Why was my patient suddenly falling apart after decades of healthy living?
Why was my patient suddenly falling apart after decades of healthy living?. Although I had known Pop Katz and his family for a long time, I had not seen him in years. Now I scarcely recognized him. He was standing in my office-just barely. If his grandson hadn’t been holding him up, he’d have pitched straight forward onto his face. Saliva dribbled from the corners of his mouth. His eyes were vacant.
The two had just flown in from Miami to see me. Pop’s wife said she couldn’t take care of him anymore, but she didn’t want him to end up in a nursing home. So she asked their grandson, a psychologist, to bring the octogenarian to me for an evaluation.
Together we reviewed the history. A month ago, the grandson had visited his grandparents and as usual, Pop took him on a three-mile run, joking all the while about how his strict vegetarian habits helped him outperform his juniors. A week or so later, Pop’s wife was troubled. “He cries so easily,” she told her grandson. The grandson had advised a visit to their doctor, even though he knew Pop liked doctors about as much as rare steak. His wife managed to get him there anyway, and after a cursory exam and blood count, he went away with a clean bill of health.
Then, about two weeks ago, Pop disappeared. Eight hours later, the police brought him home. They had found his car parked on the shoulder of a highway. Pop sat inside, confused. He had been there for hours.
A second visit to the doctor and Pop’s condition was diagnosed as “senile dementia.” He had lost control of his bladder, was wandering around at night, refusing to eat, leaving the house partially clothed.
Pop was still well nourished and tanned, but he couldn’t run three yards, to say nothing of three miles. Something physical had to be wrong. This had come on too quickly, and it didn’t fit the scenario of pseudo-dementia some depressed patients develop.
Doctor On Call
In medical school, Leslie Bernstein was undecided about whether to become an internist or a surgeon. He settled on gastroenterology because it allowed him to work with his hands and stay within internal medicine. “I get to use all kinds of instruments and endoscopes to see inside the body,” he says. Bernstein is a professor of medicine at the Albert Einstein College of Medicine in New York City and the former head of gastroenterology at Montefiore Medical Center. In 1998, he won the clinical achievement award from the American College of Gastroenterology. This is his first piece for Vital Signs.
“How are you, Pop?” I asked. He looked up from his seat, broke into a broad grin, then burst into tears. I admitted him and ordered a workup.
Within a few hours, we got some test results. A cat scan showed no evidence of cerebral atrophy, a shrinkage of the brain that can accompany Alzheimer’s. There was no sign of stroke or tumor, nor was fluid accumulating inside the brain, which could create pressure. A spinal tap revealed clear, normal fluid. The blood work was normal, although the red cells were slightly larger than they should have been. There were no signs of infection or cancer.
After a consultation with a neurologist, Pop’s problems were given an obvious diagnosis: “rapidly progressive dementia of unknown origin, with severe changes in coordination, emotional lability, and signs of frontal lobe dysfunction involving higher centers of reasoning and memory.”
A psychiatrist concluded that Pop suffered from “toxic/organic disease without significant depression.” Yet there was no trace in his blood of surreptitious or accidental ingestion of sedatives, narcotics, or tranquilizers, or exposure to poisonous metals, such as lead, thallium, or mercury. A test for exposure to pesticides was negative.
On the second day of hospitalization, more results came back. Pop’s thyroid was normal. That ruled out problems with mental function from low levels of thyroid hormone. The results of another brain-imaging test, which traced the path of spinal fluid over the surface of his brain, showed normal results. Still, Pop was getting worse. He could barely stand, even with assistance, and he had lost control of his bowel movements.
I was worried. The longer the cause remained a mystery, the slimmer the chances of a full recovery. “The diagnosis is in the history 90 percent of the time,” I thought. “What are we missing?”
The history was simple: In a matter of weeks, a man who hadn’t been sick for 80 years suddenly became demented. Yet none of his lab work was abnormal-except for that slight increase in the size of his red blood cells. Liver tests were normal; nothing suggested exposure to a toxin.
What about a deficiency? Iodine deficiency in mothers has been associated with cretinism in the newborn and hypothyroidism in adults, but Pop’s tests were negative and his thyroid was normal. What about a vitamin deficiency? The three D’s of pellagra include dementia, diarrhea, and dermatitis, but Pop was missing the last two signs. Besides, who ever heard of niacin or any other vitamin deficiency in a vegetarian?
“Holy smoke!” I thought. “I’m an idiot! The man’s been a vegetarian for 38 years. No meat. No fish. No eggs. No milk. He hasn’t had any animal protein in four decades. He has to be B12 deficient!”
Within minutes a new blood sample was drawn. Then we gave Pop an injection of 1,000 micrograms of vitamin B12. Five hours later, the blood work was back: The level of B12 had been too low to measure.
By the following morning, Pop could sit without help, and within 48 hours, his bladder and bowel control had returned. By the end of the week he could play simple card games, read his get-well cards, and talk on the phone. Unfortunately, some personality changes still remained. He still cried easily, and his attention span was so short that he couldn’t go back to work.
