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Not an ordinary case of traveler's diarrhea

Posted by Dr. Sushrut Jangi  January 14, 2013 07:00 AM

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This is the case of a real patient treated at a Boston-area hospital. After reading the description of the case, I invite you to submit a comment guessing the cause of the patient's symptoms. The answer will be posted Friday.


"I was a nurse for 39 years," she says, "but that didn't help me figure this out at all." Mrs. C has been haunted by debilitating symptoms for more than a decade -- since her mid-50s, she says. She's been seen by several doctors and has wracked her own brain for answers, considering various exposures, angles, and ailments. 

Mrs. C is a lively, resilient, and adventurous woman. "My husband's job often required him to travel," she says. "We were chaperones along with another couple for a group of 20 teenagers on a trip to Haiti. The other lady had severe dysentery while there. She thought it was from eating salad containing unwashed lettuce. She's the one where I first heard the expression about passing 'cut glass' with diarrhea. That's how I'd describe my episodes as well." 

For more than a decade, Mrs. C has had random, intermittent, and worsening episodes of diarrhea. "There's no warning," she says. The episodes occur completely out-of-the-blue, with no preceeding cramps, nausea, or vomiting. She never passes blood or has much gurgling or indigestion. What she eats doesn't seem to matter. "The worst part was it became a social problem."  Always on the move, Mrs. C describes her numerous responsibilities -- a part-time nurse, a mother of three, a church-goer and volunteer. "I was very active," she says, "and now I had to bring extra sets of clothes wherever I went, and heavy pads in case there was an accident. Things were horrible whenever I had to travel or fly." 

Things became almost unbearable within the last year. She lost more than 30 pounds, with no appetite. "And I started having these episodes at night -- sometimes I was on the toilet for more than an hour. It felt just like that lady in Haiti had said -- like passing cut glass." While she was sitting there on the toilet, there was only one thing that kept circling in her mind. "This is no way to live," she thought. 

Mrs. C had thought about getting evaluated several years earlier, when her symptoms had gone on for so long. Unfortunately, she was diagnosed with breast cancer, which required a mastectomy, chemotherapy, and radiation. "It took a year to get myself back together after that," she says, explaining that she sort of letting her gastrointestinal symptoms go over that period.  But in the past year, as her symptoms got increasingly disruptive, she needed to find an answer. 

At the gastroenterologist's office, she awaited the results of several tests. One of them was an endoscopy (see results below). Her mind reeled with the possibilities. She thought back to her travel experiences: "We were very careful about what we ate [in Haiti] even to the point of refusing Coca-Cola that had been poured into glasses in the Haitian homes we visited." She remembered her trip to China and Inner Mongolia. "I was in China in 1990, before the symptoms had started. I had eaten several things from the street vendors -- none of which I liked -- and by the time we returned to Beijing, I'd lost seven pounds. But I don't recall worrying about any one particular incident," she says. That trip to China, she points out, was the trip closest to the onset of her symptoms.

Last year, her gastroenterologist started her on several antibiotics, none of which worked. All the tests for infectious diseases returned negative. She was treated with Asacol, a medication used for inflammatory bowel disease -- with no effect. She tried yogurts, probiotic capsules. Nothing helped -- in fact, over the last few months, things just kept getting worse. Finally, for the first time, her doctor had a breakthrough. The gastroenterologist ordered a single test that led to Mrs. C to experience severe stomach pain, burning, and gas. Fortunately, the same test also pointed to the answer to a decade-long mystery. 

What was Mrs. C's diagnosis? 


Click on the "Comment on this story" link below to post your guess and your reasoning. I'll post the answers on Friday.


 Endoscopy Results:

Screen Shot 2013-01-10 at 10.48.32 PM.png

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

Sushrut Jangi is an internist at Beth Israel Deaconess Medical Center and an editorial fellow at The New England Journal of Medicine. More »

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