PB is a 37 year old man, presenting to the emergency room with fever, chills and abdominal
pain.
He tells the admitting nurse that he woke up overnight in a pool of cold sweat, shaking
and crying, as he could feel aches all over his body. His stomach curling inside of him.
You see, PB was an American professor living in Vietnam. He was there with his wife and
two kids. He lived in the city, and took his family on trips all around the region.
About 6 weeks ago, PB was at a fancy dinner. On the menu was Norweigan salmon, fresh and
shipped in to Vietnam earlier that day.
Ever since he was a kid, PB had a habit of not really chewing his food when he ate. His
mom used to give him a hard time about it. When he was in middle school, he had dinner
at a friends house. Friend’s mom served canned chicken noodle soup, and the boys played
basketball afterwards. PB didn’t feel well during the game, and up came the soup, with
canned carrots fully in tact because he didn’t chew his food before putting it down.
After THIS fancy dinner, PB felt great. But a few days later, he could feel a sharp, throbbing
feeling on his right side. These would come and go for about twenty to thirty minutes
at a time, but then they’d go away. This lasted for a few days before PB started developing
a fever. He start shaking in the middle of the night because even though he felt chilly,
his body temperature was hot, and his sweat was cold. He took some ibuprofen hoping it
would help the pain and his fever. But it didn’t do anything.
At physical exam in the emergency room, doctors didn’t find anything wrong. Even a blood
test returned normal. PB had gotten his appropriate travel vaccinations. Americans can have exposure
to pathogens in Southeast Asia, or really, any other continent for that matter. These
are things that just aren’t endemic to North America. Everything he needed to do for his
health, he did.
But an ultrasound on his abdomen suggested hepatosplenomegaly. Hepato referring to liver.
Spleno referring to the spleen, which is an organ that recycles old RED blood cells and
stores WHITE blood cells, that’s connected to the liver. And megaly from mega, indicating
an enlarged size. A possible enlargement of the liver and the spleen. Ultrasound won’t
show you everything, it’s sound waves bouncing around giving an idea of shapes and sizes
of things, but its suggestions tell doctors if more imaging is needed. And in PB, more
images were needed. All of this happening with a fever that wasn’t improving with
repeat doses of Tylenol and ibuprofen.
As the days go by, those additional images of PB’s abdomen were taken. All of them
were still suggesting hepatosplenomegaly, but it was still borderline. They could be
enlarged, but not out of the realm of being a little bigger than average. One of PB’s
friends was a prominent doctor in Vietnam. “I love my country, but I think it’s time
for you to leave,” he said, thinking that adequate resources for his case, may not be
available at this community level hospital.
As an American professor, PB had academic medical colleagues at big institutions. They
recommended him for transfer to a larger hospital in Thailand. One with international accreditation.
As PB was flown in by helicopter, his case was still unclear. He had a fever, that wasn’t
responding to medicine. But his sinuses and lungs were clear, so no respiratory infection.
His urine was clear, so no urinary tract infection. His stool was free of parasites, so no infection
there either.
A CT scan at the International hospital did confirm: PB had hepatosplenomegaly. But that
wasn’t the only problem. Doctors found what looked like a liver cyst, 1 centimeter in
diameter. Doctors collected blood from PB to culture and grow, to find out if bacteria
was floating around in his body, because no matter what, everything points to some kind
of infection happening somewhere. But these cultures will take some time to grow.
As the days go by, doctors at the international hospital keep looking to see what’s wrong.
But they couldn’t find anything. PB’s body temperature kept increasing. Doctors
kept asking PB if he had any recollection of ingesting some kind of medicine or some
kind of food that may have been out of his normal routine, but he couldn’t remember
anything that could have been a problem.
On day 4 of hospitalization, one of the blood cultures returned. Bacteria that’s normally
found in the human mouth, named Streptococcus constellatus was growing in that culture,
meaning that was the bacteria floating around in his blood, causing his fever. But, if it’s
normally found in the mouth, how did it get into his blood stream? And what would it have
to do with any kind of suspicious fish dinner?
Antibiotics were started. Over the next 2 days, PB started feeling better. His fever,
completely resolved. Repeat blood tests returned normal, and repeat blood cultures were clear—
no more bacteremia, or bacterial presence in blood.
Everything seemed to be going well. Thai doctors were getting ready for PB’s discharge from
the hospital. Except, the doctor in America asked for more tests. She wasn’t convinced
that PB was fine, because even if the bacteria is cleared from the blood now, it doesnt mean
it won’t come back. Antibiotics can kill the bacteria temporarily. But different bacteria
can mean different things. And when Streptococcus constellatus shows up in the blood, doctors
need to find an abscess, or a bag of pus, that’s formed somewhere in the body, because
this bacteria specifically, can spread and form new abscesses in other organs. It might
have already started spreading around in his body. Whatever was on his liver, isn’t good,
but it might not be his only problem.
On this request, doctors at the international hospital do repeat scans of PB’s abdomen.
