Welcome to the first installment of a new monthly column highlighting the mysterious diseases and amazing human stories occuring in our city’s medical field.
Dr. Mousab Tabbaa has done more than 40,000 colonoscopies in his career as a gastroenterologist. That’s a doctor who specializes in the digestive system, which includes the liver, gallbladder, intestines and more. So you could say he’s “seen a lot of shit.” But when Stacy, a 40-year-old woman, came to see him, he would diagnose something he had never seen before or ever again in his 30 years of practice.
Patient from Afar
Stacy was mostly healthy but had a unique history. Born in Vietnam, she had been a sex worker before immigrating to Cleveland and becoming a seamstress. Things were going well for her since moving. So when her doctor found her liver enzymes to be elevated on a blood test, it came as a surprise. She didn’t drink excessive alcohol and was not obese, both of which can cause problems in the liver. She did however appear slightly jaundiced (yellowing of the skin) according to the doctor, which prompted the referral to the gastroenterologist. When she showed up at Dr. Tabbaa’s Rocky River office, where he has practiced since the early 1990s, she had no pain or symptoms. She was even cracking jokes, acting her normal jovial self.
Dr. Tabbaa was no stranger to seeing people from all parts of the world. He started his medical education in Syria and completed training in Cleveland. Cleveland has always been a multicultural city. While the percent of foreign born people in Cleveland slumped from 33% in 1900 to around 5% now, it is not unusual for doctors to see refugees or immigrants with rare conditions. Like Stacy, 25% of lawfully present immigrants do not have insurance long after they arrive in the United States. While Medicaid is offered to this group, there is a 5 year waiting period to be eligible. Navigating this time period can be very challenging, even if subsidies are available. But initially, Dr. Tabbaa started with simple inexpensive blood tests.
The Tree Within the Liver
He knew to check for viral infections to the liver (hepatitis A, B and C) which can be more common in people from distant parts of the globe due to variable access to vaccines and healthcare. No virus detected in Stacy. But what does jaundice make all doctors think of?…. That’s right, elevated bilirubin. Bilirubin is a waste product from the breakdown of red blood cells. It gets processed in the liver, stored within the gallbladder in bile, and excreted into the intestines through the biliary tree- aptly named for its beautiful branches sprawling throughout the liver. So when bilirubin backs up in the biliary tree it spills back into the blood and deposits in the skin, just like a jaundiced newborn baby. Dr. Tabbaa ordered a CT scan of Stacy’s liver to see what he couldn’t see through blood tests, suspicious that a stiffened liver or a gallstone was disrupting the biliary tract flow.
At this point, Stacy still had her sense of humor and had the staff in the office laughing at each visit. She would tease Dr Tabbaa saying, “you better figure this out!” This is when things started getting unusual. The CT scan showed inflamed and dilated branches of the biliary tree without a stone blocking the way.
Now Dr. Tabbaa had to do a procedure called an ERCP to test the cells of the biliary tract and see the branches in greater detail, lit up like a Christmas tree. He put a camera from the mouth all the way in to her small intestine right where the biliary tract empties into it, then pushed dye into the tree so it can be visualized on X-ray. He found that the biliary tract was sclerosed, or hardened. It would appear she had a disease called primary sclerosis cholangitis (PSC), difficult to treat and much more common in men. But further lab markers for this disease couldn’t confirm it. It wasn’t a “slam dunk” diagnosis, as some doctors says, and he needed more information because something didn’t make sense.
Gut Punch Surprise
Perplexed, Dr. Tabbaa called his mentor Dr. Tony Tavill, a renowned gastroenterologist that helped put Cleveland on the map as a center for innovation in gastroenterology. People with PSC often have inflammation in their bowels. To be certain of this diagnosis they decided Dr. Tabba should do what he does best, a colonoscopy. He found a slightly irritated and inflamed portion of the colon just after the small intestine ends. He biopsied the area. They wondered if there was something more unusual causing this inflammation- something more unique to Stacy.
People can be exhausted, scared, and feeling hopeless after the battery of tests Stacy had been through. But Stacy was relentless, hopeful and always full of life through it all, Dr. Tabbaa recalled. She felt she was in good hands. They all just wanted answers from what started as an abnormal lab.
Then the biopsy came back: parasites. Finally, the story made sense. Having travelled the world on her way to the U.S., Stacy would have been exposed to parasites that are unheard of in Cleveland. Doctors only read about Trypanosoma cruzi in text books, but there it was, found in her colon causing that inflammation. Simply treating this parasite wouldn’t be enough.
There is a rule in medicine, called “true and true.” It means two separate facts can be independently true, even if they seem related. She had inflammation in her biliary tree and liver, and in her colon. But did she have two problems, two truths, to explain each issue or was it all caused by Trypanosoma? Dr. Tabba was suspicious and had to confirm. Would he find this parasite hiding in the liver and biliary tree too?
Two Is Too Many
Inflammation disrupts the normal architecture of tissue. It makes cells work overtime or even regenerate. But cells make mistakes when overworked. Sound familiar? This can result in permanent problems with structure and function of tissue or worse yet cause cells to become rogue, leading to cancer. To evaluate how badly the inflammation damaged the liver, Dr. Tabbaa biopsied the liver. They had already found an exceedingly rare infection. But then they found another.
What at first seemed to be an unusual case of PSC turns out was scarring of the liver and biliary tree due to a second parasite, called Clonorchis or “liver fluke”. This parasite is ingested in seafood and found most commonly in Southeast Asia. It can silently cause damage in the liver and biliary tree over years. For Stacy, she finally had answers. Because she had permanent scarring in her liver at this point, she would require monitoring for cancer even after being treated for the infections. Years later, she ultimately succumbed to cancer stemming from this scarring from the infection.
No one ever wants to stump their doctor. But in Cleveland, many come to get their medical mysteries solved. Dr. Tabbaa exemplified the special attention to detail and expertise needed to solve Stacy’s mysterious case and helped her live happily for many more years.
Dr. Corey Meador is a practicing family medicine physician in Cleveland who has written for PBS NewsHour and The Washington Post. He obtained degrees from Loyola Marymount University School of Film & Television in Los Angeles and Drexel University College of Medicine.