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Is Running the Boston Marathon Good for You?
Most of us have heard of Jim Fixx - the celebrity author of The Complete Guide to Running who got America hooked onto jogging. Ironically, he died of a sudden heart attack at a young age of 52 after one of his daily runs and was found to have extensive blockages in the coronaries supplying his heart.
Every so often, we hear of athletic tragedies - last fall an 18 year old lineman fatally collapsed after a tackle at his team's homecoming game from a heart arrhythmia. And just this weekend, a 24 year old died during a half-marathon in Berlin, according to preliminary reports.
But such dramatic stories - however haunting and unfortunate - don't stop Americans from making vigorous exercise a part of their lives. A decade ago, about 1 million people participated in long-distance races each year. As of 2010, that number has climbed to 2 million. Here in Boston, about 10,000 people registered for the Boston Marathon in 1992; last year that number more than doubled to nearly 22,000 participants. That the popularity of marathons continues to increase is no surprise. Even though Jim Fixx is long gone, the legacy of his lifestyle is apparent in the average Bostonian. On many of the city's street corners we find evidence of this perpetual health renaissance: yoga centers are as common-place as coffeehouses, organic fruits are sold at Downtown Crossing even in the dark of December, and thousands of joggers brave the ice along the Charles River in mid-winter. Recently, Forbes Magazine rated Boston the third-healthiest city in the country. We've begun to believe that attaining good health requires constant, even aggressive attention to the condition of the body. The lifestyle of the marathoner - the long, dutied morning runs, the loyalty to a good diet, and participating in the annual day of reckoning, is a homage to challenging the self and bringing us closer to our ideal health. But is running a marathon - in actuality - good for us? Or are the apparent dangers the media intermittently reports a kind of warning?
To find out, I went to see Dr. Baggish, a young and bright cardiologist at MGH who is also the associate director of the Cardiovascular Performance Program. His clinic is anything but ordinary. The seats in his waiting room, for the most part, are occupied by athletes young and old. Among his patients are marathoners, mountain-climbers, and competitive bicyclists. Many come into his clinic armed with reams of data from their Garmin and Polar Heart Rate Monitors, a collection of physiologic parameters and race performance times exhaustively organized into spreadsheets. "Most of the patients I see are highly motivated," he laughs. But although Dr. Baggish is no stranger to the language of athletics (he has run 30 marathons himself), he is not seeing his patients to compare long-distance times. Instead, he is systematically searching his patients for red flags, early signs that suggest an athlete may be at high risk for heart disease. "Being athletic," he warns, "in no way grants you any kind of immunity."
When the Boston Marathon first began more than a century ago, the doctors of yesteryear were actually really worried. They considered marathoners akin to astronauts or pioneers, crazy people full of bravado who were testing the limits of the human physique. Consider the medical paranoia in this 1903 report from The New England Journal of Medicine documenting the race that year:
The course covers a rolling country, one or two hills, notably in Newton, being extremely long and trying. Each contestant is accompanied by an official guard on bicycle, usually a volunteer from the Ambulance Service of the State Militia. At the end of the race, they were taken in the elevator to the dressing rooms of the clubhouse and immediately examined.
Although we no longer have personal escorts for every marathoner in 2013, the Boston Marathon is still taken seriously by the medical community. A station is set up every mile along the route with supplies for first aid along with cardiac defibrillators. Some of the stations have bags of intravenous saline, EKG machines, and computers that can analyze blood chemistries in seconds. "We have the ability to track every runner, medically," says Chris Troyanos, the medical coordinator for the event. "There are barcodes built into bibs and wristbands. We know when runners check into emergency rooms at any of the Boston hospitals. We know when they check out." The ten hospitals along the route are on high-alert; their emergency rooms declare the Boston Marathon a "mass casualty event," the same category reserved for bioterrorism or natural disasters. Clearly, more than a hundred years later, it appears the medical community is still worried. Why are we so cautious?
