One of My Toughest Cases
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PHOTOGRAPHED BY SARA ESSEX
The man whose body turned red
Erin Boh | Dermatology | Tulane Medical Center
Dr. Erin Boh frequently sees patients with debilitating skin diseases. Generally, the case is a straightforward incidence of eczema, psoriasis or any number of cutaneous diseases. However, sometimes a patient walks in with a rash that’s a complete mystery.
One such case was a 62-year-old man who seemed to be in perfectly good health other than presenting with a red rash over his entire body. After being passed from one stumped dermatologist to the next, the man ended up in Boh’s office.
“He developed what we call erythroderma, which is basically the ‘red man’ syndrome. He presented, over the course of about a month or two, with total body redness, and as a consequence of that his skin started to peel off.”
According to Boh, “red man” syndrome is like the worst sunburn imaginable, complete with peeling and itching. The patient was experiencing all of that along with losing fluid through his painfully swollen skin. The loss of fluid eventually led to his heart beating faster and working harder until finally his kidneys started to fail, meaning his skin rash had left him almost completely incapacitated.
Boh suspects that other dermatologists simply hadn’t listened to the patient, and they were quite literally only looking skin-deep for the source of his problem. “They sort of looked at the skin and thought they could treat it with topicals and this-or-that. They didn’t know what was causing it, but they didn’t even listen to him. So, he’s in my office and he’s sitting there and he’s miserable. His hands are swollen, his feet are swollen, he can’t put on shoes, his pants are kind of wet because he’s got oozey, dripping fluid from all over and he’s very, very miserable.
His joints are so swollen that he can’t put on a shirt; his wife has to dress him. So, here’s this 60-something-year-old man who’s been the pillar of strength his whole life, taking care of the family, the kids and he can’t go to the bathroom without help because he’s so devastated and crippled and swollen.”
Boh looks at skin the way a tourist looks at a map of the French Quarter – as if it holds some rare, precious knowledge. According to Boh the skin can be an incredible tool in uncovering a patient’s particular ailment, and in medical dermatology it isn’t rare to see cases where the skin gives some clue to what’s going on inside of a patient.
Years of experience have taught Boh that the best way to get to the heart of the matter is to simply listen to the patient; not only the words they are speaking, but also the internal cues a persistent doctor can pick up on. “Of course, then, the first thing we do is listen to him and hear that he has an irregular heart beat, so we recognize that what tripped him into this state of erthyroderma was his irregular heart beat.” She discovered the man was experiencing a vicious cycle of symptoms: an irregular heartbeat causing a horrible skin rash, a rash causing blood loss and blood loss causing an even more distressed heart.
Figuring out the internal problem wasn’t the end, though, as Boh still needed to understand how the whole attack had started. “Was his skin red all over because he had lymphoma? Or was it because he just had psoriasis, which was out of control because his heart wasn’t pumping right?” In order to understand exactly what was going on with the patient, she ordered a spate of biopsies and blood tests and consulted with a cardiologist. “We were able to find out from our biopsies and our blood work that the patient indeed had psoriasis. He had had an irregular heart beat which, not uncommonly, is associated with psoriasis and that irregular heartbeat had then finally made his psoriasis so bad, without causing him symptoms of his heart, that he then went to the doctor because he was red all over.”
Armed with the proper diagnosis, Boh determined the best course of treatment. “We were able, by working with the cardiologist, to put him on medicines by mouth and then subsequently an infusion. His skin and joints went totally back to normal, he was able to get put on medications for his heart and get his heart treated, and so now, years later, he continues with this infusion. And all of that came about not because he was symptomatic with his heart but it was because his skin manifested negatively to what was going on internally.”
22 years in practice
PhD in Biochemistry – 1980
MD from Tulane University – 1985
Native of New Orleans
The impossible baby
Peter Lu | Obstetrics and Gynecology | Fertility Institute of New Orleans
Everyone knows the old adage “If at first you don’t succeed: try, try again.” Dr. Peter Lu of the Fertility Institute of New Orleans takes this advice to heart every time he steps into his office to treat an infertile couple.
“The challenges generally come from keeping the couple optimistic that the medical science, the treatment, will find an answer for them and that we do have an answer for them.” Lu remembers a particularly difficult case he took years ago, when fertility treatment was far more obscure and unknown than it is now.
The couple had already tried numerous treatments across the country. “They did in vitro fertilization twice at the IVF center where they lived. It didn’t work, so they moved on and went to a quite well known – world-famous – fertility center in Colorado. That’s where they were evaluated and told that they weren’t going to get pregnant with their own eggs.”
Lu says that the relatively new science of fertility treatments was far from perfect at the time. Because of this, even a world-famous doctor was incapable of seeing beyond statistics and hormone profiles. Previous doctors had tested the woman and seen that her level of follicle stimulating hormone, a hormone linked to a woman’s fertility, was that of a 40-year-old woman. “The doctors were drawing on just blank statistics. What was told to the couple, that an FSH level of a 40-year-old in a 40-year-old has virtually no chance of leading to a pregnancy, was correct.”
The couple was crushed, thinking that they would never produce a child on their own, when they remembered an old college acquaintance whose wife had given birth to triplets. A call to the newly minted parents revealed that they had been treated by Dr. Lu at the Mayo Clinic in Rochester, Minn.
