A quick and sudden decline

After returning home from a business trip, a woman became concerned about her husband. He was much quieter than usual, and he wasn't always making sense when he spoke. Although she was initially concerned that he had had a stroke, he insisted that he was fine.

Over the next few weeks, he continued to experience more strange symptoms. His hands would shake so much that he cut himself repeatedly while shaving and could not hold utensils to eat. He also experienced a fall and seemed to be confused about his own actions at times.

The day after Thanksgiving, his wife made him an appointment at his doctor's office, where they were seen by the physician assistant (PA). During the visit, the PA found that the man could not correctly tell her what day it was, his hand shook significantly when he tried to touch his nose, and his "entire body wobbled dangerously" when he tried to stand, Sanders writes. In comparison, the man had been walking 10 to 15 miles a day just a few weeks earlier.

The PA reviewed his lab tests, but they were all normal. She then ordered an MRI of his brain, which she said would give them a better idea of how to proceed. However, she recommended the man be taken to the ED if he fell or seemed unsafe at any point.

After the visit, the man's wife decided to drive him to the ED at Danbury Hospital, where he was admitted. The hospital's neurology department ran multiple tests, including blood tests, CT scans, and MRI, and EEG, and a spinal tap, but there was nothing that could explain his rapid mental and physical decline.

His wife expressed concern about the high dosage of Pepto-Bismol he was taking to combat gastritis, but when doctors checked for the level of the aspirin-like compound in the medicine, which can cause problems, the man's levels were normal.

After five days at the hospitals, the neurologists were unable to find a cause of the man's symptoms, so they referred him to a neurologist at Yale University. Because the man was too weak to go home but not sick enough to be in the hospital, he was sent to Care One's River Glen Health Care Center, a short-term rehabilitation center.

A nurse pinpoints the culprit

At River Glen, the man's nurse, Nicole DiCenso, also noticed the high dose of Pepto-Bismol he was taking. Although doctors at the hospital had tested for the aspirin-like compound, they had not tested for the metal bismuth, another ingredient in the medication.

Although bismuth is considered safe, DiCenso wondered if taking too much of it could cause the severe symptoms the man was experiencing. After a quick search, she found a report of a similar patient who had also experienced a rapid mental and physical decline after taking bismuth-containing products for more than a year. According to the man's wife, he had been taking four pills of Pepto-Bismol a day for eight months.

DiCenso then arranged for the man to be tested for bismuth. Days later, the results came in and showed that his bismuth levels were 28 times higher than normal, "well into the toxic range," Sanders writes.

According to Sanders, bismuth has been used to treat a variety of health problems, from stomach pains to syphilis, for over 300 years. In the 1970s, its potential to cause neurological symptoms was discovered after an epidemic of bismuth toxicity broke out in France due to the use of cosmetics containing the metal. Avoiding use of the products reversed the symptoms, but recovery was slow since the half-life of bismuth, or how long it takes to eliminate half of it, is over two months.

After receiving his bismuth results, the man was admitted to Yale New Haven Hospital for treatment, which was supervised by Anthony Tomassoni, the toxicologist on staff.

To speed up the elimination of bismuth from the man's body, Tomassoni suggested they use a process called chelation. During this process, patients are given a medication that binds to bismuth and is excreted in urine. After a few days of taking the medication at the hospital, the man was able to be discharged.

"The change in the patient was immediate," Sanders writes. "He had arrived at Yale New Haven Hospital in a wheelchair, unable to do anything for himself. When he returned home, six days later, he was walking."

Now, it's been a few months since his hospitalization, and "he's well on his way back to normal," Sanders writes. "He is walking 10 to 15 miles a day again. From his wife's perspective, he is still quieter than he used to be. A little more forgetful. But every day he gets a little better — a little closer to the man she married so long ago." (Sanders, New York Times Magazine, 3/7)

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