Dr. Baggish ran his first marathon in 1997 when he was twenty-one years old, years before he became a doctor. He had no concerns - he says he was blind to the concept of risk. Nowadays, he has changed his perspective a bit. Of all the athletes he sees in his clinic, many - like him - will go on to run dozens of marathons without a problem. But among those athletes, there are a select few who are high risk for experiencing an event. "I've seen many of these people who have gotten into trouble with real heart disease," Dr. Baggish says. He refers to the exercise paradox: that exercise is the best way to reduce cardiac disease, but a cardiac event is most likely to occur during exercise. "A marathon is not inherently dangerous," he says. "But if you are already at risk for a heart attack, the marathon might bring it out."
Okay - then how to figure out who is at risk before such an event occurs? Dr. Baggish shrugs, implying that it's not easy to figure that out. The common symptoms of heart disease - chest pressure, shortness of breath, nausea - are often absent in devoted athletes. Instead, he says, the signs are more subtle. For instance, when Dr. Baggish reviews the performance times and heart rate spreadsheets his athletes so dutifully document, he looks for sudden changes in exercise habits: a sudden drop-off in performance or a new heart-rate trend. Most at-risk athletes do have traditional risk factors, like high cholesterol or high blood pressure. But many will forego getting treated, expecting their vigorous exercise regimens will afford them protection. In other words, athletes often wear a veil of immunity that does not really exist. "These people end up getting missed," Dr. Baggish says.
Now, with the upcoming Boston Marathon next week, Dr. Baggish's vigilance has been kicked into high gear. He offers a set up of tips for every runner. He urges respecting periodicity, or ensuring that runners build up towards the marathon, with equal periods of exercise and recovery. Similarly, he directs attention to warming up and cooling down. "The body hates abrupt starts and stops," he says. On marathon day, he asks runners to adjust their expectations according to what the day brings to them. For example, during last year's marathon, the temperature rose to nearly ninety degrees Farenheit, a situation that prompted organizers to offer participants an automatic requalification for 2013 if they opted not to run in the scorching heat. Most runners ran anyway. "You should be willing to change your routine on marathon day if necessary," Dr. Baggish reminds everyone. Finally, if you're sick with a virus, even something as slight as a cold, he suggests staying at seventy percent of the maximal heart rate.
Despite his suggestions, some will go to emergency rooms or will have trouble during the race. The chances of something extreme happening - like a heart attack - are exceedingly low. According to his group's study, the chances of a runner experiencing a cardiac event during a long distance race is 1 in 184,000. "You're more likely to die in a car crash going to and from the event," Dr. Baggish says. Still - the best thing runners can do to minimize such an event is to avoid a surge of activity during the last few miles of the race. When heart attacks do occur, its often in the last quarter, when participants decide to push themselves harder, a practice that can lead to undue strain on the heart muscle.
The Boston Athletic Association, which hosts the annual race, is obviously aware of the potential dangers of long-distance running. The BAA sends out emails to all participants on how to avoid heat stroke or overhydration. "We even teach the runners to pay attention to each other, so that if someone goes down, they can help start CPR," Troyanos says. "We're the first marathon in the country to do that." This year, in 2013, they have more medical cots than ever before, in part to reduce the strain on the local hospitals. Dr. Baggish will be at the front-lines to help provide medical assistance to anyone in need. But despite his calls for caution, he does not want to discourage the practice of running marathons. "Yes, every so often, there is a tragedy." But such events are still rare. "There is so much good that comes from this lifestyle," he says, his face brightening.
I won't be running the marathon this year - I get shin splits (whatever those are). But I'll be watching. I remember when I was a kid, it was part of my family's tradition to gather at the sidelines of Route 135 every spring with cut slices of oranges in our hands, until a sweaty marathoner swiped the fruit from our palms. When the runners finally arrived around the bend, their inhalations, the drumming of their feet against the asphalt, and their steady exhalations were the sounds of otherwordly machines. I never considered them flesh-and blood human; to me, they were composed of elbows, pivots, tendons and pistons. Now that I've grown up a bit, I've found that the truth is even more surprising: those who run the Boston Marathon each year (some of whom are my colleagues) are regular, disciplined people who often complete the marathon without any serious problems and go on to run several more. Dr Baggish's enthusiasm is encouraging. "I fully believe," he says, "that routine, consistent exercise and training, including training for a marathon or two each year, is the key to long-term health." Maybe one day, I'll try it myself. For now, I think, opening my notepad, I'm okay writing about it.
Revealed: Why was this Boston marathoner suddenly out of shape?
Several people guessed the answer correctly - exitseven7 figured it out first.
