Diagnosis -
It Was Like the Vigor Had Suddenly Been Sucked Out of His Body. What Was It? -- (edited)
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The 70-year-old man rapidly went from walking 10 to 15 miles a day to being nearly helpless. His wife wondered if he’d had a stroke.
By Lisa Sanders, M.D.
March 7, 2024
Surrounded by the detritus of a Thanksgiving dinner, the woman was loading the dishwasher when a loud thump thundered through the house. She hurried out of the kitchen to find her husband of 37 years sitting on the second-floor landing. Her son and son-in-law, an emergency-room doctor, crouched at his side. Her husband protested that he was fine, then began to scooch himself on his bottom into the bedroom. The two young men helped him to his feet. The man’s body shook with a wild tremor that nearly knocked him down again. “I was getting into bed and fell,” he explained — though the bed was too far away to make this at all likely. “Get some sleep,” the woman said gently once her husband was settled in the bed. “We’ll go to the hospital in the morning.”
Her daughter and son-in-law had arrived that morning and already mentioned the change they noticed in the 70-year-old senior. The normally gregarious man was oddly quiet. And the tremor he had for as long as they could remember was much more prominent. His hands shook so much he had trouble using his fork and ended up eating much of his Thanksgiving dinner with his fingers. And now this fall, this confusion — they were worried.
His wife was also worried. Just after Halloween, she traveled for business, and when she came back, her husband was much quieter than usual. Even more concerning: When he spoke, he didn’t always make sense. “Have you had a stroke?” she asked her first day home. He was fine, he insisted. But a few days later she came home from work to find his face covered with cuts. He was shaving, he said, but his hand shook so much that he kept cutting himself. “There is something wrong with me,” he acknowledged. It was Thanksgiving week, but she was able to get him an appointment at his doctor’s office the next day.
They were seen by the physician assistant (P.A.). She was kind, careful and thorough. After hearing of his confusion, she asked the man what day it was. “Friday?” he offered uncertainly. It was Wednesday. Could he touch his finger to his nose and then to her finger, held an arm’s length away? He could not. His index finger carved jagged teeth in the air as he sought his own nose then stretched to touch her finger. And when she asked him to stand, his entire body wobbled dangerously. “It’s all happened so quickly,” the man’s wife said. The P.A. reviewed his lab tests. They were all normal. She then ordered an M.R.I. of the brain. That, she explained, should give them a better idea of what direction to take. But, she added, if he falls or seems unsafe at any point, you should take him to the emergency room.
And so, early that Friday, the woman drove her husband to Danbury Hospital, the emergency room closest to the couple’s small Connecticut town. He walked in on his own. It was the last time he would walk without help for weeks.
Many Pink Pills
He was admitted to the hospital. Neurology was consulted and did an extensive work-up: blood tests, CT scans, an M.R.I., an EEG, a spinal tap. While there were some abnormalities, nothing explained his rapid mental and physical decline. There was no sign of infection or tumor. No evidence of seizures. His vitamin levels were normal. And the gastritis he had earlier that spring was responding well to a daily acid-reducing medication, pantoprazole.
Although he had the stiffness and tremor that would be typical of a patient with Parkinson’s, his speedy decline was not. Creutzfeldt-Jakob disease can cause a rapidly progressive mental and physical disability, but neither the EEG nor the M.R.I. showed any evidence of the rare disease. One thing worried his wife: He was taking a very high dose of Pepto-Bismol — four pills a day — which had been prescribed for the gastritis. When too much Pepto-Bismol causes problems, it’s usually because of an overload of the aspirin-like compound in the medicine, but when they checked, that level was normal.
Finally, after five days of intense investigation, the neurologists had found nothing and decided to refer him to a neurologist at Yale University. While he wasn’t sick enough to need to be in the hospital, his doctors and wife agreed that he was too weak to go home. Instead, he was sent to a short-term rehabilitation center, where he could get the care he needed and possibly some of his strength back.
It was evening by the time the man and his wife arrived at CareOne’s River Glen Health Care Center in Southbury, Conn. Nicole DiCenso, the nurse on duty, came to see the patient once he got to his room. Right from the start, DiCenso thought there was something odd about his story. He looked healthy and strong — fitter than her parents, who were about his age. And yet when she tried to move him to the chair scale to weigh him, she was surprised that he was too weak to move himself to the edge of the bed — even with her help. It was hard to reconcile his profound disability with his wife’s report that he had been walking 10 to 15 miles a day just weeks earlier. It looked as if the vigor had somehow been sucked out of his body, leaving his muscles present but powerless.
DiCenso was also struck by the high dose of Pepto-Bismol listed in his medications. She knew that the Bismol in the name indicated that the drug contained a metal called bismuth. It was the ingredient that helped to “coat” the stomach. Like Pepto-Bismol itself, the metal was considered safe, but could too much of it cause these kinds of neurological changes? She did a quick search on her computer. Almost immediately she found a report of a woman who, like her patient, developed rapidly progressive mental and physical problems after taking bismuth-containing products for more than a year. DiCenso thought solving problems was the best part of her 20-year career in nursing. Had she solved this one? She called the man’s wife, told her what she found and asked her how long her husband had been taking Pepto-Bismol. Four pills a day for the past eight months, the wife replied. And he never misses a dose of any of his medicines. Never.
An Epidemic in France
DiCenso arranged for a test to look for bismuth, and waited impatiently for the results. It took days. Finally, it came in: His bismuth levels were sky high — 28 times higher than normal, well into the toxic range. The patient was admitted to Yale New Haven Hospital for treatment supervised by Dr. Anthony Tomassoni, a toxicologist on staff there.
Bismuth has been used to treat everything from syphilis to stomach pains for more than 300 years. That it can cause neurological symptoms has been known since the mid-1970s, when an epidemic of a thousand cases of bismuth toxicity broke out in France after the promotion of cosmetics containing the metal. In those cases, it was seen that just avoiding the use of these products could slowly reverse the symptoms. The half-life of bismuth in the body — that is, how long it takes to eliminate half of the metal — is more than two months, so recovery is slow.
One common oddity in many of the reported cases was the rapid progression of symptoms after long periods of exposure — in this patient’s case, months; in other reported cases, years. According to Tomassoni, this is probably because of the accumulation of the metal in the body. It doesn’t reach the brain easily, but once it does, it can cause headaches, apathy and an unsteady gait, progressing to confusion, difficulty speaking and seizures as it builds up. Tomassoni suggested that they speed up the elimination of the metal from the body through a process called chelation. Patients are given a medication that binds to bismuth and is excreted in the urine. The medication is administered in pill form, so the man was discharged after a few days of supervision.
The change in the patient was immediate. He had arrived at Yale New Haven Hospital in a wheelchair, unable to do anything for himself. When he returned home, six days later, he was walking. DiCenso was overwhelmed when, after Christmas, he strolled into River Glen to thank her for saving his life.
These days, just a few months after his hospitalization, he’s well on his way back to normal. He is walking 10 to 15 miles a day again. From his wife’s perspective, he is still quieter than he used to be. A little more forgetful. But every day he gets a little better — a little closer to the man she married so long ago.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis:Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write her at [email protected]
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