29.05.2024

Why Was This Patient Turning So Yellow?

By morning, the man was feeling better — the jammed gallstone must have gotten loose and moved on. He was sitting up in bed, reading his phone, when he noticed a small group of doctors collecting outside his door. A young woman gave what he recognized as a description of his own presentation to the emergency room.

Then an older doctor began talking about jaundice, the yellowing of the skin and eyes. The color came from a buildup of something known as bilirubin, a breakdown product of red blood cells. Normally there is a constant low level of this dark-colored waste created and disposed of as red blood cells are born and die. But there are diseases that can increase bilirubin levels — either because something happens to block its excretion or because more red blood cells are being broken down, causing more bilirubin to be made.

In this patient’s case, the stuck gallstone blocked the flow of bilirubin into the gastrointestinal tract. But that doesn’t usually cause jaundice like this. The whites of a patient’s eyes might be a little yellow — it’s where jaundice is most easily seen — but this man was visibly yellow everywhere. He had far more bilirubin than would be expected in a blocked gallbladder. Our job, he explained to the doctors in training, is to figure out why.

“Do you think I’m hemolyzing?” the patient called out from his bed. Silence fell as every face turned toward him. Hemolyzing, they knew, was the destruction of red blood cells. But this wasn’t a word patients usually used. The patient got out of bed and ambled to the doorway. He could see the unasked question in their eyes. He went to medical school, he told the group, though he never went into practice.

Dr. Peter Braverman introduced himself and the three doctors in training on the team. Here’s something else interesting, he told the patient and the trainees. If you look at the blood-cell count, you can see that this young man has an anemia — a lower-than-usual number of red blood cells. That’s rare in a man. And the blood cells he does have are very, very small. Usually you see that only with a severe iron deficiency or with some anomaly in the shape of the red blood cells. Normal ones are shaped like SweeTarts candies — disc-shaped, with an indentation on each side.

That shape allows the cells maximal flexibility in order to move through the narrowest capillaries in the body. Red blood cells with any other shape are destroyed at a much higher rate. That can give you jaundice, especially if the elimination of the extra bilirubin is blocked. Let’s reach out to the hematology service, the doctor said, to help us figure out the mysteries of this man’s blood.

Braverman, meanwhile, was curious. This young man had medical training. What did he make of his yellowed skin and eyes? The patient looked away uncomfortably. Actually, he hadn’t noticed it. During the pandemic, he moved in with his parents and was working from home. He had been quite isolated. Hadn’t been to his office. Hadn’t seen his friends. His parents, who were elderly, hadn’t said a word. And he didn’t look in the mirror much. In past years he noticed that the whites of his eyes sometimes had a yellow tint to them.

Based on that, he had diagnosed himself with Gilbert’s syndrome, a benign condition that is caused by not having enough of the enzymes that break down bilirubin. People with Gilbert’s may have a yellowish cast to their eyes, especially during times of physical or emotional stress, when red blood cells are broken down more rapidly. But he never connected the yellow he sometimes saw in the mirror to the bouts of abdominal pains. And he had never been this yellow.

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