"While I was in there, the technician did a test scan first." He starts laughing. "Turns out that was enough for her. She rushed right in after the test scan, and said 'You need to talk to your daughter.' I knew something was wrong. She told me to sit in a wheelchair and not to move. I couldn't believe it. Just an hour ago, I had been driving down the Mass Pike on my motorcycle!"
D's story is not uncommon - a man in perfect health whose life is suddenly altered by unexpected illness. Susan Sontag, the famous writer and critic, forecast the inevitability and randomness of how disease affects each of our lives: "Everyone who is born," she said, "holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Sooner or later each of use is obliged, at least for a spell, to identify ourselves as citizens of that other place."
Most of us, whether in youth or in older age, will find ourselves grappling with some form of illness and with that territory comes Sontag's unfamiliar kingdom: the waiting rooms of doctor's offices, the dark and the clatter of an MRI machine, the long and dim hallways of a hospital. Such a transition is as dramatic as arriving in a new and unknown country. We respond with a kind of culture shock.
A radiologist called D in the scanning room. "I said - what's up doctor?" D laughs. "But the doctor was totally serious with me. 'This is no joke,' he said to me. 'You're lucky to be alive right now. You've got lungs blocked by large blood clots. If you weren't in the shape you were in, you would have had a really big problem.'"
D had multiple pulmonary emboli - blood clots that usually form in the legs and travel up into the vessels of the lungs. If they are huge, they can interrupt blood flow and cause shock or respiratory failure. Smaller clots can cause breathing problems like D was experiencing; if they are not treated, the symptoms can progress. "I went straight to the hospital and they put me on oxygen immediately," D says. "They started me on a Coumadin," he says, naming the commonly prescribed blood thinner. "I might have to stay on it for life," he sighs.
Pulmonary emboli can happen to anyone. In D's case, they were most likely caused by the long, 12 hour truck ride home from West Virginia to Boston after his motorcycle excursion. "Usually," says Dr. Praveen Akuthota, a pulmonary doctor in Boston, "this happens with prolonged air travel, particularly on very long, trans-oceanic flights that last in the 6-8 hour range. But even just being seated for most of a 12 hour journey puts him at increased risk."
There are other known risk factors for clot formation: cancer, structural problems in the vessels, dehydration, smoking, and certain blood disorders. But immobility, by itself, can be enough. You shouldn't sit in one place too long, Dr. Akuthota says - whether you are at work, driving, or flying. Get up and walk around often. But even then, Akuthota goes on, even if you are mobile and active, you can still get a pulmonary embolus. He points to his chest. I could get one right now.
Thankfully, D's doctor picked up signs that something was critically wrong on the EKG - he had a pattern called right heart strain, which is seen when the heart is pumping harder than usual, sometimes indicative of a clot in the lungs. But things could have gone worse. People can go into cardiac arrest from a pulmonary embolus.
As long as the human body remains complex, medicine will be imperfect, illnesses will strike seemingly at random. There is nothing fair about any of this. But the same flawed mechanisms that bring us into disease sometimes bring us back out again.
D thinks back to the days he used to run marathons. "During the run," he says, "it was a mental game with myself. I had to keep telling myself I could do it, I can do this. I've trained and today's the day to put it all out there."
The words of a marathoner are the same sentiment I've heard from patients who have been affected by illness; these are the words every fighter carries close to his heart.
Stay tuned for a follow-up post which will address the current medical controversies, risks, and benefits of running marathons. The 117th Boston Marathon will be run next month, on Patriot's Day.
Why was this Boston marathoner suddenly out of shape?
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?
FULL ENTRY
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.
Mr. G walked into a mini-epidemic
Isles of White in a Sea of Red
Sometimes, physicians describe a finding as pathognomonic, which means that the finding almost certainly suggest a diagnosis. A good example are the white spots seen on the inside of the cheeks, called Koplik spots, which are quite specific for measles. However, pathognomonic signs are rare. Usually, a diagnosis is riddled with uncertainty. "I took one look at his legs and saw a brilliant erythema," Dr. Golding says. Erythema - a deep, red color of the skin - stood out among Mr. G's signs and symptoms. Woven through the dark red was a faint tracery of a lighter color that Mr. G had referred to as a "fishnet" in appearance. One of Dr. Golding's colleagues, who was from the Phillipines, remembered hearing about a tropical rash that presented as "isles of white in a sea of red," a pattern suggestive of dengue hemorrhagic fever.
