A Brief Honeymoon

[ioan]

A Brief Honeymoon

By LISA SANDERS, M.D.

1. Symptoms

"I thought I was having a heart attack." The young woman pushed a wisp of long blond hair from her face as she recounted her symptoms to the tall woman with bright red hair who had known her all her life. "I was so scared," the patient whispered, her eyes filled with unspilled tears. It was late Tuesday night, the patient continued, and she had been awakened by an intense pain on the left side of her chest that worsened whenever she took a breath. She sat up, waking her husband of just a few months, but her chest hurt so much that she couldn't even tell him what was going on. And then, just as suddenly as it had come, the pain was gone. Just like that. "We talked about going to the hospital, but it went away so quickly, I figured I'd just call my regular doctor in the morning."

Dr. Jeffrey Engel saw her two days later. He was young and thoughtful, and listened to her story attentively. The patient was 25, had no medical problems and had recently returned from a honeymoon in the Caribbean. She had never felt a pain like the one the night before, she told him, but since then she'd had a couple of little twinges just above her left breast. Other than that she felt fine. She wasn't tired or achy; her appetite was good. On his examination, Engel found no evidence of infection: she had no fever, no swollen lymph nodes, her lungs were clear, her heartbeat was a little fast but regular.

"The good news is that healthy young women don't have heart attacks," Engel explained. On the other hand, he wasn't sure exactly what had happened. She had been through a particularly eventful few months, with a whirlwind romance, wedding and honeymoon. Now she and her new husband were in the midst of buying a home. Could this be stress? Or perhaps heartburn - which can cause intense chest pain that is often interpreted as a heart attack. The rapid heart rate was of some concern, though. He prescribed a heartburn medicine but also ordered a chest X-ray and an EKG. They would talk again once he had the results.

2. Investigation

The patient went in for the X-ray the next morning on her way to work. By the time she reached her office there was a message to call her doctor. There was something abnormal on the X-ray, he told her: a mass in the left lung. She would need a CT scan as soon as possible.

"That's when I called you, Maureen." The patient smiled at the red-haired doctor. Maureen Zakowski was her godmother, her parents' best friend and a physician specializing in pathology at Memorial Sloan-Kettering Cancer Center. In the two days since the X-ray, the pain had gotten worse, she told her friend, now her doctor. She felt as if she were wearing an old-fashioned corset, laced up really, really tight. And when she tried to take a deep breath, she experienced this knifelike pain in the left side of her chest.

Zakowski held the X-ray up to the lamp in her apartment. "You do have a mass on the left," she said. It was Sunday; the patient was to get the CT scan the next day and bring the films to her office, the doctor said. Then they would figure out what to do next.

Late Monday afternoon, the patient arrived at Sloan-Kettering with her CT scan. She followed Zakowski into an office dominated by a wall of light boards. Zakowski introduced the patient to a radiologist, then presented the case. The patient sat quietly as the two doctors discussed her in terms that were, for the most part, foreign and, when familiar, frightening. When Zakowski saw the X-ray the day before, her first thought was cancer, and the CT scans offered little to refute that. The radiologist, a stylishly dressed woman with a kind face, studied the films carefully. She was also concerned about cancer. The most common kinds of lung cancer were unlikely - the patient was young and had never smoked - but could it be metastases spreading from someplace else? Or was it a lymphoma? The chest is a frequent site of that cancer. There were other possibilities as well. Was this an infection? She didn't have a fever or other symptoms, but infection is the most common cause of lung disease in young adults. The patient had honeymooned in the Caribbean - could this be tuberculosis? Or was this some sort of virus or an exotic tropical disease? The scan could not distinguish between any of those possibilities. To get an answer they needed tissue; they needed a biopsy.

The patient returned to the hospital two days later for a bronchoscopy. A tiny camera was advanced through her mouth, down her windpipe to the lung. Although the patient was sedated, she could feel the tube snaking down her throat. It made her gag, but finally the doctor pulled out a small bloody sample. Zakowski hurried to the lab. She carefully scanned the tissue fragments under the microscope. The results were inconclusive - they hadn't gotten enough to make a diagnosis. They would have to operate to get a sample of the mass they had seen.

The surgery was scheduled for the end of the week. It took about an hour for the surgeon to excise a mass from her lung. In the lab, Zakowski eyed the specimen with dread. The well-defined mass looked so much like a cancer that she could hardly make herself examine it. "I was so afraid," she told me later. "I love this little girl. I didn't even want to look at it." But as soon as she saw the tissue under the microscope she knew for certain - it wasn't cancer.

Now that she knew what it wasn't, she needed to figure out what it was. Samples of the tissue had already been shipped to the microbiology lab to look for evidence of infection. Zakowski began the familiar and painstaking process of examining the cells, which had been treated with special stains, to look for clues to their identity.

3. Resolution

It took several days, but finally the stain revealed what the mass was made of: a collection of white blood cells, including highly specialized cells known as eosinophils. These cells are always in the blood in small numbers, and increase rapidly when the body needs to fight off a parasite. But they also multiply whenever the body is exposed to something it's allergic to. What they'd seen on the CT scan, and what Zakowski now saw under the microscope, was called eosinophilic pneumonia - not an infection, but an unusual and potentially deadly response to an allergen, most commonly a reaction to a medication.

The doctor called the patient right away. "These masses are some kind of allergy - probably to a medicine you're taking," she said. "Whatever you're on, stop taking them." At first the patient was confused. She didn't really take any medicines other than birth-control pills. Then she remembered: some months ago, a note in her wedding planner suggested seeing a dermatologist to make sure her skin would be clear for the wedding. The patient had never had any problems with acne, but she figured this was no time to start. She made an appointment with a local dermatologist, who gave her a medicine called minocycline. It's an antibiotic used frequently by dermatologists in the treatment of acne. She had taken the minocycline right up to the day of the bronchoscopy. It's considered a relatively safe medicine, but has been associated with this type of severe allergic response in several reported cases.

I spoke with the patient recently. She celebrated her first anniversary this summer. The usual treatment for eosinophilic pneumonia is steroids, but in this case the patient improved so much when she stopped taking the medicine that her doctors decided not to treat her with anything. She had several follow-up CT scans that showed the mass going and finally gone. "I feel fine - but a little silly," she said. "And pretty upset. I'd have never taken this medicine if I'd known about this. Even if it's a one-in-a-million chance - when you're the one, it's bad."

[KonstantinosMD]

"And pretty upset. I'd have never taken this medicine if I'd known about this. Even if it's a one-in-a-million chance - when you're the one, it's bad."

yeah, sure!!!!!