Opinion – Luciano Melo: The apathetic woman who barely walked

A 28-year-old woman was admitted to a hospital because she was greatly weakened. A contrast to her condition from months ago, when she was fine, very fine, by the way. She had even given up therapy for her diabetes, understanding her body as invulnerable. But that impression didn’t last, her recklessness made her blood sugar skyrocket, with obvious physical consequences. Fearfully, she returned to her insulin shots. As the diabetes monitoring tests readjusted, surprisingly, she weakened. She suffered persistent nausea, complained of constant abdominal pain, at times very intense. She felt burning and tingling from her feet to her knees and in her hands. She also couldn’t eat properly. In this way, she lost her strength, could barely hold a mug full of water and only walked if properly supported.

In the ward, she underwent an extensive laboratory investigation. Some tests came back altered, but no results revealed the cause of those growing problems. What was left for the young woman were generic diagnoses, such as gastritis, nerve disease, diabetic decompensation.

Despite the dramatic situation, the woman seemed disengaged from her condition, as if she didn’t care. She did not ask questions of doctors and nurses, nor did she show interest in the unsatisfactory explanations that were given. She responded evasively to doctors, with monosyllables. She had stopped collaborating with rehabilitation therapies. She eventually got emotional, with sudden, very short cries. She had those who recommended trying hard, helping yourself, being proactive, and another list of motivational advice; willpower would be enough for the recovery of health. But between us, the hardship would not be resolved with optimism.

More worried than optimistic, a young neurologist remembered that there is a disease capable of causing abdominal pain and nerve dysfunction: the rare porphyria, a disease caused by genetic failure. The diagnosis is almost magical, the urine of those affected, if exposed to light for hours, takes on a violet color. Unfortunately, too long under the sun, the patient’s urine insisted on a monotonous citrine yellow. Other laboratory tests buried the porphyria hypothesis once and for all.

Frustrated, the doctor decided to talk to an old-time neurologist, very experienced in rare diseases, including porphyria. The older colleague did not give him the diagnosis. But he warned her of the obvious: there would be something diffuse in the patient’s body; she should follow this motto to reach the diagnosis. The neurologist, without the desired answer, thought she had wasted her time with the conversation. She didn’t realize that she had been treated as an equal and subtly advised not to behave like the tutor’s dependent student anymore.

The next day, he forgot about the disappointment and bravely faced the question: what would attack the organism diffusely? “Intoxication”. The word came into his mind after long reflection. Would you be facing a case of poisoning? To begin the new investigation, he requested measurements of heavy metals in the blood, aware that the analysis would take a few days to complete. He asked the patient’s relatives questions about her habits, after informing them of the new assumption. However, none of the relatives had revealed anything suspicious.

The results came. There was a high blood concentration of lead. With the find in hand, she confronted the patient’s relatives: “there is missing information, please find it”. Surely, the metal in the blood wasn’t a punishment from chance or some vengeful demon.

This time, she got more effective collaboration and so an aunt of the hospitalized young woman brought a small bottle to the hospital that was in the drawer of the sick room. The girl ingested several drops of the liquid from that vial, with the belief that she would improve from her diabetes, since she had given up insulin. The imported product, with mentions of Ayurvedic therapy, contained herbal extracts enriched with chromium and lead. The habit was not mentioned, as no one suspected a product labeled as natural, they considered the information irrelevant.

Lead was the cause of his apathy, emotional lability, pain and weakness. Fortunately, there is therapy against lead poisoning.

References:

1. Willett LL, Bromberg GK, Chung R, Leaf RK, Goldman RH, Dickey AK. Case 38-2021: A 76-Year-Old Woman with Abdominal Pain, Weight Loss, and Memory Impairment. N Engl J Med. 2021 Dec 16;385(25):2378–88.