Fat-Bias Could Have Killed This Patient

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Mikhail Varshavski, DO, who goes by “Doctor Mike” on social media, is a board-certified family medicine physician at the Atlantic Health System’s Overlook Medical Center in Summit, New Jersey.

In this video, Varshavski recounts the story of a patient who came to him after being misdiagnosed by other doctors due to fat-bias.

Following is a transcript (note that errors are possible):

Varshavski: A young adult presents to the office with body aches, fatigue, and joint pain. What happened next may surprise you. Let’s get started.

Before I walk in to see the patient, I actually do a chart review to see if the patient has been seen before, what the vitals are, and what information has been shared with my medical assistant. I find out that the patient has actually seen several other doctors over the last few weeks for the same issue and hasn’t gotten a satisfactory answer, meaning a diagnosis, or treatment to solve the issue. In looking through the notes, I saw that the patient was initially diagnosed with arthritis that they attribute it to the patient being overweight. His BMI, I think, put him into the category of morbid obesity.

While that can cause osteoarthritis, he seemed to be a little bit too young for that to start happening. I walk in to see the patient, I introduced myself. One of the first questions is, what has been the diagnosis thus far? What have all the doctors told you?

He went to see a doctor first who diagnosed the patient with arthritis related to his weight. The treatment for that was some over-the-counter medications, which I thought was a rather incomplete treatment, even if that was the correct diagnosis. Then the patient said when they went home and tried the over-the-counter options, the pain did not get better at all. In fact, it got worse and then a rash appeared.

The patient over the weekend went to an urgent care facility where they gave the patient a cream. When I investigated what the cream was, it happens to be a topical steroid and the rashes did go away with the cream. However, over the period of about 10 days the pain in the joints, in the muscles, specifically the knees, and the elbows started to return for the patient.

He came back to that same doctor and said, “Hey, why am I not getting better with the treatment? What’s going on?” The doctor made some other evaluations and ended up sending the patient for x-rays to see if there was anything going on from the imaging side of things, and again reiterated to the patient that the suspicion was all the symptoms were coming from the fact that the patient was overweight. Clearly, that wasn’t the issue.

If you look at the course of illness for this patient — the fact that it was getting worse, there is not only joint pain, but there is also body aches, there is also fatigue setting in, rashes starting to happen — these are multiple systems being involved and that tells me something systemic is going on.

I decided to ask the patient if he sent a message to any of his friends of the rashes. Typically we do that, right? We’re like, “Oh my God, what is this?” We take a picture with our iPhones. To my luck, he did. He took a picture of the rash early on when it started. It looked like an erythematous, meaning very red, rash of the skin. He only had a picture of one of them, but he said all of them looked quite similar.

Now, this is unique. Because the fact that it’s not happening again in one area tells me that it’s not an isolated or localized reaction to something. If I have a reaction right where my watch is, that tells me something is going on in this area. Either there is a contact dermatitis where I’m allergic to one of the components of the watch or maybe a fungal infection from trapping of the moisture, so the localized nature of the rash would tell me something. But when we have a rash that’s happening all across the body, that means that something is happening internally. Whether it’s in the blood or in the lymphatic system. I need to think further.

I started putting pieces together and I said, “Wait, you have fatigue, joint pain, body aches, and a rash.” Does this patient have Lyme disease? I asked the patient, does he spend a lot of times outdoors, hiking, gardening? He said, “No, absolutely not. I’m kind of a home body. I like to stay home. I don’t really go outside much.”

I’m like, “Do you have a dog?” He is like, “Yeah, I love my dog. I sleep with my dog.” I’m like, “Has your dog ever had a tick?” I see his eyes opened wide and he says, “Yes. My dog, I actually pulled a tick off of him not that long ago.” The way that we get exposed to ticks is not only through being outdoors and in tall grass, but through carriers or vectors. Like Bear [Varshavski points to his dog] can literally run into a big forested area, get a bunch of ticks on his fur, and him being brown, me not see it, climbs into my bed, leaves one of the ticks next to me, and they could easily start feeding and cause an infection.

Every other provider he has seen thus far wrote him off as just an allergy, needing some medications, and it’s all due to his weight. Weight is a problem for a lot of my patients. A lot of my patients do suffer with their quality of life because they fall into the category of morbid obesity. But it’s also not right to blame everything that’s going on without doing a proper history and physical. Like that gets lost right then and there.

At this point, we make a decision that I think what’s going on is that the patient had an erythema migrans rash. But what’s unique is erythema migrans sometimes appears with multiple lesions throughout the body. Sometimes they are all completely red and they don’t all look like the prototypical bull’s-eye rash that we study in our textbooks.

But then I started having to think the patient actually has early disseminated Lyme disease. Why? Because he is starting to have joint pain, migratory arthritis, and body aches, which is myalgias, basically pain in the muscles. That means the inflammation is spreading and unless we catch these and act appropriately it could lead to further Lyme, late Lyme, which is very problematic because then it could spread to your heart causing things like arrhythmias, AV blocks, and neurologic complications. We had to act quickly.

We drew blood then and there to do two tests, one is the ELISA test to make the initial diagnosis of Lyme disease and then a western blot to do the confirmation test for it. Then right away prescribed a course of doxycycline, which is an antibiotic that we like to use for the treatment of Lyme.

The patient follows up 2 weeks later. What do we find out? a) His Lyme tests both positive and b) he feels a hundred times better, zero fatigue, zero joint pain, and zero muscle aches. He is completely cured. Had he progressed to late-stage Lyme disease and had neurologic or cardiac complications, he may have needed a hospital stay for IV antibiotics. He could have lost his life as a result of a cardiac arrhythmia.

If you happen to be a patient, and you feel your provider is overly focused on your weight and you feel like you’re not getting good care because of that, you have two options. Option 1, be direct. Point out to your provider that you feel like there is an overemphasis on your weight and while you know it is an important factor in your health it’s not the sole determinant of your health and you’d like to have a further discussion on that. If they are not receptive, move to Option 2. Or if you don’t even want to have that conversation, that’s your choice to move to Option 2, which is seek a second opinion. That is your right as a patient and insurance cannot deny you for seeking a second opinion because medicine is as much art as it is a science. The relationship between a provider and a patient has to be strong in order for proper health outcomes to occur.

I want to stress this super strongly. Be careful with certain health providers who make the diagnosis of a condition, which is not really a correct condition of chronic Lyme disease. They say that you need to do all sorts of treatments like chelation therapies, extremely long courses of antibiotics that have no real evidence for them, and they blame a lot of my patient’s symptoms on this chronic Lyme disease when in reality that’s not what’s going on.

If someone is pushing on you, expensive lengthy complex treatments, seek a second opinion either with another primary care doctor or even an infectious disease specialist because there is a lot of fraud and malpractice that happens in this area. I have seen my patients truly suffer.

That’s just one of my patients’ stories, but click here to check out my bizarre life as an attending doctor. As always, stay happy and healthy.

Mike Varshavski, DO, is a board-certified family physician and social media influencer with more than 8.7 million subscribers.

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