Dr. Golding thought this was possible, especially since Mr. G had fevers and a headache, typical of the disease. Although the rash was not pathognomonic, he used it as an anchor to a possible diagnosis. He sent Mr. G's blood to a lab to get him checked for dengue. A few days later, the test returned positive.
Vectors
Dengue hemorrhagic fever has a scary name. But hemorrhage - or bleeding - is rare. Most often, people develop high fevers, terrific headaches, and bone and muscle pain. Because of these symptoms, some people call dengue "breakbone fever." Eventually, the virus is tackled by the immune system and the host gets better. In a small number of cases, people fall very ill and can even die. The disease is caused by a flavivirus - a family of pathogens that cause similar illnesses including yellow fever, West nile, and Japanese encephalitis. Most of these viruses are spread by mosquitoes. In the language of epidemiology, since mosquitoes carry the disease from human to human, they are vectors; we are the hosts. But dengue is not spread by the kind of fat, muck-water mosquitoes we are used to in Boston.
Instead, says Dr. Sharone Green, an expert in flaviviruses who works at Umass Memorial Medical Center, "dengue is spread primarily by Aedes aegypti which are different from the Culex mosquito we have here." The dengue mosquito is tiny, and is often found singly, rather than hovering in clusters like the Culex of New England. "Most people don't know if they've gotten bit." The dengue mosquitoes also feed all day long. "Many people tend to put on mosquito repellant and put up nets at night," says Dr. Green. But that's not enough to protect against the dengue mosquito who feeds at any hour. Perhaps most disturbingly, Aedes loves to live indoors. The moment it bites a person who has dengue, the mosquito remains infected for life. Consequently, a single insect may infect an entire household. "Dengue transmission is very focal," she says. "When cases occur in Puerto Rico, they are often found in little clusters of homes and neighborhoods."
Hosts
So Dr. Green isn't surprised to hear that Mr. G lived in the same house as someone who might have had similar symptoms. A few days after Mr. G had received his diagnosis, he received an email from D - the woman whose husband had fallen ill in Puerto Rico. In her email, she described the disease that had afflicted M.
Hi,
Yes,he (M) had it has as you left. After you left the numbers of people with the dengue skyrocketed. The goverment has increased awareness and people are really taking care of themselves. Here some neighbors in [name of the community omitted] have even a group in facebook to inform about it. We have had always had a (dengue) season but not this long. After you told me I have been telling my guests about it and that they protect themselves with Off spray, mostly in the afternoons and night that they come out. Climate change has made what has always been our dry seasons rainy seasons.
I hope it changes soon.
During his trip to Puerto Rico, Mr. G had walked into a mini-epidemic that had risen around him. Clusters of people in San Juan soon became infected. According to the CDC, reports of dengue in Puerto Rico in December of 2012 were above traditional epidemic levels.
What happened throughout the region, had occurred on a smaller scale within the house where Mr. and Mrs. G had stayed. "It's possible the same infected mosquito had bitten [the host] and the patient," Dr. Green postulates. [see CDC graph]
Printed with permission from the CDC
Every Place Has Something
Although every country hosts numerous diseases, tropical countries often have more opportunities for travelers to get sick than other environments. Dr. Green recommends that anyone traveling to a warm or tropical climate should go to the travel clinic or visit their physician to get advice about the kinds of illnesses that exist in the country.
The classic reference doctors use to track illnesses globally is a book published by the Center for Disease Control called the CDC Yellow Book http://wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htmhttp://healthmap.org/en/. Other references include the Health Map, founded by Boston Children's Hospital in 2006, that follows epidemics across the world in real-time by surveying official disease reports, accounts from social media, newspapers, and magazines. The project is even currently reporting on the active outbreak of dengue that Mr. G experienced during his recent trip. The same research group has even discovered that what people search on Google may help predict where nascent epidemics are emerging. Even D's email mentions a facebook group that helps monitor symptoms in the neighborhood. Epidemiology detectives now use footprints on the web and in social media to help track new epidemics of disease the moment they arise.
