A Grandma Ate Cookie Dough Every Week For Lunch.
This Is What Happened To Her Bones.
CC is a 78 year old woman, presenting to the emergency room with night sweats, hot flashes,
and insomnia.
She tells the admitting nurse that she had unintentionally lost at least 25 pounds over
the last 2 months.
CC was a grandma originally from South America.
She came to the United States with her son in the 1980s.
Every week, CC would bake cookies for her grandkids.
This was their favorite part of the week.
Grandma knew exactly the kind of cookies they loved to eat, and she never forgot to make
extras for them to bring back home.
While baking, CC would always eat some of the cookie dough.
There was always more than enough for everyone, and she thought to take the opportunity to
have some herself.
About 4 months ago she started having trouble sleeping.
She was getting night sweats and hot flashes.
Everyday, she’d notice her weight decrease on the scale.
She wasn’t eating less.
She wasn’t exercising more.
She wasn’t sure how this was happening but she didn’t think too much of it.
Skin deep, CC was relatively healthy for a 78 year old.
She had type 2 diabetes, but she took her medicines every day.
She had high blood pressure and a heart condition known as atrial fibrillation, where one part
of the heart beats so quickly it doesn’t actually produce a good contraction allowing
blood to pool which could form a clot and get lodged into her brain and cause a stroke,
but this was controlled with medicines too.
Just having these 3 problems at 78 years old isn’t bad.
But unintentionally losing 25 pounds in 2 months is probably something very bad.
The weight loss isn’t associated with diabetes because, well she’s eating sugary cookie
dough at least once a week and that’s not exactly something that’ll help you lose
weight.
CC asked the admitting nurse if the hot flashes were some sort of low key fever.
She was aware of the risks of eating cookie dough because raw eggs can have the bacteria
salmonella, so she wanted to make sure that she wasn’t getting some kind of infection.
Without presenting with nausea, vomiting, diarrhea, or an actual fever, it doesn’t
seem like she has any kind of food poisoning.
Because she’s 78, she’s well past menopause, meaning her night sweats are probably not
hormonal.
Not much has changed in her lifestyle, so it’s likely that this sudden weight loss,
given her age, could be cancer.
Analysis of CC’s blood finds anemia.
An meaning without and emia meaning presence of blood.
The size of her red blood cells are normal, but the problem is she just doesn’t have
a lot them floating around in her body.
2 months earlier, CC had come in for her regular checkup.
Blood was drawn then too giving us a baseline measurement.
She had this anemia back then, but it’s worse now.
Nitrogen and a waste product called creatinine are present at a level 3 times higher now,
compared to 2 months ago.
The kidneys are supposed to be filtering these things out of the blood, but now they’re
not.
Her kidneys are failing.
A massive amount of protein in her urine, more than 40 times the upper limit of normal
is collected.
Cookie dough has raw eggs.
Eggs have a lot of protein.
But this isn’t the protein in CC’s urine.
Eggs don’t cause kidney failure.
Cookie dough can cause food poisoning, but food poisoning isn’t kidney dysfunction.
But diabetes causes kidney damage.
Elevated blood sugar levels and increased inflammation contribute to kidney injury.
But if we have a baseline measurement from 2 months ago, the rate of decline is too quick
to count this as diabetic nephropathy, meaning that something else must be causing this problem,
which brings us back to cancer.
CT scans of her chest, abdomen and pelvis reveal nothing.
Her lymph nodes, which are typically the first sites to where cancer spreads, were clear.
No primary tumor or metastatic disease to be found so, it doesn’t look like she has
a solid organ cancer.
But how about bone marrow cancer?
That would cause problems with her blood cells and she does have anemia.
Except, analysis of her blood proteins also reveals no cancer.
But the results are borderline and nonspecific.
Clearly something is wrong.
They show maybe an infection of some sort, which might point us back to the cookie dough
she eats every week.
But time is up.
