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A Little Girl with Puffy Eyes
Saturday, March 29, 2008
(Chase's dictation taken by Jenny)
Late one afternoon after clinic was closed Doctora Nelson came to me to tell me about a patient of hers who she had scheduled to follow up with the next day. The patient was a little girl, 8 years old, with bilateral periorbital adema (eye swelling) for the past 2 months. Doctora Nelson had checked her kidney function and found it to be normal. She said, "I found her liver enzymes were elevated, but checked a liver ultrasound and it was normal. She's had no other lab abnormalities." The patient had traveled to Shell from the jungle, and her mother did not want to return to the jungle until an answer was found. Doctora Nelson was not going to be in clinic the next day, but her husband Doctor Nelson would be. She said that I didn't need to feel I had to figure this out - I could call Dr. Nelson and we could try to formulate a plan together the next day.
I tried to read on patients as much as possible but I had not researched any articles for this patient when I went to bed that night. I couldn't sleep, and felt that God was telling me to get up and read. So, I read for about three hours that night on periorbital adema. The differential diagnosis is not particularly large - it includes kidney disease, leishimaniasis (a parasite similar to malaria commonly seen in the jungle of Ecuador), juvenile dermatomyositis, and a few other things. I read through approximately 10 Up to Date articles and looked at pictures until I was too tired to continue.
The next day the little girl with puffy eyes came to see me. I asked her about any other symptoms. She'd had problems with constipation, abdominal swelling, proximal muscle weakness (shoulders and thighs), little white spots on her chest and back, and the swelling around her eyes presented first with purple discoloration on her eyelids. The purple had been slowly fading as the swelling persisted in both eyes. It was this last symptom reminded me of a picture I'd seen the night before. I pulled the picture up on the hospital computer and had the patient's mother look at it - she said that was exactly how her daughter's eyes had looked. I ordered some confirmatory labs (LDH and CK), both of which came back extremely high. These labs confirmed there was a muscle breakdown disease and we started the patient on a steroid - prednisone - to reduce her body's autoimmune attack on her muscles.
Praise God for using me to help figure out what was going on with this little girl by waking me up in the middle of the night and prompting me to go and read! I know that I'm smart to have made it this far in medicine, and I know that I had to use some good ol' fashioned elbow grease and do the reading, but it was clearly a Divine urging that led me to the right answer. It has been amazing to see God work in this and other cases during my time in Shell.
Thebault, MD
Posted byJennifer Thebault at 8:35 AM