A 61-year-old woman lifted a laundry basket and stared grimly at the stairs leading up from the basement. It felt like the climb was getting tougher day by day. Before she was halfway up, she felt her heart pounding and heard heavy, rapid breathing. She also held onto the wooden railing in case she started to feel lightheaded. Once she reached the main floor of her home, she let her burden go and nearly cradled softly on her living room couch.
A few months ago, the woman first noticed that she often felt short of breath. She wondered if it was because of her weight. She liked the way she looked, but her regular caregiver, a highly trusted nurse in the Yale Medical School medical group, said she would be happy if she lost a few pounds. I doubted it. Her daughter was worried that the cause of her shortness of breath was the COVID-19 she had suffered years ago.
She finally called the PCP office when her right leg started hurting. The combination of her shortness of breath and the pain in her leg made the nurses worried that the patient had a blood clot in her leg that had broken off and lodged in her lungs. She sent her to have an ultrasound of her leg. She was relieved she didn’t have a blood clot, but she was still short of breath.
Referral to Long Covid Center
Since then, she seemed to get video consultations almost every week. Each visit focused on the most recent of her various symptoms. One week she was so dizzy that she had difficulty walking. The following week, she shared her concerns about her recent weight loss. She lost 10 pounds in just 2 weeks. Another time, she met a doctor who worked with her nurse. When facing her on the other side of her linked computer, the doctor suggested that the lightheadedness was caused by not drinking enough water. Her shortness of breath and her elevated heart rate were probably due to her lack of exercise. At her next video visit, her nurse said she might have POTS, which stands for Postural Orthostatic Tachycardia Syndrome. In this rare disorder, patients experience a rapid heart rate or tachycardia every time they stand up. Occasionally seen in patients who have recovered from COVID-19.
More tests were done with each new concern. She had an ultrasound and a chest x-ray. Her echocardiogram showed that her heart was beating normally. And a 24-hour heart-tracking wearable device called a Holter monitor only showed that her heart was beating fast at times. She had an MRI of her brain, a CT scan of her chest, and lots of blood work. After all this, the patient was frustrated and horrified that no one could explain why he suddenly felt so unwell in so many ways. She was referred to a neurologist, a cardiologist, and Yale University’s Long Corona Multidisciplinary Care Center.
She was first seen at the Long Covid Center, where I am the medical director. That April morning she told me she was out of breath all the time. She had to quit her job as a cashier. Her eyes lit up as she spoke of her rapid decline. Her heart and lungs have already been extensively examined, and her only abnormality was seen on a Holter monitor examination. Like her practitioner, I wondered if she had developed her POTS. Indeed, POTS was something that was regularly seen in patients with long periods of Covid.Recent Studies estimate that up to 14 percent of patients developed POTS after recovering from COVID-19.
This fault can be diagnosed using something called an active stand test. The test monitors heart rate and blood pressure while the patient is lying on his back and while he stands in place for 10 minutes. POTS is diagnosed when the heart rate increases by at least 30 beats per minute and the blood pressure remains stable.
Within minutes of taking the test, the patient developed lightheadedness and shortness of breath, and the test had to be stopped early. Her heart rate increased from her 101 to 140. POTS is not well understood, but is thought to represent damage to the autonomic nervous system. Normally, the act of standing causes a rapid increase in blood from the legs and lower body to the heart, allowing it to be redistributed to the upper body and brain. With POTS that doesn’t happen. Your heart must beat fast (usually much faster) to supply enough blood to your brain. In this patient, like many others I have seen, the heart rate is not sufficiently elevated and the patient feels dizzy. POTS often appears after a viral infection. Although there are effective drugs, the first treatment is to increase the amount of water stored in the body and use compression garments to draw blood from the legs back to the heart.
I wasn’t sure if all of this patient’s symptoms were due to POTS, but I thought treating POTS was the right first step. I encouraged her to drink more of her water and prescribed her clothes as she needed them. Two weeks later, when she reported that her heart was still pounding, I started giving her drugs to slow down her heart.
A few weeks later she returned to the office. Her heart condition has improved, but she has lost weight, she said. She “looks in her mirror and can barely see her own face.” Her normally plump and round cheeks looked flat and firm. She lost her 25 pounds her weight in her 3 months. So I stopped. Her weight loss was not a normal symptom of her POTS. Was the diagnosis wrong?
Critical step skipped
Suddenly her symptoms took a completely different shape. I had speculated about her case based on the fact that the doctors who referred her to our center thought her symptoms were due to the long-term effects of COVID-19. . But the truth is, none of us knew if she had been suffering from COVID-19 for a long time. There is no definitive test to link your current symptoms to the COVID-19 you experienced weeks, months, or even years ago. The first reports of symptoms persisting after contracting the virus were published in April 2020, just months after the virus reached the United States. And since then, various symptoms have appeared. However, the association between symptoms and hypothetical causes was temporary. Only patient experience can suggest relevance. However, like many diseases for which there are no definitive tests, this is a diagnosis made only after other possibilities have been ruled out. In examining this patient, I skipped that crucial step.
She was a middle-aged woman with a pounding heart, shortness of breath with any exercise, and rapid weight loss. This is a classic symptom of excess thyroid hormone, a condition known as hyperthyroidism. This tiny gland in her neck is part of a complex system that controls the body’s metabolism. When too much thyroid hormone is released, your body’s engine spins, as if someone had stepped on the accelerator and not let it go. She had all the symptoms of hyperthyroidism and I didn’t see it at all. I sent her out of the office to her lab down the hallway. Within hours, it became apparent that her body was filled with these hormones.
I immediately called the patient and explained that despite the positive active stand test, it was probably not POTS, but a thyroid disorder instead. It is usually the result of an autoimmune disease known as Graves’ disease, in which antibodies bind to thyroid receptors, mistaking these normal cells for attacking invaders, and causing a near-continuous release of that hormone. cause Even before the diagnosis of Graves’ disease was established, the patient was started on drugs that block hormone production.
I’ve spent the last 20 years writing and thinking about diagnostic errors. And I understand how this happened. In medicine, most diagnoses are made through a process of cognition. We see something, perceive it, and act on what we see. Most of the time we are right. most of the time. I asked this patient to take a picture and put it on his desk. I hope you remember that not only the first diagnosis that comes to mind is considered.
As for my patients, they have been feeling much better since they started taking these drugs. Her heart rate has slowed down and the stairs in the basement are getting easier. She said her weight loss has stopped, but she doesn’t feel like she’s back to her old self until her cheekbones grow back.
Lisa Saunders, M.D., is a contributor to this journal. Her most recent book is Diagnosis: Solving the Most Baffling Medical Mysteries. If you would like to share a resolved case, please email Lisa.Sandersmdnyt@gmail.com.
