.

An E.R. Visit

After spending the entire night in the bright, noisy emergency room, having dozens of tubes of blood taken as well as an X-ray and EKG, she was seen by an infectious disease specialist. He asked her no questions but simply looked at the sore on her leg.

"That little thing?" he remarked dismissively. He told her it was healing nicely and sent her home.

The woman was finally able to see her own primary-care provider after she'd been sick for over two weeks. The doctor examined her carefully. She grimaced as the doctor probed the left side of her abdomen. That hurts? the doctor asked.

The patient nodded, a little surprised by the sudden pain. That's when the doctor ordered the CT scan. And it was what she saw on the scan – an enlarged spleen – that made her think the patient might have cancer.

Cancer Scare?

What about the sore on my leg? the patient asked after the doctor mentioned cancer on the phone. The doctor wasn't sure what to make of that – maybe it was a spider bite. She was much more concerned about the enlarged spleen and wasn't sure the two problems were related. The doctors at the cancer center will help us figure it out, she told the patient, then hung up.

The woman's husband put his arm around her and drew her close. I think it's time to call your brother, he told her.

His wife's brother was a physician who had trained at Johns Hopkins Hospital in Baltimore, just over an hour away from where they lived. After hearing about her illness and her repeated visits to her local doctors, he urged them to get a second opinion at Hopkins.

Up to now she'd felt too sick to want to drive that far when her own doctor was just up the street. This phone call made a second opinion sound like a good idea.

And so the next day, the patient left her toddler with her husband and drove to the Baltimore suburb of Lutherville to see Dr. Heather Sateia, an internist in the Hopkins system. She had only just checked in with the front desk when the young doctor came to the waiting room to bring her in.

Another Opinion:

The doctor listened as the patient carefully retold her story. She had brought a DVD of the CT scan but had no other records. You can see the CT scan image of the spleen below.

As Dr. Sateia examined the patient, she felt for the enlarged spleen she had seen so clearly on the scan. The patient squirmed with discomfort as the doctor felt for but did not find the enlarged organ.

The most common cause of splenomegaly, or an enlarged spleen, in a young healthy woman was mononucleosis. This patient had had a febrile illness – though her temperature was normal in the office – and that fit the picture of mono as well. An in-office test for mono was negative, but since that test is less accurate later in the infection, Dr. Sateia ordered a different test to look for the presence of the Epstein-Barr virus, which causes mono.

Cat scratch fever was also possible. Although the patient didn't have a cat, her neighbor did, and she often played with it while visiting. Cancer, too, was a possibility. Splenomegaly is often seen in the so-called liquid tumors — leukemia and certain lymphomas. Dr. Sateia ordered tests to look for these possibilities and explained her thinking to the patient.

What about the sore on my leg? the patient asked. No one seemed to be able to link that to any of the other problems she had. Like the doctors before her, Dr. Sateia wasn't sure how to connect those dots. But, she told the patient, she would read up on spider bites to see if she could link the small open sore to the rest of her symptoms.

A few days later Dr. Sateia called the woman, who reported that she still felt awful. The fevers weren't as high, and the diarrhea was gone. But she was so fatigued and her chest hurt so much that it was almost impossible for her to pick up her child.

Did the doctor have any answers for her? Well, the doctor answered, all the tests she had done were negative. However, she'd been reading up on spider bites and made an important discovery. The sore was probably not caused by a spider. Spider bites can cause terrible tissue injuries, but the wound on her leg didn't look at all like the kind of lesion caused by spider venom.

However, she had read up on a close cousin to the spider that was known to carry a wide variety of infections. Had she seen a tick on her leg at any time during the summer?

A tick! The very idea of it horrified the patient. She had never found a tick anywhere on her body, nor on the two chihuahuas her family had.

Perhaps not, the doctor told her, but several of the tick-borne diseases she'd read about could have caused both the sore and the rest of her symptoms. Lyme disease was the most well known of these, but there were others – a disease called anaplasmosis and another called babesiosis. All three were carried by the same tiny deer tick. All caused awful febrile illness, and all three were becoming more and more common. The patient needed to go to her local lab; Dr. Sateia had already sent an order for her to get tested. She was convinced that this was the right direction.

The patient went to the lab the very next day. A few days later the results were back – all negative.

The doctor didn't give up. She had some ideas and figured out the answer.

You can see Dr. Sateia's notes here:

You can view the patient's lab results here:

You can read more about the imaging results here:

Solving the Mystery

What about you? Do you have any ideas about what this patient might have?

Post your guesses in the comments box. I'll post the answer on Friday.

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