They weren’t looking for a diagnosis, the middle-aged woman explained. Her husband had a diagnosis. They just wanted help figuring out why, even with all the treatments he was getting, he wasn’t getting better.
Until a year and a half earlier, her 54-year-old husband had been perfectly healthy. Never missed a day of work, never took so much as an aspirin. Then he got what he thought was the flu. But even after the fever and congestion went away, the terrible body aches remained. He coughed constantly and felt so tired that just walking to the mailbox would leave him panting for air and shaking with fatigue.
Still, he went back to work. He enjoyed his job driving a locomotive for a manufacturing plant in rural Connecticut. Besides, his wife told me, he was a guy who needed to be busy. And he stayed busy until, one morning a couple of weeks after starting back at the job, he was driving to work and suddenly found himself rumbling over the shoulder, drifting toward the strip of grass and the woods beyond. All he remembered was that one minute he was on the road, and the next he wasn’t. For the first time since he initially got sick, he was worried.
He went to an urgent-care center. A chest X-ray showed fluid surrounding his lungs. And his EKG was abnormal. The nurse who saw the man was concerned. She ordered an antibiotic to treat a possible pneumonia and referred him to a cardiologist.
That was the first of many doctor’s appointments but the last one he went to alone. His wife was worried that her husband, a quiet man who seemed to be wasting away in front of her eyes, wouldn’t ask the questions that needed to be asked.
The cardiologist ordered a second chest X-ray, which showed even more fluid in the sack surrounding his lungs — so much that it was hard for the man to take a deep breath. The cardiologist sent him to have the sack drained of more than a liter of a clear yellow fluid. It made the patient feel better, but it didn’t last; within days the shortness of breath returned.
Two weeks later, when the man saw a pulmonologist, that doctor referred him to have another liter of the same yellow fluid drained from his lungs. The man’s abdomen began to swell with even more fluid. Where was it all coming from? No one could tell him. After the fluid reaccumulated just as quickly, his doctors sent the man to the hospital.
There, an echocardiogram — an ultrasound of the heart — showed that he now had fluid in the pericardium, the sack surrounding his heart. The heart could barely pump. He was rushed to the operating room, and a hole was cut into the pericardium to allow the fluid to drain and give his heart room enough to beat normally. A retinue of subspecialists searched for an explanation for this flood of fluids. His heart was strong, he was told. His lungs were fine. His liver was fine. There was no infection, and no cancer.
Finally, a rheumatologist found an answer. The patient tested positive for something called Sjogren’s syndrome. In this autoimmune disorder, white blood cells attack the organs that make the fluids needed to lubricate the body. Those with Sjogren’s often have dry eyes because they don’t make enough tears, or a dry mouth because they don’t make enough saliva. They have problems with dry skin, as well as with their joints and G.I. tract.
The patient and his doctors were thrilled to finally have a diagnosis. Still, most with Sjogren’s don’t need treatment for the disease, only for the annoying symptoms of dryness and discomfort it causes. It was strange that the syndrome would, in this patient, produce this extraordinary fluid overload. The rheumatologist theorized that a second disease called undifferentiated connective tissue disorder (U.C.T.D.) might be involved. The patient was immediately started on two immune-suppressing medications.
He continued to need to have his lungs and abdomen drained of 10 to 20 liters of fluids every couple of weeks. More drugs were added. But when, after months of treatment, he was no better, his wife insisted they get a second opinion. He was referred to a rheumatologist in New York. That doctor suggested still another immune-suppressing agent.
The patient was on four of these medications when I first met him this summer. Despite the medications, he continued to have liters of fluid drained from his belly and around his lungs.
After hearing about their terrible journey, I examined the patient carefully, trying to find some clue to what could be going on. His arms were thin and wiry, just bone and sinewy muscle; the overlying skin hung loosely, reflecting significant muscle loss. In contrast, his abdomen was huge — the belly of two Santas. The skin there was drum-tight. His neck, like his arms, was thin, and the veins on each side were hugely distended with blood.
Once he had dressed and I was able to gather my thoughts, I told the couple that only the heart could cause such a huge buildup of fluids. No, the man emphatically said: My cardiologist assured me that all the tests show that my heart is strong. I told them I’d pore through the thick folder of carefully organized records they had collected and come up with a plan.
I didn’t believe it was his autoimmune disease causing all this. Even though he had Sjogren’s and possibly U.C.T.D., he was being treated. And when a remedy fails, you must consider the possibility that what it’s treating is not the cause of the problem, and ask: What else could this be?