Using novel ways to diagnose and track illness can help travelers and natives prevent transmission early. Since dengue mosquitoes are day-biting, Dr. Green recommends frequent use of repellent and even treating clothing with permethrin. Choosing light or beige colored clothing is preferred over bright colors, which tend to attract mosquitoes. And, she says, "if [you] are sleeping in the house with someone with suspected dengue, [you] should be sure to use spray and consider using a bednet at night."
Many physicians, unlike Dr. Golding, may not recognize dengue when they see it. Patients should be aware of the diseases prevalent in a country so that if they fall ill when they return, they can bring it to the attention of the doctor.
Mr. G has since recovered. The rash has faded and his fevers are gone. I don't want people to be paranoid when they travel, he says. But, as Dr. Sharone Green reminds us - "every place has something going on."
A Host in Puerto Rico
This is the case of a real patient. After reading the description of the case, I invite you to guess the patient's diagnosis. The answer will be posted Friday.
Mr. G's photograph of the El Yunque Forest in Puerto Rico
"When we first arrived, [M] looked pale and leaned heavily on the wall for just a few moments, not saying much," he said. The man's wife, D, seemed unaffacted. She was gracious and talkative, and soon, Mr. and Mrs. G were settled into their new home.
The next day, Mr. and Mrs. G stepped out into the city. They strolled down the Plaza del Mercado de Rio Piedra, a busy marketplace that bustled with natives and tourists. Vendors hawked cigars, old books, candles; food stalls sold cut coconut, giant avocadoes, and meat smoked on the open flame.
On December 7th, the couple traveled to the slopes of the Sierra de Luquillo mountains, descending into the tropical rainforest called El Yunque [see photo that Mr. G took]. "The weather was gorgeous," Mr. G recalled. The air was moist, but not humid; the sky threatened rain, but none fell. The river that ran through the rainforest stood still. Ferns and palms grew alongside the path, some reaching a height of 50 feet; the canopy was thin enough to make out crescents of blue sky and the wings of colored birds. A few giant snails clung to the underside of the sparse underbrush.
By noon, the couple had descended deep into the rainforest, where they broke for lunch. "We sat in an open-air pavillion built by Boy Scouts. She ate sardines. I had a banana, dried dates and some nuts," Mr. G said. During that hour, he remembered, something had bit him, four or five times. He guessed it was a mosquito. "I thought the bites pretty weird at the time. It wasn't very buggy around there." On the trip, they hadn't seen many bugs or animals at all -- just clouds of gnats, little lizards that scampered underfoot, and the birds in the trees.
The couple hadn't forgotten the health of their host. Between trips to old San Juan, a swim at Guanica, and a hike through the Dry Forest nearby, they saw that M's condition was improving. One evening, he joined them on the veranda in conversation. The illness he had seemed to have passed.
But just as M had recovered, on December 10th Mr. G awoke in the middle of the night in a profuse sweat. Although he had no thermometer, it was evident that he had broken out in a fever. As the night pressed on, strange and recurring dreams occupied his mind. "A dream replayed over and over and into the day -- some delusion about a mass I had in my stomach, with little hairy projections I had to snip," he said, without laughing, as though remembering the potency of the dream. The delusions and fevers were persistent.
Even a short trip to a botanical garden with his wife exhausted him. Moreover -- he had developed a wincing headache that came and went nearly every minute -- unusual in a man who never had headaches at all.
FULL ENTRY
What caused Mrs. C's chronic diarrhea?
In a previous post, we asked you to try to diagnose our patient, Mrs. C. What follows below is the actual diagnosis, but visit the previous entry if you want to see what folks guessed.
This winter season in Boston, we've been struck with an early and particularly vile spate of influenza cases that have filled hospitals to capacity and have Boston residents scrambling for vaccinations. What's unusual about this year's flu is that in addition to respiratory symptoms, many are suffering from gastrointestinal distress, including vomiting, abdominal cramps, and diarrhea.
The symptoms of this flu virus resemble those of another bug that sweeps through the city nearly every winter. That bug is norovirus, a fast-moving and highly infectious virus that causes 24 hours of vomiting and often violent diarrheal episodes. But both the flu virus and norovirus usually get better: these are examples of acute diarrheal illnesses, and for the most part, such viruses and their cousins are to blame for short-lived cases of diarrhea. Since these bugs can't be treated, doctors usually let acute diarrheal episodes resolve on their own, without aggressive treatment or further investigations.