Images show that he still has hepatosplenomegaly. But now lymph nodes in his abdomen are swollen,
when they weren’t before. Multiple lesions were found on his liver that weren’t there
before. Parts of his pancreas were now swollen, when they weren’t, before. And the vein
that feeds from the small intestines IN to the liver now had a blood clot formed inside
of it, meaning that even if the bacteremia isn’t detectable by the lab, it could still
be hanging around somewhere and spreading.
Doctors at the international hospital were confused by what was happening. They looked
over the scans, and how the images changed over time. They had been looking at them for
days. PB’s dad was with him at the hospital in Thailand. He was a doctor himself too.
The surgeon, working on PB’s case, flagged dad down and
said, “hey, look at this. It really looks like there's some kind of fish bone in his pancreas” The dad,
looked at the surgeon and said, “that’s ridiculous. The chances of that happening
are slim to none, and I’ve never seen it in my practice. There’s no way.”
As the images were transmitted to American doctors, PB was transferred out of the international
hospital, and flown back to the US, as he arrived at his colleagues’ hospital.
On admission to the American hospital, doctors immediately started looking for an abscess.
Despite the scans in Vietnam and Thailand suggesting a cyst on his liver, the problem
now is that the bacteria that was found in his blood, could have already spread to other
organs. It could be on his lungs. On his kidneys, and on his brain.
The lesions found on his liver could be the source of all of PB’s problems, but something’s
wrong. Usually, liver abscess like this also means some kind of underlying disease. It’s
just not common that you… grow a big zit on your liver. But PB had no past medical
history. There usually isn’t any kind of known pathogen in fresh salmon that could
have caused these problems either. His pancreas was inflamed, so that could be it. But his
pancreas was fine earlier in the Vietnam hospital. And it only entered the picture after his
bacteremia was cleared.
A bacteria known as Klebsiella pneumoniae can cause a liver abscess, and this is well
documented to happen in Asia, but it’s something that often appears before someone gets diagnosed
with colon cancer. And knowing that colon cancer patients have been getting younger
over the years, affecting people in their 30s rather than age 50 and above, PB at 37
years old, living in Asia, could be at risk. All of these are reasons why the American
doctors transferred him back to the states, but there’s more.
PB had a blood clot in the vein leading up to his liver. When someone has cancer, their
blood can be in a hypercoagulable state, meaning more clots can form compared to normal. But
an infection, can cause the same clot in that same vein too, meaning no matter what, surgeons
need to open him up, and take a look at what’s happening.
Before he was sent in for surgery, doctors took another look at all of the images taken
of PB since he was hospitalized. In the early images, a foreign body was found in the part
of his small intestines near where it connects to the stomach called the duodenum. Doctors
had to know what they were looking for to find it in those early images. But the later
images show this same body, migrating from the duodenum. As it keeps moving throughout
the days, it finally pierced his intestines, and lodged itself in to the head of his pancreas.
Whatever this foreign body was, it traversed the superior mesenteric vein, causing that
blood clot. And because it punctured a hole in his intestines, this is what might have
caused the bacteremia, specifically, bacteria that would usually be found in the mouth.
This object, looked like it could have been a toothpick, or a needle, or, as the Thai
doctors said to PB’s dad, a fishbone.
As surgeons open up PB to explore, they found marked inflammation by his pancreas, leading
them directly to the object. They placed metal clips on each end, and extracted it after
cutting it in half. And there they saw a fishbone, sharp and brittle, as they sewed him back
up, and sent him in to the recovery room.
Fish bone ingestion, isn’t really that uncommon. They’re smaller than chicken and pork bones.
And when they do get lodged in the body, usually it often right after the mouth, by the tonsils.
If it doesnt happen in children because they’re young and don’t know, it could be because
someone is elderly and they have dentures. Or if it is a middle age person, it could
be because they’re drunk, or they don’t chew their food well before swallowing. Usually
they get passed without problem, but if they do perforate something, it usually happens
in the intestines, and those cases have been reported in literature for at least 100 years
now, bringing us back to PB.
Looking back on it, he realized his mom had a point when she always gave him trouble for
not chewing his food well. After he woke up from surgery, he remembered the exact dinner
where he thought he might have swallowed a fishbone. He thought he bit something tough,
but didn’t feel anything on the way down. At the time, he didn’t think twice about
it.
His illness spanned 3 countries. There was suspicion of colorectal cancer because of
the abscess on his liver, the bacteria found in his blood, and because of the region where
he was living. Everything put together, indicated a possibility of colorectal cancer. But the
Thai doctors were right, there was actually a fishbone lodged in his pancreas, that broke
his intestines causing liver abscess, causing bacteremia, fever and abdominal pain, and
thrombosis of the superior mesenteric vein, that all would have probably gotten worse
had this bone not been found and removed.
And as he was discharged from the hospital in America, PB returned to Vietnam, to move
back stateside, as he made a full recovery.
Take care of yourself. Chew your food. and be well.