So I dug and thought and came up with a list of rarities that could cause these symptoms. I put the question to my friend and mentor at Yale, Andre Sofair, an internist on the faculty of the program where I had trained and now taught. His answer was familiar — surely this was the heart. I told him what the patient told me, that his heart had been tested and was in the clear. Andre was surprised but turned his mind to thinking of other causes. He added a couple more items to my list.
I sent the patient for more tests, and when they came up with nothing, I thought back to Andre’s first instinct. Was it his heart? In such a setting, I think of the Russian proverb Ronald Reagan used during his negotiations with Mikhail Gorbachev on the treaty regulating intermediate-range missiles: One must trust, but also verify.
When the heart muscle has been damaged by, say, a heart attack, it doesn’t pump as well, and fluids can back up. We call that congestive heart failure, and it was one possibility. But the bulging neck veins I saw suggested another, rarer possibility: constrictive pericarditis. In this disorder, the pericardium is injured — usually by a viral infection — and as it heals, it shrinks. Stuck in this shrunken jacket, the heart can only pump a fraction of the blood needed by the body. Could the virus that caused the flulike symptoms at the start of this illness have attacked his pericardium?
I sent the patient for another echocardiogram. It showed a heart pumping hard but constrained inside a shrunken, thickened pericardium, unable to process the normal measure of blood. I spoke with his rheumatologist, who stopped all the immune-suppressing agents, and I sent him to John Elefteriades, a well-respected heart surgeon at Yale. Elefteriades cut away the damaged sack. Once he made the initial incision down the length of the scarred pericardium, the blood flow through the heart more than doubled.
The man’s recovery from this surgery has been remarkably fast. He had a foot-long incision down the middle of his chest, but within two weeks of the operation he was home and walking around. Three weeks later he was back at work — just in time for him and his wife to prepare for a holiday season they had worried they would never see together.B:
【第】35【章】【新】【的】【境】【界】！【招】【揽】【之】【意】！ 【当】【太】【一】【问】【天】【跳】【进】【灵】【池】【的】【那】【一】【刻】，【处】【在】【灵】【池】【内】【正】【在】【吸】【收】【灵】【力】【的】【五】【人】【立】【即】【感】【知】【到】【了】，【每】【个】【人】【都】【睁】【开】【眼】【朝】【着】【太】【一】【问】【天】【的】【方】【向】【看】【了】【一】【眼】，【知】【道】【又】【有】【一】【个】【人】【进】【来】【了】，【然】【而】【太】【一】【问】【天】【进】【入】【的】【速】【度】【实】【在】【是】【太】【快】【了】，【五】【人】【只】【是】【模】【糊】【看】【到】【了】【一】【道】【人】【影】，【至】【于】【样】【貌】【什】【么】【的】【都】【没】【看】【不】【清】【楚】。 【但】【是】，【他】【们】【都】
“【这】【个】？”【沈】【凉】【姩】【挑】【眉】【示】【意】【唐】【让】【看】【看】【前】【面】【那】【件】【红】【色】【的】【毛】【衣】【背】【心】。 【唐】【让】【摸】【着】【红】【色】【的】【毛】【衣】【背】【心】，【点】【点】【头】，【这】【种】【颜】【色】【是】【他】【喜】【欢】【的】，【不】【过】【就】【是】【款】【式】【有】【点】【老】【了】。 【见】【她】【如】【有】【所】【思】【的】【样】【子】，【沈】【凉】【姩】【摇】【头】，【看】【别】【的】【衣】【服】【去】【了】。 【顾】【攸】【宁】【平】【时】【穿】【的】【都】【是】【手】【工】【定】【制】【的】，【从】【外】【面】【买】【的】【他】【不】【一】【定】【的】【喜】【欢】。【沈】【凉】【姩】【寻】【思】【着】【给】【顾】【攸】【宁】【也】【带】【一】【件】2017马会挂牌全篇【医】【院】，【秦】【易】【陪】【秦】【父】【秦】【母】【说】【了】【大】【半】【个】【小】【时】【的】【话】，【尽】【量】【让】【他】【们】【安】【心】，【不】【必】【再】【害】【怕】。 “【易】【儿】，【你】【不】【必】【担】【心】【我】【们】。【我】【们】【老】【了】，【哪】【怕】【有】【什】【么】【好】【歹】，【也】【没】【什】【么】。【倒】【是】【你】，【一】【定】【要】【小】【心】。”【秦】【父】【秦】【母】【后】【怕】【道】。 【秦】【易】【点】【点】【头】：“【爸】【爸】【妈】【妈】，【您】【们】【放】【心】，【天】【下】【没】【有】【人】【能】【伤】【害】【到】【我】。” 【门】【外】【响】【起】【敲】【门】【声】，【秦】【易】【去】【开】【门】，【是】【曹】【琨】。
“【对】，【这】【不】【是】【活】【着】【的】【真】【凤】，【而】【是】【如】【同】【龙】【神】【舟】【那】【般】【的】【存】【在】！” 【一】【个】【身】【着】【绿】【色】【长】【衫】，【鼻】【如】【鹰】【钩】【的】【青】【年】，【此】【时】【摇】【着】【扇】【子】【轻】【笑】【道】。 “【绿】【莹】【衫】，【青】【影】【扇】，【莫】【非】【阁】【下】【便】【是】【青】【翼】【鹰】【王】，【成】【长】【空】？” 【见】【到】【绿】【衫】【青】【年】【的】【模】【样】，【很】【快】【便】【有】【人】【将】【他】【认】【出】【来】【了】。 【毕】【竟】，【纵】【然】【在】【整】【个】【三】【界】【之】【中】，【身】【穿】【绿】【色】【长】【衫】【的】【都】【不】【多】，【而】【其】【中】【的】【成】
“【你】……”【法】【则】【的】【声】【音】【忽】【然】【惊】【疑】【不】【定】【起】【来】：“【你】【并】【非】【筑】【基】【初】【期】！【是】【宝】【物】？” “【对】【啊】。”【对】【方】【乃】【是】【法】【则】，【并】【非】【这】【世】【上】【的】【任】【何】【一】【个】【人】，【聂】【云】【婳】【倒】【是】【没】【有】【太】【多】【顾】【忌】，【径】【直】【望】【向】【虚】【空】【道】：“【是】【幻】【梦】【霜】【花】，【一】【个】【隐】【藏】【修】【为】【的】【宝】【物】。” “【那】【么】，【法】【则】，【你】【既】【然】【并】【非】【是】【这】【世】【上】【之】【人】，【可】【看】【得】【出】【我】【身】【上】【旁】【的】【秘】【密】？” 【聂】【云】【婳】【早】
【顾】【墨】【殇】【说】【完】，【扶】【着】【白】【忆】【离】【开】。 【罗】【烟】【婷】【从】【地】【上】【爬】【起】【来】，【手】【上】【还】【流】【着】【鲜】【血】。【她】【瞪】【着】【他】【们】【两】【个】【人】【离】【开】【的】【背】【影】，【虽】【然】【没】【有】【说】【一】【句】【话】，【但】【是】【牙】【齿】【咬】【得】【咯】【咯】【作】【响】，【眼】【睛】【里】【面】【就】【像】【是】【有】【火】【一】【样】【在】【看】【着】【他】【们】【两】【个】【人】。 【这】【件】【事】【情】，【她】【不】【会】【就】【这】【样】【过】【去】【的】。 “【这】【到】【底】【是】【怎】【么】【回】【事】？【你】【知】【不】【知】【道】【顾】【墨】【殇】【的】【身】【份】【是】【什】【么】？【你】【怎】【么】【能】【够】【得】
【一】【缕】【清】【风】【飘】【过】，【让】【田】【不】【易】【严】【肃】【的】【脸】【上】【忽】【然】【闪】【过】【了】【无】【奈】。 【他】【明】【明】【与】【这】【个】【老】【七】【相】【处】【不】【长】，【偏】【偏】【有】【一】【种】【两】【人】【十】【分】【熟】【悉】【的】【感】【觉】，【就】【如】【同】【张】【小】【凡】【知】【道】【他】【脾】【气】【不】【好】，【吃】【软】【不】【吃】【硬】。 【而】【田】【不】【易】【也】【知】【道】【张】【小】【凡】【这】【个】【徒】【弟】，【脾】【气】【倔】【强】【得】【跟】【牛】【一】【样】，【十】【个】【人】【拉】【都】【不】【回】【头】【的】【那】【种】【脖】【子】【硬】。 “【你】【好】【自】【为】【之】【吧】” “【我】【懒】【得】【管】【你】