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Posted by Dr. Sushrut Jangi March 18, 2013 09:26 AM
This is the case of a real patient. After reading the description of the case, I invite you to guess the patient's diagnosis in the comments section below. The answer will be posted Friday.
Why Was This Boston Marathoner Suddenly Out Of Shape?
Next month, nearly 30,000 people will run the annual Boston Marathon, although D isn't planning on running it this year; he's still recuperating.
For a long time, people have known that long races can be traumatic to the body.
During the running of the first Boston Marathon in 1897, doctors waited at the sidelines, anticipating that runners might collapse or suffer permanent heart injury. Perhaps they were reminded by the case of a famous Athenian athlete: around 500 BC, a man named Phidippides ran twenty-six miles across the Plains of Marathon to announce to the city of Athens that the Greeks had triumped over the Persians. Soon after delivering the message to the joyful city, he fell dead, presumably from cardiac strain. Even now, 115 years after the first Boston marathon, many hospitals prepare for a mass influx of patients, anticipating that runners will come into emergency rooms with heat exhaustion, dramatically low sodium levels, and dehydration.
"My doctor actually told me to stop running because it was hard on the body," says D. Up until recently, he was in great shape: he completed 3 marathons and several half-marathons throughout the country. His exuberance in fitness carries over into his attitude: he's a cheerful guy - in his mid 40s, quick to joke and nonchalant in conversation. Exercise was a part of his life: he lifted weights at the gym on Monday, Wednesday and Friday, then ran or bicycled on alternative days. He never thought that practiced routine would ever change.
But it did.
One day, after returning home to Boston from a motorbiking trip in West Virginia, he climbed a single flight of stairs and found himself completely exhausted. "At the top of the flight, I was completely out of breath," he says. "I couldn't believe it. I felt like I was breathing through a straw." Although he had bouts of asthma in very cold air, he'd never had any lung problems. "Never smoked," he told me. Knowing nothing about off-road motorbiking, he told me about an excursion in West Virginia he went on before he fell ill: "Basically," he says, "you take a motorcycle into the woods. It's got knobby tires so you can drive over roots, rocks, stumps, tree logs." But he couldn't remember anything going wrong during the trip. It was only after he was back at home that the shortness-of-breath descended upon him.
The feeling began to scare him.
The sensation of an inability to breathe is frightening; depriving a human of oxygen elicits a primal fear response similar to a panic attack. People who are short of breath may describe an overwhelming hunger for air. We borrow from the Greeks again when doctors call this distressing sensation dyspnea. If the sensation occurs after physical activity, it's called dyspnea on exertion. "I started to have lots of fearful thoughts about what this could be," he said. "I broke down and called my primary care doctor."
His PCP knew him well. "He's a fit guy," the doctor told me. "It was unusual to see him unable to exercise." His doctor checked his peak flow, a test used to detect an asthma attack. Negative. He then put a pulse oximeter on his index finger and had him walk around the room. Normally, oxygen levels will read near 98 - 100%. Upon walking, his oxygen fell to 88% - concerningly low for a healthy man, and a successful marathoner at that.
A chest x-ray was normal. Other than dyspnea, D had no other complaints - no fever, no loss of weight, no cough, no pain in his chest. Nevertheless, his primary care doctor obtained an electrocardiogram. What he saw in the tracing was alarming.
Why was this Boston marathoner suddenly out of shape?
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About the authorSushrut 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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