“They called the Mayo Clinic, really looking for me, and they found out I was in New Orleans, just a several hour drive from where they were. I remember that first consultation when they came by. They were hopeful but not expecting much, knowing that miracles aren’t just handed out. What our assessment showed was that even though she had the FSH of a 40-year-old, if we could get any eggs out of her, they’re not 40-year-old eggs; they’re 30-year-old eggs. Therefore, what’s true in a 40-year-old probably didn’t apply to this 30-year-old woman. This is well understood today, but I think 10 years ago this wasn’t appreciated.”
Lu prides himself on never turning away a difficult case just to keep his numbers up. He informed the couple that the likelihood of a pregnancy was very low, but he would treat them if they wanted to try.
Despite their misgivings, the couple decided to again take on the emotional and financial burden of IVF (each cycle costing around $20,000). “The first IVF cycle they tried a successful pregnancy didn’t occur, but she had a miscarriage, so that was a little bit more promising than it had been before. On their second IVF cycle they ended up having their little boy. IVF requires many office visits; in a course of six weeks there may be 15 office visits.
And so, it was a tremendous burden for this couple.”
Lu is most proud of making the couple feel safe in his care, even though they were so far from home. “I feel like my success in them was not so much that we were successful on the science side, but that I convinced this well-educated couple why it is that it could still work.”
The couple has since returned to Lu for more treatment, leaving with twins the second time around. “The husband always remembered his consultation with the world famous fertility doctor and we would occasionally mention, ‘You know, I’ve got to let that doctor know what eventually happened to us,’ because it was completely different from what he suggested.”
Lu remains in contact with the family, receiving Christmas cards and birthday announcements. The family even offered the Lus a place to stay during a hurricane evacuation. “I do remember that couple well. When I look at pictures of the son and his two younger siblings over the years, that’s what keeps that case in my mind.”
14 years in practice
MS from Georgetown University – 1985
MD from Georgetown University – 1989
Native of Taipei, Taiwan
The woman with brand new hands
Donald C. Faust | Hand Surgery and Orthopaedic Surgery | 2633 Napoleon Ave., Suite 600
It isn’t uncommon for an elderly woman with rheumatoid arthritis to walk into Dr. Donald Faust’s office. In fact, he could see many of the same type of case in one day. According to him, though, that doesn’t make it any easier to treat. “I’ll say prayers sometimes before I go get involved in something.”
Faust recently treated a 92-year-old woman with arthritis so severe that it had almost completely crippled both of her hands. The arthritis had caused her to lose most of the strength in her fingers, which caused frustrating clumsiness. Her joints were swollen and painful and she felt she had to hide her hands. All around, rheumatoid arthritis had taken over her life. “Just daily living she had difficulty with.” Even still, Faust remembers her as a vivacious, happy woman: “She was a delightful lady with an Alabama accent.”
Because of the advanced stage of the disease, Faust had little room for mistake. Going into surgery, he knew that he could either greatly improve his patient’s quality of life, or he could cause even more damage. “It’s a balancing act.
You don’t want to get on a horse and then fall off the other side.”
Faust takes nothing for granted; for him, paying attention to every little detail is one of the most important aspects of his job. “It’s the joke about minor surgery: Minor surgery is what happens to other people, but when it’s you it isn’t minor. Every case I do I worry about. And if you stop worrying about it, it’s probably time to retire.”
With that in mind, Faust went ahead with the intensive procedure on the patient’s right hand in January of this year.
Faust credits his passion for carpentry and his fascination with model building for his skill in joint replacement.
“My father made boats in a bottle. You’re tying all these knots and rigging it all together and making little models.
And that’s all the surgery I do – it’s like model making in a lot of ways.”
The replacement of knee and hip joints is a commonly accepted idea among the general population; most everyone has a grandmother or grandfather with a chrome hip. Artificial knuckle joints, though, are a bit harder to grasp.
The procedure involves taking apart a hand and then reconstructing it so that it regains its entire range of motion. The artificial joints are made out of high-tech materials made to withstand the wear and tear of being human. “The space program and the computers have been able to machine these things so remarkably now. They’re made out of chrome and silastic [a combination of silicone and plastic] and they’ve got these pyrocarbons that we use, too.”
The entire operation on the one hand took a total of about two hours. The healing process for such an involved procedure can take a long time, and Faust’s patient was bandaged for three weeks, healing completely in six weeks.
The woman was so happy with the results on her right hand that she decided to go ahead and do the surgery on her left hand, as well. Faust performed the surgery in May, and since then she has recovered and healed. Faust recently saw her for a post-op office visit where she expressed her gratitude for his ability to save her joints. “Some people have high expectations about pain and they want to have an operation, and you tell them ‘I’m not sure it’s going to help you.’ The more trouble they’re having before, the more they appreciate what you do for them. If you’re too quick to operate for pain they’re not going to appreciate the operation as much as people that have really been hurting for several years.” That was the case with this woman: she had been in so much pain for so long that the operation was like giving her a life again. “She told me she was going to a wedding and now she doesn’t have to hide her hands. She’s just so excited that she can clap now.”
Speaking of this 92-year-old woman whose life was greatly improved, Faust is clearly gratified by his work. It’s the every day, minor surgeries and the care he takes with each of his patients that truly makes him one of the best doctors in New Orleans.
30 years in practice
BS from Loyola – 1973
MD from LSU School of Medicine – 1977
Native of New Orleans