Initially diagnosed with a urinary-tract infection, a 75-year-old man sought emergency treatment for increasingly severe symptoms, including kidney failure—ultimately leading doctors to a far more unusual diagnosis, Lisa Sanders writes for the New York Times Magazine.

Unexplained fainting spells

Over the course of a 10-day period, the patient experienced several fainting episodes. The first occurred while he was napping outside. The second happened at night, on his way to the bathroom—and when he woke up on the floor, he learned he had also been incontinent.

After that second occurrence, the patient arranged a visit with his provider. He explained to his PA that in addition to the fainting spells, he had not been feeling well and was tired, feverish, foggy; had no appetite; and experienced some discomfort while urinating. The PA ordered some lab tests, ultimately concluding that he was likely suffering from a urinary-tract infection. The PA prescribed antibiotics and instructed him to go to the hospital if he started to feel worse. 

Two days later, the patient experienced another fainting spell, this time while taking his medications. He went to the ED at Yale New Haven Hospital to learn more.

Eager to find the right answers

At Yale New Haven, the patient presented with a fever of 101, a racing heart, and abnormally low blood pressure. Lab results revealed that the patient's kidneys were failing—even though there had been no sign of failure just two days earlier. 

Doctors were initially focused on the patient's failing kidneys. However, Alan Lee—an intern in his last year of medical school and the first clinician to see the patient—was eager to determine the cause of his fever and other symptoms. Together with his supervising resident, Roger Ying, Lee learned that in addition the fainting spells, the patient had felt too ill to eat or drink anything and lost 10 pounds in a week as a result. Curious, Ying asked if there was any chance the patient had been bitten by a tick—but the patient assured him that while he often went on walks in the woods with his dog, he was confident he had not been bitten, since he always meticulously checked his body for ticks afterward. 

Joined by the attending physician, Joseph Donroe, the doctors agreed that a urinary-tract infection could have caused the patient's urinary issues, fever, and kidney damage resulting from dehydration. However, they acknowledged that a 10-pound weight loss and persistent night sweats are not typical symptoms associated with a urinary-tract infection. 

Looking beyond the likely diagnosis 

Donroe concluded that the patient likely had urosepsis—an infection caused by a urinary-tract infection that affects the whole body.  Since the patient was on antibiotics, Lee called the patient's primary-care doctor to obtain the lab results from before he began the antibiotics. The urine culture did not show any abnormalities other than blood in the urine. And while the patient began to feel significantly better on the antibiotics, his kidneys were still not improving. 

Then, the providers learned from one of the labs that the patient's red blood cells looked like they were being destroyed—and everything started to make sense. Additional lab tests confirmed Donroe's suspicions; the patient suffered from two tick-borne diseases, babesiosis and Lyme disease.  After taking antibiotics for both conditions, the patient immediately started to feel better—and said he plans to inspect himself more carefully after walking in the woods. (Sanders, New York Times Magazine, 8/26)