She doesn’t have a life threatening emergency.
Without a good reason to admit her into the hospital, CC is discharged from the emergency
room and referred to the kidney clinic.
They sample some kidney tissue from her to look at under a microscope.
As the days go by, CC’s night sweats become more intense.
She continues to bake the cookies for her grandkids because she doesn’t want to stress
them out.
She doesn’t want them to even think that anything is wrong.
This health scare shakes her confidence, but she doesn’t have cancer, so it might not
be that serious, she thought.
In the kidney clinic, 2 weeks later, it’s revealed that CC has deposits of antibodies
and complexes in the capsules of her kidneys.
These regions of dense build-up tell a story.
That her something has been happening with her immune system for some time now.
Antibodies that would be used to combat infections have infiltrated her kidneys.
This accumulation means that maybe she’s had a chronic, or long term infection ongoing,
or that maybe she has an autoimmune disease, meaning that her immune system has been wrongly
activated to attack her own body’s cells.
If she’s eaten cookie dough every week for a long time, and salmonella from the uncooked
eggs are in there, then maybe that could be her chronic infection?
But that doesn’t make sense since that would mean the bacteria would have spilled into
her blood at some point in time and that bacteremia, or bacterial presence in blood, would have
been obvious.
And without a history of lupus, or arthritis, or anything like that it also doesn’t look
like she has autoimmune disease, we can’t know for sure.
But what we can know for sure, is that CC’s kidney function has worsened again.
Over the next 24 hours, more than 10 grams of protein are collected from her urine indicating
severe kidney injury.
Whatever the case is it looks like her immune system is active.
The best way to resolve this inflammation is to give her corticosteroids, which are
medicines that reduce the activity of the immune system.
She’s started on a high daily dose of prednisone and sent home.
But things only got worse.
It’s one week later, CC presents again to the emergency room.
This time with fevers, chills, and hematuria.
There is now a presence of blood in her urine.
She’s nauseous, vomiting and has severe diarrhea.
Salmonella enteritidis, the bacteria commonly found in uncooked eggs from cookie dough,
was isolated from her urine and blood cultures, as well as her stool, confirming an acute
infection.
High dose corticosteroids immediately increases the risk of infection because of its action
on the immune system.
Her steroid dose is tapered and she’s started on antibiotics, and her fever quickly resolves.
Her urine and blood cultures become sterile as her infection is rapidly cleared.
As she’s discharged again from the hospital, she is told to stop eating cookie dough.
She’s told to stop eating anything uncooked.
She’s given a 4 week prescription for antibiotics to make absolutely sure that her infection
is cleared.
Explicit instructions given to her were to complete the entire course, even if she feels
ok.
And she feels great, until 2 weeks pass.
CC can’t stand on her own because of a sharp pain in her right leg.
She starts scratching her back and it becomes painful as she realizes a giant rash has developed
as her fever, nausea, and vomiting return.
Back in the emergency room again.
The medical team looks at the rash closely.
Small plaques and scaling were observed.
Usually, rashes come from an allergy.
Because she’s on new antibiotics, this might be an allergic reaction to them.
But, an antibiotic rash doesn’t look like plaques and scales, meaning that this is something
else, which is confirmed because CC tells the medical team, she never filled her prescription
of antibiotics because she felt she didn’t need them.
As CC is triaged in the emergency room, she needs to use the bathroom.
Despite the searing, stabbing pain in her right leg, she didn’t tell the medical team
about it.
She was too preoccupied with scratching her back for them to notice.
As she gets up, she feels her right leg pulse.
She hears a fibrous snap, as she suddenly collapses on the ground.
The medical team suddenly rushes to her.
Imaging finds multiple lesions in her fractured right tibia.
CC didn’t tell the medical team that several years ago, she had broken her leg at this
exact spot.
Bone biopsy finds salmonella enteritidis as the causative agent of this osteomyelitis.
Osteo meaning bone.
