A fall, acetaminophen, and a liver scare

Matt Smith, a now 72-year-old farmer from Wisconsin, was mostly healthy in late 2020. That November, he underwent an ablation procedure to correct a racing heartbeat. Eight days later, as he carried a rolled-up king-size mattress up the stairs, he lost his grip. The bed slipped and slammed him into a post, breaking two of his ribs.

"The pain afterward was so intense that when he got in or out of the car, he bit down on wooden sticks," Wahlberg writes. Smith took extra-strength acetaminophen, also known as Tylenol, to help with the pain. According to Smith, he took no more than four 500-mg pills a day, "staying well below the maximum daily dose of six extra-strength pills, or 3,000 milligrams, per day."

By early December, though, Smith's appetite suddenly vanished. "There was no desire to eat, " he recalled. "The sensation of food was gone."

After Smith lost his appetite, he went to see a doctor at a local clinic, who ordered blood tests. Smith and his wife, Susan, were delivering spinach to a pandemic-era market when the doctor called with an urgent instruction.

The doctor told Smith he needed to go straight to the ED. Susan dropped him off at the ED soon after but could not go inside due to COVID-19 restrictions. The blood test revealed two liver proteins associated with metabolism were 30 times and 47 times higher than normal — dangerously high levels.

At the hospitals, doctors suspected acetaminophen poisoning and gave Smith an antidote, though he had not overdosed. The doctors also ruled out cancer, viral infection, and alcohol use. Prednisone, a steroid, brought his liver levels back to normal. That suggested autoimmune involvement, but no one could explain the severity of his results.

Over the next months, Smith's condition worsened. His hands and feet grew swollen, his fingertips turned blue in the cold, and hives appeared across his chest. Smith's muscles weakened, particularly in the shoulders. A rheumatologist diagnosed inflammatory arthritis and autoimmune hepatitis but admitted uncertainty. "I cannot explain his elevated LFTs [liver function tests] … on the basis of any discrete rheumatological process," the specialist wrote.

The clue in his hands

With answers elusive, Smith and Susan sought a second opinion at the Mayo Clinic in Rochester, Minnesota, in summer 2021. Smith's hands had become an increasing source of discomfort. "They were swollen, red and funky," he said. "They were sausage fingers."

Kristen Hanzel, an internist at Mayo, recalled, "They looked thickened. The skin didn't look quite right."

Rheumatologist Kerry Wright examined them up close. "You have mechanic's hands," she told Smith — not from farm equipment, but as a clinical sign of antisynthetase syndrome, a rare autoimmune disease.

Gradual improvement leads to eventual remission

Treatment began with rituximab infusions and later mycophenolate, alongside prednisone. The therapies eased Smith's flare-ups. By January 2024, after nearly three years of treatment, scans showed Smith's interstitial lung disease was gone.

However, he later faced a setback after contracting COVID-19 and pneumonia, which led to two hospitalizations. According to doctors, his treatments for antisynthetase syndrome likely suppressed his immune system, which made it harder for him to recover from COVID-19. Eventually, a 10-day course of antiviral drugs helped Smith fully recover from his viral infection.

Today, Smith is mostly retired from farming, and while his hands still occasionally tingle and his fingertips sometimes turn blue, he no longer has joint pain or rashes. Earlier this year, he stopped taking prednisone, and his new rheumatologist said his antisynthetase syndrome is currently in remission.

Smith credits persistence — and the decision to press for a second opinion — for his recovery. If they hadn't pressed for more information, "the outlook would have been a lot bleaker," he said. "I'm really lucky. I'm feeling blessed."

Hanzel agreed. "Without the diagnosis, I don't think he would have been on those medicines," she said. "These are a little bit more heavy-duty."

Susan hopes their story encourages others to seek answers. "Some people worry about hurting their doctors' feelings," she said. "But most insurance pays for a second opinion. If [your regular doctors] don't know what you have, people should take advantage of that."