Why Was This Patient Turning So Yellow?

By morning the man was feeling better. He must have loosened the clogged gallstone and moved on. As he sat on his bed reading his cell phone, he noticed a small group of doctors gathering outside his door. A young woman described her own presentation to her emergency room and told what she perceived to be. Then an elderly doctor started talking about jaundice, the yellowing of the skin and eyes. This color is caused by the accumulation of something known as bilirubin, a breakdown product of red blood cells. Normally, as red blood cells are born and die, this dark waste product is always produced at low levels and disposed of. However, there are disorders that can increase bilirubin levels because something is blocking the excretion of bilirubin or causing more red blood cells to break down and produce more bilirubin. In this patient, a blocked gallstone obstructed the flow of bilirubin into the gastrointestinal tract. However, it does not usually cause this type of jaundice. The whites of the patient’s eyes may be slightly yellow, which is where jaundice is most likely to appear. But this man looked yellow everywhere. He had much more bilirubin than expected with gallbladder obstruction. He explained to his doctors in training that our job was to figure out why.

“You think I’m bleeding?” cried the patient from the bed. Silence came as all the faces turned to him. They knew that hemolysis is the destruction of red blood cells. However, this was not a word the patient usually used. The patient got out of bed and walked to the doorway. He could see the unanswered question in their eyes. Although he attended medical school, he actually told the group that he had never been in the medical field.

Dr. Peter Braverman introduced himself and the three doctors in training on the team. There’s another interesting thing, he told patients and trainees. A blood count reveals that this young man is anemic, or has a lower than normal number of red blood cells. It’s rare for men. And the blood cells he has are very small. This is usually seen only in severe iron deficiency or in some abnormalities in the shape of red blood cells. The regular ones are shaped like SweetTarts candies, disc-shaped, with dimples on each side. This shape gives cells maximum flexibility to move through the narrowest capillaries in the body. Other shapes of red blood cells are destroyed at a much higher rate. Jaundice can occur, especially if excess bilirubin is blocked. The doctor said let’s call hematology to solve the mystery of this man’s blood.

Braverman, on the other hand, was intrigued. This young man was in medical training. What did he think of his yellow skin and eyes? The patient looked away in displeasure. In fact he was unaware of it. During the pandemic, he moved in with his parents and was working from home. He was pretty isolated. He didn’t go to his office. He hadn’t met his friend. His elderly parents said nothing. And he didn’t look in the mirror much. Over the last few years, he has noticed that the whites of his eyes are sometimes tinged with yellow. On that basis, he diagnosed himself with Gilbert’s Syndrome, a benign disease caused by not having enough enzymes to break down bilirubin. People with Gilbert disease may have yellowish eyes, especially during physical or emotional stress, because red blood cells break down more quickly. But he did not associate the occasional yellow reflection in the mirror with bouts of abdominal pain. And he had never been so yellow.

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