Sternlieb, a yoga and meditation teacher who worked in the Pediatric Pain Program at the University of California, Los Angeles, was able to uncover the cause of the mysterious illness, which occurs two to three times a year and lasts about five days. I had undergone numerous tests that I had never had. Seventeen years later, in 2004, the illness began to occur more frequently, and Sternlieb never fully recovered between attacks. A year later, she developed high fever, chills, and fatigue, which lasted for five months and left her bedridden.
After Sternlieb underwent surgery and was eventually cured, the cause of this surprising and extremely rare condition was finally identified.
“It's good that my abdomen turned red because it got the doctor's attention,” Sternlieb said recently. “Something was really wrong, but no one imagined this.”
The first episode occurred in December 1987, two weeks after Sternlieb's second child was born. “I felt worse than ever,” said Sternlieb, who was 37 at the time. “It was flu season, and it was a bad flu season that year.” Doctors therefore attributed her illness to influenza.
Six months later, the disease returned, and this pattern continued for years.
At first, Sternlieb didn't pay much attention to the small red dots covering her abdomen. The rash resembled a sunburn, but it wasn't itchy or painful. Doctors ultimately determined it was hives, a common skin condition that can occur as an allergic reaction to food or drugs. Often the cause is never discovered.
“She was sicker than ever before. … It was flu season, and that year was a bad flu season.” So doctors attributed her illness to the flu. I did.
— Beth Sternlieb
Her primary care physician referred her to a rheumatologist who specialized in treating autoimmune diseases, and she continued to see him for several years. He ordered blood tests, which he said suggested the presence of an unspecified autoimmune disease in which the body mistakenly attacks itself.
Over the years, Sternlieb has noticed that the episodes seem to occur during times of stress, “both good and bad,” such as traveling, partying, or lack of sleep. “I thought there had to be a psychological component to this,” she said.
She learned to incorporate the matches into her life and was relieved that no one found anything serious. She hoped that doctors would be able to figure out what the problem was so they could treat and eradicate whatever it was.
By 2005, Sternlieb's calm was shattered by a sharp decline in his health.
That summer she became seriously ill and never recovered. Her fever regularly rose to her 104 degrees, and she suffered from drenching night sweats and deep weakness and fatigue. She lost 15 pounds, was unable to work, and spent most of her time in bed or on the couch. A rash that was limited to her abdomen spread to her neck and torso. Her blood tests showed increased levels of inflammation and an increased white blood cell count.
Sternlieb began recruiting new experts. Infectious disease doctors thoroughly investigated her travel history, including a trip to India several years ago, and ultimately ruled out malaria or other parasitic infections. Doctors considered and dismissed various diagnoses, including an unexplained fever that could be related to some autoimmune disease. Familial Mediterranean fever, an inherited genetic disease that causes recurrent fever and inflammation. The same goes for HIV and hepatitis.
Infection or allergies may be the cause. Despite the recurrence of the hives, the latter seems unlikely, said Raffi Takjian, then a fellow in allergy and immunology at UCLA and one of the doctors Sternlieb consulted. Stated.
“Hives usually last 24 hours, but these were not chronic,” he recalled. “We had to take a closer look to see if there was anything unusual. It looked like there was something trapping heat somewhere.” Sternlieb's Immune System.
“We see this phenomenon in the sinuses, where antibiotics don't reach the infected tissue,” resulting in a smoldering infection that is virtually impossible to eradicate with drug therapy, he added.
A CT scan ordered by an infectious disease doctor revealed multiple uterine fibroids, common benign tumors that don't require treatment unless they cause problems. The scan showed that one of the fibroids had grown so large that it may be undergoing degeneration (death) or necrosis (death), which occurs when a tumor loses its blood supply.
Degenerative fibroids can grow very quickly. But doctors were also concerned about the possibility of rare cancers such as leiomyosarcoma, which grows in smooth muscle, including uterine tissue. None of her doctors, including her new gynecologist Jessica Schneider, knew whether her long-standing illness and uterine fibroids were related.
And why are the hives not related to uterine fibroids or this cancer explained?
