Hepatitis, joint pain, and missing the solution to the mystery


To what disease do the symptoms belong,

When dark urine lacks odor so strong?

     I made a few points

     When I asked about joints

But the truth is I’d rather be wrong.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks away, I’m having adventures working in new places and visiting friends and relatives.  Right now I’m staffing a clinic in Keosauqua in southeast Iowa.

My month in Keosauqua draws to a close tomorrow.

A patient (who gave me permission to write this information) came in today with a puzzling constellation of symptoms for two weeks: fatigue, malaise, chills and sweats, joint pain, morning stiffness, abdominal pain, vomiting and diarrhea.   The fingers on the right hand were swollen, visibly larger than those of the left hand, and index and middle fingers had swelling of the knuckle joint close to the hand.  I found other abnormal items on the physical exam, my fingers gliding over tiny, painful lymph nodes at the inside of the upper arm, just above the elbow.

On the basis of an impulse whose source I do not know, I asked the patientiof the color of stools had lightened and that of the urine had darkened.  They had.

At the end of the visit I said, “You want me to be wrong about everything I’m thinking of because the best diagnosis we can hope for is infectious mononucleosis.  That’s the best one.  You don’t want rheumatoid arthritis, Lyme disease, or hepatitis, or any of the worst things that I can think of.  And I suppose it’s possible that it’s work related.  We’ll have to see.”

Not widely known, but the rheumatologists make the diagnosis of hepatitis B more often than the gastroenterologists. Early in the course of the disease, any hepatitis can look like rheumatoid arthritis.  Patients can, and do, have severe joint pains without any abnormality of the liver function tests. 

Hepatitis B should be prevented by immunizations administered in infancy.  However, some parents choose against immunization (which I find foolish) and a very few people will not make antibodies in response to the vaccine.

Hepatitis C can cause similar joint pains, but usually doesn’t.  Mostly it causes an overall sensation of fatigue, less often the classic signs of hepatitis, with jaundice and swollen liver.

In medical school, hepatitis came in the classifications of infectious and serum.  By the time I finished residency, infectious hepatitis bore the name A and serum hepatitis was called B.  The third one, called non-A non-B hepatitis, eventually found the name C.  Ten years ago, hepatitis C mostly smoldered along and every once in a while resulted in liver cancer.   Five years ago we had a cure rate of 10% and now we have a cure rate better than 50%, and improving.

In the end, the patient’s diagnosis will come from lab work, but by the time the results come back I will have moved on.  I will not witness the denouement, the answer to the mystery.

At the end of the afternoon, I introduced the patient to one of the other docs here and made arrangements for follow-up.

The patient lives in a world, a social context with relatives, friends, and a job or two.  I will miss out on seeing how the disease affects the person and the world around them.

I will wonder.

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4 Responses to “Hepatitis, joint pain, and missing the solution to the mystery”

  1. DAVE STERLING Says:

    Steve – I was surprised to learn that you have many talents, including poetry and cooking. You are indeed a talented doc. But I believe that the landscape is more than what appears on the surface when one looks at the possibilities for this kind of talent.

    I am talking about a gig in Las Vegas. You can polish up your routine for some one-nighters at one of the big hotels on the strip. With all the Jews (among the goyim who attend), your appearance both as the walkabout doc and the “wandering Jew” could make you a headliner. The pay there is not bad either. I could be your straight man if you need a two-some.

    Just a few thoughts to add to your resume’.

    Let me know when you are ready to take this next step!!

    DAVE STERLING

  2. Arletta Ketterman Says:

    Hepatitis is a viral disease but the great thing about is that you can always get a Hepatitis Vaccine. ”

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    • walkaboutdoc Says:

      We have good vaccines to prevent hepatitis A and B, but none for hepatitis C. About 5% of the population never respond to the hepatitis B vaccine. Hepatitis C, not vaccine preventable, turns out to be our big hepatitis problem in the country; it leads to cirrhosis and liver cancer. It’s treatable, our cure rate is now 80%, but the treatment is obnoxious and last for close to a year.

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