A_few_months_after_bariatric_s1.pdf

18 6.6.21 Photo illustrations by Ina Jang

Diagnosis By Lisa Sanders, M.D.

The 21-year-old woman stood at the
sink washing the bottles her baby went
through that day. She was exhausted. As a
plastic bottle fi lled with water, it sudden-
ly felt strangely heavy. Her hands began
to shake from the strain. She felt her
legs threaten to buckle beneath her and
grabbed the counter to keep from col-
lapsing. ‘‘Mama, help me,’’ she called out.

The young woman had been to Griffi n
Hospital, in nearby Derby, Conn., twice
in the last two weeks. Since having bar-
iatric surgery three months earlier, she
had vomited several times a day, almost
every day. She had been excited about
the surgery but had no idea it would be
this bad afterward. Sure, she lost weight:
nearly 50 pounds. But she felt just awful
since the operation, and lately the nausea
and vomiting were even worse.

Her mother persuaded her to go back
to the hospital. She helped support her
daughter’s weight as they walked to the
car. Along the way, her daughter said she
could barely see the ground. Every object
was fuzzy, the whole world out of focus.

In the E.R., the young woman wasn’t
surprised to hear that her potassium was
dangerously low or that a test of her kid-
neys showed that she was severely dehy-
drated. It’s what she was told the last two
times she was there. This time, though,
the decision was made to admit her.

The next morning the patient’s potassi-
um was normal; so were her kidneys. But
she was still too weak to get out of bed. And
the world still looked blurry. Her mother
demanded to know why she wasn’t better.
The doctors weren’t sure. Potassium is one
of the electrolytes muscles depend on to
do their work. But once it was replenished,
her strength should have returned. And so
they called in the neurology team.

↓
Paralyzed Eyes

Dr. James Butler was the neurologist
seeing patients in the hospital that week.
The young woman looked tired; her face,
impassive. She was slow to respond to
the doctor’s questions, but when she did,
her answers were reasonable. She wasn’t
confused, just tired, and — based on what
she’d told the E.R. doctor — depressed
by how awful she felt since her surgery.

Butler’s examination of the patient
focused on her nervous system. Three
abnormalities concerned him. First,
she didn’t seem to be able to move her

A few months after bariatric surgery,
the young mother found herself
cripplingly weak, her eyes unable to
focus. Did the operation cause this?

19

eyes. ‘‘Follow the light with your eyes,’’
he instructed her as he moved a penlight
to the right and the left, up and down.
But she didn’t. She couldn’t, she told him.
And when he asked her to smile — a way
of testing facial-muscle strength — it was
a pale whisper of a smile. Was she too
depressed to participate in the examina-
tion? Or was this real weakness?

Despite her complaints of feeling weak,
her arms and legs seemed strong. She
could move her arms and legs even when
he tried to hold her in place. Yet when he
tapped her knees, ankles and the backs of
her elbows, she had no refl exes. Tapping
these locations causes a jerk because of
a rapid-transit nerve circuit between the
tapped tendon and the spinal cord. Loss
of this refl exive jerk usually indicates an
injury somewhere in the system.

All the tests they sent out once her
potassium and fl uids were replaced came
back normal. An M.R.I. of her brain and
its blood vessels was also normal.

But clearly, her condition was not nor-
mal. Butler was particularly struck by the
eye exam. You could have paralysis of one
of the six muscles that move the eye; but for
all of them to be paralyzed, so that virtually
no movement was possible? That would be
extremely unusual. But he couldn’t believe
this was a manifestation of her depression.
He had seen patients whose depression
made them feel that they couldn’t move
their arms or legs — but eyes? Never.

There was another possibility, though
an unlikely one. A rare disease called Miller
Fisher syndrome (M.F.S.), an autoimmune
disease that is a variant of Guillain-Barré
syndrome (G.B.S.), aff ects the muscles of
the eyes as well as those of the face, arms
and legs, the usual target of G.B.S. Like
G.B.S., it is often linked to a recent infec-
tion. This type of autoimmune dis can
be caused by antibodies created to fi ght off
the infecting bug, which then, mistakenly,
start to attack the nerves of the body. But
this patient hadn’t had an infection.

