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August 4, 2021

The patient was coughing up blood—but the problem wasn't his lungs

Daily Briefing
    Editor's note: This popular story from the Daily Briefing's archives was republished on Aug. 3, 2022.

    When a patient began coughing up blood and experiencing low oxygen levels, the first thought was to look at his lungs. But a CT scan led doctors to focus on his heart, and that's where they found answers, Lisa Sanders writes for the New York Times Magazine.

    'I've been coughing up blood'

    One day, the patient—a 59-year-old man from Connecticut—turned to his wife and told her, "I've been coughing up blood," saying that the issue had begun the night before.

    Immediately, his wife took him to a nearby urgent care center. The patient said that, over the past few days, he'd been experiencing a runny nose and a cough, which would occasionally produce streaks of blood. He said that aside from some chest pain when he breathed deeply, he felt fine.

    However, according to Sanders, the patient's vital signs showed more pressing issues. His oxygen level was at 91%—even though it should have been between 98% and 100%, even with a strong cold. When asked if he felt short of breath, the patient said maybe, when he walked from the car to the urgent care center, but not now when he was just sitting.

    The nurse at the urgent care center said the patient needed a CT scan for his chest, and he was transferred to the ED at Northern Westchester Hospital. But the scan raised more questions than it answered, Sanders writes. Although the scan did not show clots in the arteries of his lungs—which would have indicated a pulmonary embolus that could have caused his symptoms—it revealed light, hazy patches in areas of his lungs that should have been dark.

    With no other answer for his low oxygen level, the hospital admitted the man for pneumonia and placed him on antibiotics.

    Looking into his heart—not his lungs

    However, Tara Shapiro, the doctor assigned to the patient's care, wasn't sure if his lungs were actually the problem, Sanders writes. In addition to the hazy patches on his lungs, his CT scan showed his heart was thicker and more muscular than it should have been. Shapiro could have chalked that up to high blood pressure—if it weren’t for the fact that the patient's blood pressure was perfectly normal.

    Still concerned, Shapiro decided to reach out to one of her colleagues, Ronald Wallach, a cardiologist, to see if he could pinpoint a cause, Sanders writes. After hearing the patient's symptoms, Wallach asked the man if he had trouble breathing before.

    The patient conceded that he had been short of breath several times in recent months, Sanders writes, starting in the summer. At the time, however, a pulmonologist and a cardiologist had diagnosed him with asthma—although, the patient said, the inhaler he had been prescribed didn't help him breathe more easily.

    The 'Aunt Tilly Sign'

    In the end, an EKG test done at the hospital's ED led Wallach to the cause of the problem. Although a thick, muscular heart tends to generate a bigger EKG signal than normal, the patient's heart had created a smaller-than-normal EKG signal, Sanders writes.

    According to Sanders, some diseases can cause cardiac muscles to appear bigger but be weaker, which would account for the patient's symptoms—including his thicker-looking heart, fluid in his lungs, difficulty breathing, and even coughing up blood. Concerned that the patient might be dealing with "something serious," Wallach ordered a cardiac MRI.

    That MRI revealed the patient had a disease called amyloidosis. According to Sanders, amyloidosis causes "zigzag-shaped" fibers to develop in different muscles of the body, including the heart. Further testing revealed the patient's amyloidosis was caused by aging, Sanders writes, and the patient would require a heart transplant to survive.

    Three years later, the patient wrote to Wallach to say that he had received a heart transplant and was doing well. "You saved my life," the patient wrote.

    For his part, Wallach credited his ability to spot the issue when others had not to the "Aunt Tilly Sign." As he explained, "If I described Aunt Tilly to you and sent you out into a crowd to find her, you'd probably fail. But if you'd ever seen Aunt Tilly no problem. You'd find her in a second. It's all about recognition." (Sanders, New York Times Magazine, 8/2)

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