He Had Chest Pain and Dangerously Low Blood Pressure. What Was Wrong?
Could a wayward breath mint have caused his symptoms?,
The young woman was awakened by the screams of her 39-year-old husband. “Please make it stop!” he shouted, leaping from the bed. “It hurts!” He paced back and forth across the room, arms crossed over his chest as if to protect himself. Two days earlier, he had inhaled a breath mint when his wife startled him. He felt it move slowly down his throat as he swallowed repeatedly. His chest had hurt ever since. But not like this.
The man squirmed miserably throughout the short drive to the emergency room at Westerly Hospital, near the Rhode Island and Connecticut border. No position was comfortable. Everything hurt. Even breathing was hard. Although the doctors in the E.R. immediately determined that the young man wasn’t having a heart attack, it was clear something was very wrong. His blood pressure was so low that it was hard to measure. A normal blood pressure may be 120/80. On arrival, his was 63/32. With a pressure this low, blood couldn’t get everywhere it was needed — a condition known as shock. His lips, hands and feet had a dusky hue from this lack of well-oxygenated blood. He was given intravenous fluids to bring up his pressure, and when that didn’t work, he was started on medications for it. Three hours later, he was on two of these medicines and his fourth liter of fluid. Despite that, his pressure remained in the 70s. He had to be put on a breathing machine to help him keep up with his body’s demand for more oxygen.
The most common cause of shock is infection. But this man, as sick as he was, had no signs of infection. The medical team started him on antibiotics anyway. Could the painful mint have torn his esophagus? Up to 50 percent of patients with that injury will die. A CT scan showed no evidence of perforation or of fluid in his chest. What else could this be? There was no sign of a clot keeping blood from entering the lungs, another cause of deadly low blood pressure. An ultrasound of the heart showed that he had some fluid in the sac called the pericardium, which contains and protects the heart, but not enough to interfere with how well it was beating. He was tested for Covid and for recreational drugs — both negative.
The doctors in the small community hospital began to worry that they wouldn’t figure out what was going on with this young man in time to save his life. They reached out to Yale New Haven Hospital an hour and a half away, which was better equipped to handle tough cases. Dr. Laura Glick, a resident finishing her second year of training at Yale New Haven, heard about this pending transfer and looked him up in the electronic medical record shared by the two hospitals. The patient was getting a CT of his abdomen and pelvis. Could there be a hidden infection there? As she read through his chart, an event note popped up. The patient’s heart had stopped while he was in the scanner. Was he going to die before he even got to Yale?
His rapid deterioration — from a previously healthy young man who had walked into the E.R. complaining of severe pain a few hours earlier to someone who had “coded” while being scanned — was terrifying. More notes appeared. CPR was started, and after about seven minutes, the man’s heart began to beat on its own. More notes: He was awake. He was able to answer yes-or-no questions, though the breathing tube kept him from speaking. He was loaded into the transport helicopter and flown to Yale New Haven.
Glick estimated she had 20 minutes, maybe a little more, to figure out how to save this dying man. She reached out to the I.C.U. specialist in training, Dr. Stella Savarimuthu. There are only a few things that can kill you this fast, Glick acknowledged, and at Westerly they’d done a good job of ruling out most of them. She listed other possibilities she was considering. One: If the man had a perforated esophagus, he would need to go to the operating room, so she would alert surgery. Two: Maybe he didn’t have enough cortisol, one of the “fight or flight” hormones, which could cause persistent and dangerously low blood pressure. They would need to check that right away. Three: The only abnormality seen at Westerly was the small amount of fluid around his heart. In medicine, when it really matters, the rule is “Trust but verify.” With a patient this sick, things can change rapidly. When he arrived, she would have cardiologists ready to examine his heart.
A couple of hours later, Glick stood watching the ultrasound monitor. The pixelated gray-and-white image of the patient’s rapidly beating heart muscle was surrounded by an unnatural black halo, indicating the presence of excess fluid in the pericardial sac. The pump was hard at work, but there wasn’t enough room for blood to even enter his heart. No wonder his blood pressure was so low.
The patient was moved to the O.R., and a cardiologist inserted a thick needle into the fluid-filled sac. Just under a cup of pale yellow liquid poured out. On the screen, the halo shrank until it disappeared. His doctors would still need to figure out why he had this fluid in the first place, but now that it was gone, his blood pressure should return to normal.
Back in the I.C.U., Glick followed the patient closely. Hours passed, then days, and though his blood pressure was better, it remained too low. Why? Glick sent test tube after test tube to the lab, looking for signs of infection, inflammation, autoimmune disorders — everything she could think of. After the man’s near-death experience, Glick knew that many of his lab results would be abnormal. His liver was damaged, his kidneys, his heart. Her job was to identify which abnormalities were a result of his rapid deterioration and which were the cause.
Aberrant results streamed in, but only one surprised the resident. The man’s thyroid wasn’t making its essential hormone. The thyroid is like the carburetor in an old internal-combustion engine. It tells the body when to rev up and when to slow down. Right now the man’s body needed to be fully revved up, but without this hormone, it couldn’t do it. Before giving the man replacement hormones, Savarimuthu reminded Glick they had to recheck his cortisol level. They had checked it when he arrived, and it was high — as expected, given the physiological stress he was under. But administering thyroid hormone to someone who is cortisol-deficient is like jump-starting a car that has no oil in the engine. You could ruin the whole machine. So Glick sent off a second cortisol-level test. This time, the level was undetectable. She checked again: undetectable.
The Steroid Test
A different test revealed the cause: His adrenal glands, where cortisol is made, weren’t working at all, just like his thyroid gland. She started the man on steroids — an artificial form of cortisol — along with thyroid hormone, and consulted the endocrine team. She then reviewed the records from Westerly, where she saw, buried deep in his chart, that he had been given steroids there. Because he wasn’t deficient when he arrived, and they hadn’t mentioned the steroids in their notes, Glick hadn’t administered them at Yale New Haven. She now turned to the medical literature to figure out just what might have caused these devastating twin hormone deficiencies.
It didn’t take long to determine that he must have autoimmune polyglandular syndrome Type 2. In this rare disorder, the immune system suddenly and mistakenly starts to attack parts of the patient’s own body — in this case, the thyroid gland and the adrenal glands. Why this happens is not well understood. A few hours after getting both replacement hormones, the young man was well enough to begin tapering the medications sustaining his blood pressure. A couple of days later, he was well enough to leave the I.C.U. Ten days later, he was able to go home.
Once the patient understood what he had and started to feel the benefit of the treatment, he realized he’d been sick long before that mint went down wrong. He will have to take these hormones for the rest of his life, but he feels better than he has for years. No one can be certain exactly when his glands were destroyed; it was probably long ago. “I’m not a guy who goes to the doctor,” he admitted. He thought he was just getting old: “You know what they say — after 30, it’s all downhill.” But not anymore. Not for him, anyway.
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 with Dr. Sanders, write her at Lisa.Sandersmd@gmail.com.