Myelo referring to marrow and itis meaning inflammation, or in this case infection.
A bone infection that was found along with a blood culture confirming again salmonella bacteremia, meaning
that within the timespan of just a few weeks, the exact same bacteria from the eggs in her
cookie dough is again infecting CC.
The mysterious kidney failure.
The severe infection after steroids.
The rash.
The recurring infection.
The medical team realizes that this is a case of immunocompromise.
There only a couple of situations where recurrent salmonella enteritidis bacteremia could happen.
The first is in organ transplant, where medicines would have been given to suppress the immune
activity to prevent the body from rejecting the donated organ.
But CC never had an organ transplant.
Meaning that this could be a case of Acquired Immunodeficiency Syndrome, also known as AIDS.
At this realization, the medical team immediately tests her for Human Immunodeficiency Virus.
Serologic testing returned positive.
A viral load of 550,000 copies per milliliter of blood was found.
And a measure of her CD4 T cells, which are the immune cells targeted by the virus, was
60 cells per milliliter of blood.
Under 200 cells per milliliter is the criteria for AIDS as she’s diagnosed with it for
the first time, at age 78.
This finding is consistent with, everything.
HIV is known to cause kidney damage in late stage disease.
This nephropathy is characterized by gross proteinuria with rapidly progressive kidney
disease.
The collapsing form of focal segmental glomerulosclerosis with interstitial inflammation is a classic
presentation of HIV associated nephropathy, but only obvious in retrospect.
Rashes are common in HIV patients, and this rash was not characteristic of an antibiotic
hypersensitivity.
Very high dose prednisone like the one CC received is not something you want to give
an AIDS patient because the medicine increases the infection risk of a patient and AIDS itself
is a disease where the human immunodeficiency virus exhausts the immune system, leaving
the host vulnerable to infections that just don’t happen in people who haven’t been
infected with the virus.
The cookie dough that CC ate every week was a source of salmonella enteritidis.
It put her at risk every time as she ate it for lunch.
And in immunocompetent people, the infection that you can get from uncooked eggs or mishandled
poultry is not common, definitely not recurrent and mostly likely never in this severity.
CC tells the medical team that about 10 years ago, she broke her right leg.
It seemed to heal, but the doctor at the time noticed reactive sclerosis surrounding an
irregular lesion.
She never went back for follow-up after her leg healed, because she never felt the need
to.
We can only speculate here, but it’s likely that she was already had HIV, when she was
68.
Which brings us to the final consideration of this case.
Most notably, I can’t think of any of my colleagues, who’d get a history of activity
with partners in an elderly woman.
It should be obtained, no matter how awkward depending on the person.
HIV is just not the first thing that comes to mind in someone over 70 years old.
Most common are going to be cancer, heart problems, diabetes.
When she was asked, CC did not have much to say about her activity, except that she was
in a monogamous relationship for more than 40 years.
She did have a blood transfusion after an accident about 25 years ago in Latin America
which would bring us to the 1990s.
If she had hemophilia, this could be a lead to how she got the infection because well
documented violations of basic principles and ethics from western institutions exist
from that time, where HIV contaminated products were knowingly shipped to the region.
These products should have been destroyed.
Instead, they were repackaged and distributed, and sold to other to these other countries.
To protect those institutions' investments. And then it knowingly infected the people who lived in those countries
But without evidence of hemophilia which would indicate the use of these factors in CC, it
may not be likely.
So much time has passed that we can't confirm absolutely the reason for her infection,
Well, she has the virus.
It’s been replicating and depleting her immune system.
But at least, it’s nice that it was caught this time.
With support from her family and the medical team, the initiation of triplet antiretroviral
therapy, CC’s viral load was undetectable after 6 months.
Her rash resolved.
Her kidney function improving.
Her bones, healing.
CC was able to sustain a full recovery.
Thank you so much for watching.
Take care of yourself.
And be well.