Here's what happened At age 27, a healthy man named Kyle visited the dentist for a cleaning. Six weeks later, he presented to the emergency department with severe abdominal pain and a pulsating lump on his hand. Watch the video or read the transcript below to find out how this happened. This story is based on a case published in the New England Journal of Medicine. Siobhan Deshauer, MD: I'm Siobhan, a first-year medical resident. Medicine is all about storytelling, and this is the story of a 27-year-old man named Kyle, who went to the dentist to have his teeth cleaned. Six weeks later, he presented to the emergency department with severe abdominal pain and a pulsating lump on his hand. Deshauer: Kyle was an otherwise healthy man who worked in a bank. While building his career, he neglected to schedule time to visit the dentist. Feeling more settled in his job this year, he decided to make a change and went to the dentist to have his teeth cleaned. At this visit, he was told that he had gingivitis or inflammation of his gums. His gums were sore after the appointment, and he vowed to start flossing his teeth every day. He gradually started to feel ill after this appointment. Over the next few days, he would occasionally wake up in the middle of the night covered in sweat. Day by day, he realized that he was eating and drinking less. He began to take Tylenol regularly to make it through the day. He felt exhausted at the gym and didn't have his normal stamina. One month later, he started noticing some black streaks coming down his fingernail. Kyle figured he must have hit his finger at the gym and ignored it. Still not eating well, he stepped on the scale and realized he had lost 7 lbs. The next week he developed a red dot on the palm of his hand. Again, he dismissed this, thinking it was from lifting weights at the gym. Kyle rarely went to the doctor and hadn't taken a sick day in years. He pushed through his symptoms and assumed he would feel better in a few days. The following week, he woke up with excruciating pain on the left side of his abdomen and decided to go immediately to the emergency department. When Kyle arrived, he had a fever of 38.5° Celsius. He was tachycardic, or an elevated heart rate of 105 beats per minute. He was examined by a doctor who found he had a tender abdomen with guarding on the left upper quadrant, meaning he was tensing his abdominal muscles while she tried to palpate his abdomen. When she listened to his heart, she heard a distinct high-pitched decrescendo murmur during diastole, which is the time when the ventricles of the heart are filling with blood. Kyle had never been diagnosed with a heart murmur. She then examined his right hand. Over the past 2 weeks, what had started with a red dot had turned into a pulsating blue nodule. It was warm and painful to touch. Kyle had a CT scan of his abdomen, which revealed a wedge-shaped infarction in the spleen. Infarction means there was tissue death due to a lack of oxygen. The splenic artery branches off to supply blood to each part of the spleen. If something blocks one of those branches, all the tissue supplied by that artery will die. That process of infarction is painful and it explains the left upper quadrant abdominal pain that Kyle felt. Then a CT angiogram of his right arm was performed. This means an iodine-rich dye was injected into Kyle's arm during the CT scan in order to visualize the blood vessels. The results revealed an aneurysm of the ulnar artery. That's the artery that runs along the pinkie side of the arm. An aneurysm refers to the weakening of an artery wall that leads to bulging of the artery. Just as a balloon expands under pressure, so does the artery, putting it at risk of rupture. These two symptoms seem unrelated and in different parts of the body. The spleen has an artery that's blocked, whereas the hand has an artery that's bulging. Something must be tying these two symptoms together. What connects them is the blood that's rushing through the arteries being pumped by the heart. In Kyle's case, a heart with a new distinct murmur. An echocardiogram or a heart ultrasound was ordered to examine the structure of Kyle's heart, with particular interest in his valves. This is what a normal echocardiogram looks like. Now, this is what Kyle's looked like. The most striking abnormality is the growth on his aortic valve. This is called a vegetation and it's made up of bacteria. That's an infection of the endocardium, the inner layer of the heart which lines the chambers and the valves of the heart. For this reason it's called infective endocarditis, an infection of the endocardium. Blood culture sent in the emergency department grew a bacteria called Streptococcus salivarius. This is a bacteria that lives in your mouth, just like trillions of bacteria that live