Now deep into his career, Butler had
seen many patients with G.B.S. as well as
a few with M.F.S. Vomiting wasn’t part of
the usual picture. But Butler recalled one
patient he saw years earlier, when he was
an intern, who had M.F.S. and who had
come to the hospital with severe vomiting
— just like this young woman. He never saw
another case like it. But it’s good to be thor-
ough. He ed the blood test to look for
the antibody associated with M.F.S.

↓

A Confounding Test Result

Butler’s associate, Yaniv Chen, took over
at Griffi n later that week. He reviewed the
patients his partner had been following
and then went to see them. The young
woman had gotten out of bed and taken
a few wobbly steps. Her steps were pain-
ful, even though her feet felt numb. ‘‘Am
I going to die?’’ she asked the new doc-
tor. Chen reassured her. He thought his
partner’s suspicion that it might be M.F.S.
was probably right. This disease, while
serious, is not usually fatal, and over time
most patients recover fully.

On exam, the patient had all three of
the characteristic symptoms of M.F.S. Her
eye muscles were still paralyzed. She still
had no refl exes. And now that she was
able to get out of bed, it was clear that
her walk was abnormal.

Still, there were other possibilities. Was
it some version of Lyme disease? This was
Connecticut, after all. Or was it one of the
several viruses that cause encephalitis?
Could it be a diff erent type of autoim-
mune disease — maybe myasthenia gravis?
Although also rare, this frequently starts
in young women. He looked for each of
these. But even before the results came
back, Chen was pretty confi dent that the
patient had M.F.S. He started her on a fi ve-
day course of intravenous immunoglobu-
lin — antibodies taken from donors — the
usual treatment for both G.B.S. and M.F.S.

Most of the results came in over the
next few days. It wasn’t Lyme or one of
the viruses that attack the brain. It wasn’t
myasthenia gravis. But it was weeks before
the test for M.F.S. came in. And that test
was also negative. That surprised Chen.
This was a reliable test. So maybe it wasn’t
M.F.S. after all. But what else could it be?

↓

Nutrient Deficiencies?

Bariatric surgery often results in nutri-
tional defi ciencies. And she’d been vom-
iting for months; that, too, depletes nutri-
ents. Her presentation, with its strange
eye paralysis and loss of strength and
refl exes, wasn’t typical of any of the single
nutritional defi ciencies Chen could think
of. But perhaps she had multiple defi cien-
cies and together they caused this unusual
constellation of symptoms.

He ed tests to assess the levels of
the vitamins and minerals known to be
aff ected by bariatric surgery that could
cause weakness: vitamins B12, B1, C, D and
E, zinc, copper. Once the tests were drawn,
he started her on replacement levels of
these vitamins. Those test results were also
unsatisfying. The B12 and thiamine (B1)
were normal. So were the zinc and copper
levels. Her vitamin C was undetectable,
and her vitamin A and D were low; she
was already on a high-dose multivitamin,
so those were covered. But he wasn’t cer-
tain these vitamin defi ciencies would have
caused her symptoms. And if they had,
she should have gotten better once the
vitamins were replaced. She didn’t.

And so, Chen found himself back where
he started: Could this be M.F.S.? Every-
thing favored that diagnosis except the
test. The test is accurate 85 to 90 percent of
the time. He suspected a false negative, but
it was impossible to know for sure. In any
case, she had been treated for M.F.S., and
over the course of her time in the hospital
she started, slowly, to improve. Finally she
was discharged to a rehabilitation hospital.

The patient, now home, tells me that
her recovery has been maddeningly slow.
She had to relearn everything, from eat-
ing with a fork and writing with a pen to
simply walking. At this point, six months
since returning home, her eyes only both-
er her when she’s tired. She uses a walker
less and less. She’ll feel like she’s really
recovered, she says, when she can stand
and pick up her child. She’s not there yet,
but soon, she thinks. Very soon. �

Lisa Sanders, M.D.,

is a contributing writer
for the magazine. Her
latest book is ‘‘Diagnosis:
Solving the Most Baffl ing
Medical Mysteries.’’ If
you have a solved case to
share with Dr. Sanders,
write her at Lisa
[email protected].

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