Or was it something more sinister?
Chronic diarrhea is an entirely different circumstance. Diarrhea needs to last more than four weeks before it can be considered chronic. Mrs. C more than meets the definition -- she's had diarrhea for probably more than a decade. In developed countries such as the United States, people who have diarrhea off and on over a long period of time often suffer from irritable bowel syndrome (IBS), a disease that leads to an overactive and sensitive gut that may squeeze more often than it should. However, what raised flags for Mrs. C's gastroenterologist, Dr. Jacqueline Wolf at Beth Israel Deaconess Medical Center, was that these episodes started affecting her at night. Because stress is thought to be related to IBS, patients with this condition rarely present with diarrhea at night, when stress levels drop.
FULL ENTRY
Not an ordinary case of traveler's diarrhea
This is the case of a real patient treated at a Boston-area hospital. After reading the description of the case, I invite you to submit a comment guessing the cause of the patient's symptoms. The answer will be posted Friday.
"I was a nurse for 39 years," she says, "but that didn't help me figure this out at all." Mrs. C has been haunted by debilitating symptoms for more than a decade -- since her mid-50s, she says. She's been seen by several doctors and has wracked her own brain for answers, considering various exposures, angles, and ailments.
Mrs. C is a lively, resilient, and adventurous woman. "My husband's job often required him to travel," she says. "We were chaperones along with another couple for a group of 20 teenagers on a trip to Haiti. The other lady had severe dysentery while there. She thought it was from eating salad containing unwashed lettuce. She's the one where I first heard the expression about passing 'cut glass' with diarrhea. That's how I'd describe my episodes as well."
Hunting for a Diagnosis - Revealed!
Your Differential Diagnosis:
Among the many answers submitted, many of you guessed the correct answer - lead poisoning. The first person to guess correctly was patches2. Congratulations!
Almost as many people guessed lyme disease as an alternative diagnosis; other common responses included syphilis and diabetes.
In Massachusetts, many of us are familiar with Lyme Disease, a tick-borne illness that usually presents with the characteristic rash along with fatigue, headaches, muscle pain, and joint pain. Many readers felt this patient could have the later stages of lyme disease, which can present with nerve pain and arthritis. However, lyme disease is unlikely to cause hearing loss and digestive problems; foot drop would be a very rare presentation. Neurosyphilis can present in a variety of ways, but usually patients complain of meningitis - headaches and a stiff neck. Diabetes can present with a painful neuropathy as this patient describes - even when blood sugar levels are only in the pre-diabetes range. However, this patient's other symptoms and lab results suggest the leading diagnosis.
The Diagnosis:
Mr. M, over a long time period, had developed hearing loss, memory problems, constipation, numbness and tingling in his feet, and foot drop. While some of these problems could be attributed to age, the simultaneous onset along with the more unusual symptoms in his feet suggested a possible unifying diagnosis.
Foot drop, when it occurs on both sides of the body, suggests a systemic disease. Alongside the numbness and tingling, it suggests that Mr. M has a condition that is affecting his nerves, which we call neuropathy. Other than diabetes, other causes of neuropathy include alcohol (which he doesn't drink), or a vitamin B12 deficiency (his levels are normal). Other, more rare causes, may occur from toxic agents. In this situation, the doctor gathered an exhaustive history and found it remarkable for Mr. M's significant exposure to metals as a machinist - though his doctor ruled that out as a cause because he was long retired - and his interest in gun sports.
"I use regular shotgun shell bullets," Mr. M says. "As the BBs come out of the shotgun shells, you end up breathing in mist. And those pellets are made out of lead."
So his primary care physician checked his lead level with that extra blood test -- and it was sky high. "Ideally, lead levels in the blood should be less than 10 [mg/dL]," says Dr. Rose Goldman, a professor in the Department of Environmental Health at the Harvard School of Public Health. Mr. M's lead level was near 50.