in our skin or in our mouth. They're not harmful to us as long as they don't cross over into our blood. While our body is excellent at clearing a small amount of bacteria that gets through, when we cut ourselves or floss our teeth, it can have trouble clearing large amounts. In Kyle's case, he had poor underlying dental health with gingivitis and having his teeth cleaned caused small cuts in his gums, which allowed bacteria to enter his bloodstream. The bacteria flowed through his veins back to the heart, where they came in contact with his aortic valve. Unfortunately, Kyle had an underlying defect in his heart called a bicuspid aortic valve. Bicuspid, meaning his aortic valve had two leaflets rather than three, which is normal. This is the most common cardiac birth defect, affecting up to 2% of the general population. That means one in 50 people are walking around with this condition and have no idea. The reason it's important is because this defect makes it more likely for bacteria to be able to stick onto the valve. The leaflets of the valve are so thin they actually don't contain any blood vessels. This means the white blood cells, the cells that normally fight and defend our body, can't even reach the bacteria. Kyle's vegetation grew to be 12 mm in size, just larger than a regular M&M. It deformed the valves so that it couldn't close. The leaflets couldn't quite fit together anymore. Without a tight seal, blood would rush through the aortic valve, which can be heard using a stethoscope. This is why Kyle had a new heart murmur. With each contraction of the heart, this M&M-sized vegetation was being whipped around by the heart valve. Small pieces flew off called septic emboli. Septic, because they're from an infectious source and emboli to say they're an unattached mass flying through the bloodstream. Like a pinball machine, the emboli are launched into the aorta. As the arteries approach the organs, their final destination, they narrow and become smaller until eventually the embolus is lodged in the artery. Thinking back, when Kyle first noticed the black streaks on his nails, this was actually the result of a septic embolus and it was the first indication that he had of vegetation growing on his heart valve. Next, a small embolus traveled to his hand, causing inflammation of the ulnar artery. This weakened the collagen and elastin in the artery walls, causing them to balloon out into an aneurysm under his normal blood pressure. The reason Kyle didn't have an infarction or death of the tissue in his hand the way that he did in his spleen is because the hand has something called collateral circulation coming from the radial artery. In other words, the radial artery can act like a backup generator so it can supply blood to the entire hand. Finally, the large embolus that traveled to his spleen caused an infarction and tissue death. The whole time he had fevers, fatigue, night sweats, and a decreased appetite, his body was reacting to the small amounts of bacteria circulating in his body. In many ways, Kyle was fortunate because these emboli can travel to the brain causing a stroke, to the heart causing a heart attack, and even to the eye causing visual impairment. To treat Kyle, he was given fluids and IV antibiotics to fight the bacteria. Within 2 days, his fevers and night sweats had stopped and he was feeling much better. But since the vegetation was so large, Kyle required open-heart surgery a few days later to remove the infected valve and replace it with a mechanical valve. Soon after, he went back to the OR to have his ulnar aneurysm repaired. Both surgeries went smoothly and without complications. You may be wondering how will this affect the rest of Kyle's life? Now that Kyle has a valve made of metal staying in his heart, he's at increased risk of stroke because a clot can form on that valve. The treatment for that is taking an anticoagulant or a blood thinner for the rest of his life. Also, he'll have to talk with his doctor about prophylactic or preventative antibiotics before getting his next dental procedure. Treatment is different for everyone, and it really depends on the values and preferences of each patient, so it'll be up to Kyle and his doctor. The point of this video is not to scare you away from the dentist, so continue to take care of your dental health, and if you have any symptoms that are concerning, see your doctor. Thanks so much for watching, guys. If you like this new type of video about medical cases, give it a thumbs up, share it with a friend you think would enjoy it, and don't forget to subscribe to see more like it. Also, if you want to see what it's like to be a junior doctor, check out my channel where I vlog in the hospital and show you the truth about medicine. I'll see you guys next week, so bye for now! Source
