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A puzzling patient: Even when she wakes up, she feels sick

2019-12-15T12:59:16.021Z


A 39-year-old woman keeps suffering from nausea and severe vomiting. When pain, rapid heartbeat and dizziness come along, she looks for help in the emergency room.



The woman comes to the hospital with an existing diagnosis: she suffers from the so-called cyclic vomiting syndrome. At times, you experience severe nausea and you often have to vomit. When the 39-year-old went to a Massachusetts hospital, she also had diarrhea and pain in the lower right abdomen. She currently has her days.

Doctors do some tests without finding a cause for the discomfort. There are no signs of pathogens in blood and stool. However, a urine test is positive for cocaine and opiates. Computer tomography (CT) shows kidney stones, but they do not block kidney ducts or ureters. There are no signs of inflammation in the abdomen or abdomen. The ovaries look normal and healthy.

The patient receives medication that relieves nausea and pain. The very next day she was well enough to leave the clinic.

She feels weak and has a fever

Eleven weeks later, the woman inhales smoke from a fire. Shortly thereafter, she developed pain in the lower left abdomen and was very exhausted. However, she does not go to the doctor with these complaints.

Her rule begins the following day. When she wakes up, she feels sick and vomits. It vomits again and again in the next twelve hours. She feels weak, she is dizzy and she has a fever - 39.4 degrees Celsius. Finally, she visits the Massachusetts General Hospital emergency room in Boston.

Their temperature has now dropped to 37.2 degrees. Your heart beats very quickly: 165 times a minute. Her breathing is also increased with 22 breaths per minute. She speaks very quickly, sometimes indistinctly. The woman seems very restless to the doctors. Her hands are trembling slightly, her face and torso are red and warm. When you listen to your heart, you hear a heart murmur, which suggests a problem.

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The doctors mention another important detail in their case report in the "New England Journal of Medicine": the woman weighs only 52.5 kg; when she was hospitalized eleven weeks earlier, her weight was 59.3 kilos.

She claims to have used various drugs in the past - cocaine, heroin, marijuana, and ecstasy. She recently only used marijuana, she says.

She has to vomit again in the clinic

Less than half an hour after her arrival in the emergency room, the 39-year-old has to vomit again. Her pulse rises from 165 to 210.

The doctors immediately monitor their heartbeat using an EKG. They find that the patient has a so-called superaventricular tachycardia - i.e. a racing heart, the origin of which lies above the ventricles, for example in the atria. They give the woman adenosine to stop this arrhythmia. The heartbeat changes, but continues to race - now in the form of a so-called sinus tachycardia.

The amount of certain liver enzymes called alkaline phosphatases in the blood is increased. In addition, according to the test, the woman not only consumed marijuana, but also the opioids fentanyl and oxycodone.

A CT shows no problems in the lungs and heart. It confirms the diagnosis made eleven weeks ago: the woman has kidney stones, which, however, do not block any vessels. The intestine is neither inflamed nor blocked, and the appendix appears normal.

The patient is taken to the intensive care unit, where she is given intravenous fluids and given her sedative and nausea medication.

What made the heart race?

To find out what the symptoms are, the doctors first go through the possible causes of sinus tachycardia. Above all, this includes pain, infections, bleeding and a reduced amount of blood.

Although the patient reports pain, it seems unlikely to the doctors that this caused the pronounced rapid heartbeat. Because there are no other signs of infection, they also rule it out as the cause. A volume loss due to persistent vomiting would be conceivable, but the blood values ​​are not changed accordingly. The woman has not suffered any major blood loss either. Some obvious causes are therefore ruled out.

A diagnosis that explains all the symptoms

Victor Chiappa's team of doctors is therefore considering what could explain all the other symptoms - vomiting, pain, fever, weight loss, restlessness.

  • Does she have opiate withdrawal symptoms? Then she should actually have other symptoms, such as dilated pupils.
  • The fact that the woman has lost a lot of weight, is restless and sometimes speaks indistinctly could indicate an ovarian tumor. The racing heart could not be explained in this way. Even a CT scan of the pelvis shows nothing unusual.
  • An overactive thyroid could explain the patient's heart racing and weight loss. The other symptoms could also be explained by an excess of thyroid hormones.

Several tests not only confirm the latter suspicion, but also prove that the patient suffers from Graves' disease. In this autoimmune disease, the body's defenses stimulate the increased production of thyroid hormones.

The patient has developed a life-threatening condition due to the excess of thyroid hormones, a so-called thyreotoxic crisis. This manifests itself as rapid heartbeat, vomiting, diarrhea, reddening of the skin, restlessness and increased temperature: all symptoms that the doctors observed in the patient.

Four or five days after taking various medications, she's already feeling much better. After she is released from the clinic, she goes to a specialist for further treatment. Unfortunately, a few months later, tests show that she is not taking her medication as recommended. After all, she no longer shows up at the doctor, the clinicians report.

Source: spiegel

All life articles on 2019-12-15

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