Lead poisoning -- a condition that we often think of in children -- occurs in adults too. Frequently, symptoms develop chronically, especially in people with occupations or hobbies that expose them to lead over time. "Cities like Boston and Baltimore are full of old, wonderful buildings we like to renovate," Goldman says. "Construction workers who deal in demolition or who scrape bridges are exposed to old paints that contain high levels of lead." Other at-risk groups include plumbers, police officers, car mechanics, and gas station attendants. People who take Ayurvedic herbal medications, paint, remodel homes, or do pottery work can also be exposed.
Symptoms of chronic lead poisoning may be vague. Commonly, patients present with abdominal pain, constipation, headaches, and trouble concentrating. They may develop nerve damage, such as wrist drop or foot drop, or even hearing loss.
Gun ranges, especially indoor, may have poor ventilation systems and patrons may inhale lead; preparing bullets increases this risk.
"Even outdoor shooting ranges, where a lot of people stand in close quarters on hot, muggy days, can develop high levels of lead," Goldman continues. "People who shoot guns should always wash their hands afterward."
Since getting his test results back, Mr. M has stopped going to the range for now, until his levels come back down to normal. Already, they've dropped below 40. He is hoping his symptoms will get better. He has also told his friends to get tested, but they are resistant. "They don't want to stop shooting," he says, but hopefully they'll come around.
Do you have your own medical mystery?
Send me a description of your own case and I will consider writing about it. E-mail me at sushrut.jangi@gmail.com.
Hunting for a Diagnosis
This is the case of a real patient treated at a Boston-area hospital. After reading the description of the case, I invite you to submit a comment guessing the cause of the patient's symptoms. The answer will be posted Friday.
"Nah, I was never a big game hunter," Mr. M tells me. "Sure, when I was a kid I used to go shooting a lot. Mostly birds, pheasants, quail. On rare occasions, deer."
Mr. M is 74 and has lived just outside of Boston his whole life. He's a retired machinist, who worked with nylon, Teflon, and silicon. A delightful conversationalist, he tells me that other than having high blood pressure, he's been healthy. It's only in the past couple years that he's noticed strange symptoms that haven't gone away.
"So I've done my little bit of hunting," he explains. "But now I just shoot clay." For the past 28 years, Mr. M has enjoyed various gun sports, shooting as many as 20,000 rounds per year, preparing his own bullets, and usually firing at clay disks that burst open the moment the bullet makes contact. "Whenever I shoot, I'm always careful to wear ear protection. But I don't think it's been working."
Mr. M has noticed his hearing has profoundly worsened in both ears over the last two years. His wife often has to say things twice. He didn't think much of it, and figured it was part of normal aging. After all, he's had some trouble with his memory and digestion too. "I started drinking prune juice, which helps a little bit," he admits.
But what's troubled him most is that he started to have unusual sensations in his feet. "Three years ago, my feet started becoming very, very cold," he says. "I went to see a podiatrist, who recommended a [calcium-channel blocker] called nifedipine." At first, the medicine worked. But a few months later, the soles of both his feet began tingling. The sensation creeped up the side of his leg and he noticed painful, aching cramps. "I started to have some trouble walking," he says.
He went to see his primary care physician, who performed a careful physical examination. Almost immediately, his doctor noticed Mr. M was slapping his feet when he walked, a finding called "foot drop," which reflects weakness of the muscles or nerves of the lower leg. (Watch video below for an example of left-sided foot drop.)
During foot drop, the ankles and toes have difficulty moving upward, such that the forefoot drops during walking, as seen in this patient?s left foot. You can notice that the patient raises his left leg up while he walks to prevent the forefoot from dragging. Mr. M developed foot drop on both sides. Usually, this reflects a systemic disease process, rather than individual nerve injury. (Video courtesy of Larry Mellick, Medical College of Georgia)
Mr. M also had trouble feeling vibrations and light touch on his feet and ankles. His primary care physician ordered several blood tests, all of which came back normal.
Lab Results:
Hemoglobin A1c 6.0 (normal 4.5-5.9)
Vitamin B12 596 (normal 200-900)
Hematocrit 43.6 (normal 42-54%)
Before Mr. M left the office, his primary care physician, on a hunch, added on one more blood test. A few days later, this test came back positive, and his doctor immediately called the patient, and then reported the finding to the Department of Public Health.
What did Mr. M's blood test reveal?
Click on the "Comment on this story" link below to post your guess and your reasoning. I'll post the answers on Friday.