“It wasn't clear that fibroids would cause this,” said Schneider, a member of the Cedars-Sinai Medical Group. “But it didn't look like a typical uterine fibroid, so I recommended that it be removed.” Sternlieb said she was worried she might still have the disease after the hysterectomy. and agreed.
During surgery in December 2005, Schneider had eight fibroids removed. The largest one was a whopping 11 centimeters long, about the size of a large grapefruit.
Almost 20 years later, Schneider vividly remembers its unique characteristics. Fibroids are usually hard balls of muscle, she said. It was filled with pus, and when I touched it with a scalpel, it gushed out explosively.
“It was crazy,” Schneider said. He had never seen anything like it before, and never since. She administered antibiotics, took cultures, and sent them to a pathology lab for analysis.
Takjian remembers getting a call from Schneider right after the surgery to tell him what he had discovered.
“I thought, 'I need to know what the heck is growing,'” Takjian said. “We believed that whatever it was, it would be cured with surgery. But only time will tell.”
A few weeks later, the first question was answered. Culture tests detected an unknown strain of Salmonella enterica, a common bacterial infection usually caused by contaminated food. The Centers for Disease Control and Prevention estimates that it causes more than 1.3 million illnesses, more than 26,000 hospitalizations, and more than 420 deaths each year. Neither Sternlieb nor her doctor knew when or how she contracted salmonella, a bacteria known to cause hives when it colonizes her intestines, Takjian said.
In Sternlieb's case, the bacteria had invaded only one fibroid. Her remaining seven samples did not contain Salmonella.
“I kept asking older doctors if they had seen anything like this, and they said they had never seen anything like this.”
— Jessica Schneider, gynecologist
“They probably planted a seed in their gastrointestinal tract and thought, 'This is a great nest for me,'” says Dr. McConlogue, who practices in Santa Monica and is an associate clinical professor of medicine and pediatrics at the David Geffen School of Medicine at the University of California, Los Angeles. Takujian said.
However, the duration of Sternlieb's infection, its location within the uterine fibroid, and the recurrent urticaria made this case more like a fibroid. This is a medical term for an unusual and unusually interesting case, and its status will be further enhanced by the discovery of the source of the infection.
“I kept asking older doctors if they'd ever seen anything like this, and they said they hadn't,” Schneider said. Tachdjian's search of medical journals turned up nothing similar.
Salmonella is a reportable disease, so California health officials were notified.
A few months after the surgery, Sternlieb received a home visit from a public health nurse and received some surprising news. It turns out that the source of her infection was not food, but reptiles.
Turtles are known to carry salmonella, one reason federal law has long prohibited the sale of small turtles due to the risk they pose to young children. Other reptiles such as snakes, frogs, and lizards are also carriers, so public health officials emphasize the importance of hand washing after touching these reptiles.
But Sternlieb said her family has never kept reptiles as pets. Because her symptoms began shortly after she gave birth, Sternlieb's infectious disease doctor suspected she had contracted the infection at the hospital, perhaps from a staff member. During pregnancy and before birth, the mother's immune system may be suppressed to prevent rejection of the fetus.
Sternlieb racked her brain to recall another possible exposure to reptiles from about 20 years ago, when her 4-year-old son was infected by a pet reptile at his daycare center. He said it may have been transmitted. But she added that he never brought home a reptile and had no recollection of having such a pet at school.
Schneider said she started recovering almost immediately after the surgery and never had any subsequent episodes. Doctors deemed the surgery curative.
Takjian said he suspected she had contracted the infection at the hospital, adding that she was lucky to have undergone surgery. If her fibroids had ruptured, Sternlieb could have developed sepsis. Sepsis is a potentially fatal infection caused by bacteria that travels through the bloodstream.
In 2010, Tachdjian, Schneider, and two other doctors published a report on her case in the journal Obstetrics and Gynecology. Their goal, Tachdjian said, was to alert other doctors to consider abdominal hives as a possible sign of a serious pelvic infection.
“We need these reports, so next [doctor] If we encounter such problems, they are immediately imaged,” he said.
Send your solved medical mysteries to Sandra.boodman@washpost.com. No unsolved cases please. To read the mysteries of the past, wapo.st/medicalmysteries.
