Think Like a Doctor
Solve a medical mystery with Dr. Lisa Sanders.
The Challenge: A 55-year-old man loses the hair on his legs, loses weight and then loses his strength. Can you figure out why?
Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a diagnostic riddle. Below you will find the details of a case involving a retired state trooper who starts wasting away. Over a few weeks, he drops 30 pounds and grows so weak he has to use a walker to get around.
As usual, the first person to figure out the diagnosis will receive a signed copy of my book "Every Patient Tells a Story" and the pleasure of figuring out a case that stumped a bunch of doctors.
The Patient's Story
"When did you start shaving your legs?" the woman asked her husband of 20 years.
The couple sat on the porch of their rural Pennsylvania home enjoying the end of a beautiful day. Her husband, a retired state trooper, laughingly replied that he shaved them every Tuesday. But when he took a good look at the limbs emerging from his pants legs, he was surprised to note that they were as smooth as a model's.
"Have you lost some weight?" she added. He always weighed 172, he told her. But he got up and weighed himself on the bathroom scale: he was 160 pounds. The man was not sure what to make of these two wifely observations, but a couple of months later, when his weight continued to drift downward, he made an appointment to see his internist, Dr. William Oleksak.
The Doctor Visit
The patient had not had an appointment with his doctor in nearly two years, so when the doctor saw him that June day, he was shocked by the man's appearance. The retired trooper had always been a slender, fit and vigorous man. Not any more.
The doctor could see that the patient had lost a significant amount of weight. His face looked almost skeletal – the cheek bones and bones around his eyes were prominent as the fat that gave his face a good-natured roundness had melted away. Looking at him, Dr. Oleksak first thought that the man had some kind of cancer.
Although the patient considered himself a pretty healthy guy, he had several medical problems. First, he was a smoker – a pack and a half a day for 40 years. Because of that, he had some early atherosclerotic changes, or hardening of the arteries, in the blood vessels leading to his legs. It got so bad that a few years ago, he had to have one of the big vessels in his leg reopened so he could walk more than a few steps.
And when he had his colonoscopy at 50, his doctor had to cut out a few polyps. He was due for another colonoscopy to make sure they hadn't come back. He had been found to have celiac disease a while back, but he had not had symptoms for years. His thyroid was not quite as cooperative. It stopped working a decade earlier, and he had to take a medication for that every day. Most days, it was the only medicine he took.
Other than the patient's weight and hair loss, Dr. Oleksak could find nothing wrong upon examination. He told the patient he was going to send him for a colonoscopy and a chest X-ray and to get a few blood tests.
"Are you looking for cancer," the man's wife asked. He was, he told the couple, ready to answer any additional questions. There weren't any. The wife just nodded as if that's what she'd been thinking as well.
You can see the results of the blood tests here.
You can see the results of the imaging tests here.
A Summer of Testing
Those tests were the first of many for the patient that summer. The chest X-ray was normal, except for the changes caused by his years of smoking cigarettes. The colonoscopy did not show cancer – just a couple of hemorrhoids. He had a CT scan of his chest, abdomen and pelvis. Normal.
Tube after tube of the blood he gave did not seem to show much. He had a low white blood cell count and mild anemia. When rechecked a couple of weeks later, the count of white blood cells – the warriors of our immune system – was even lower, so Dr. Oleksak sent the patient to a hematologist.
That doctor was worried about cancer, too. She sent off several blood tests, and when they did not tell her what she needed to know, she took a piece of his bone marrow to make sure he did not have cancer there. He didn't.
She did find something that could account for the patient's symptoms. His vitamin B12 level was low. Was that why he felt so bad, he asked the doctor. Could be. The bone marrow needs B12 to make blood. And low B12 can cause weakness as well. It seemed the right answer, yet even taking huge doses of the vitamin did not seem to help.
You can see more of the patient's blood test results here.
And you can see the results of the bone marrow analysis here.
Falling Down
The patient continued to lose weight, drifting from the 160s down to the 140s. It seemed as if his strength was slipping away with the pounds. He was tired all the time; he needed to nap every afternoon.
And then he started falling. He knew he was in deep trouble one morning when he fell as he hurried out of his car to get into the grocery store during a rainstorm. His legs gave out, and he ended up face down on the wet pavement. He had to crawl back to the car to pull himself up.
This time, when he went back to Dr. Oleksak, his exam was not normal. The way doctors test for strength is pretty crude. We pit the strength of our arms against the strength of the patient's arms and legs. For a middle-aged man who keeps pretty active, there has to be significant weakness for the test to show anything at all. But when Dr. Oleksak held the patient's thigh down with one hand, the man could barely lift his leg off the table. And once he had raised it off the table, it was a struggle for him to keep it there.
Weakness can be caused by a problem with the muscles or a problem with the nerves that power them. And distinguishing between these two required a level of expertise that was not found in the rural Pennsylvania town where Dr. Oleksak practiced. He would have to send the patient some 50 miles away to the University of Pittsburgh Medical Center. Dr. Oleksak referred the patient to Dr. David Lacomis, a neurologist he had heard of who specialized in nerve and muscle diseases.
A Specialist Weighs In
The patient was sitting on the exam table in a flimsy cloth gown when Dr. Lacomis entered the room. He immediately made note of the wasted appearance of the patient and his hairless legs. He heard the patient's story and then examined him, focusing on the man's nerves and muscles. He was clearly quite weak. He could not get up from a chair unless he used his arms. He could not walk on his tiptoes or his heels.
Still, the patient's weakness and loss of muscle seemed to be everywhere.
Whatever the patient had, it had to be something that affected the whole body and not just one part or side. Was it a disease of the nervous system? Dr. Lacomis didn't think so, and subsequent testing of the man's nerves confirmed it.
Solving the Mystery
If not the nerves, then what?
That was the question Dr. Lacomis put to himself, and he eventually figured out what was causing this man's weakness and weight loss and why it had occurred. Can you?
Post your answers below in the comments section. The first person to answer both questions — What was the cause of this man's symptoms, and why did he get it? — will receive a copy of my book and that warm, wonderful feeling you get from solving a mystery.
Rules and Regulations: Post your questions and diagnosis in the comments section. The correct answer will appear on 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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