The yellow matter
By morning the man felt better – the stuck gallstone must have dislodged and moved on. He was sitting up in bed reading his phone when he saw a small group of doctors outside his door. A young woman gave what he recognized a description of his own presentation to the emergency room. Then an elderly doctor started 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 consistently low level of this dark-colored waste that is created and removed when red blood cells are born and die. But there are diseases that can increase bilirubin levels – either because something happens that blocks its excretion, or because more red blood cells are broken down, creating more bilirubin. In this patient’s case, the trapped gallstone blocked the flow of bilirubin to the GI tract. But that usually doesn’t cause such jaundice. The whites of a patient’s eyes may be a little yellow – that’s where jaundice is most easily seen – but this man was visibly yellow all over. He had much more bilirubin than would be expected with a blocked gallbladder. It’s our job, he explained to the junior doctors, to find out why.
“Do you think I’m hemolyzing?” cried the patient from his bed. Silence fell as all faces turned to him. Hemolysis, they knew, was the destruction of red blood cells. But this was not a word patients commonly used. The patient got out of bed and sauntered to the doorway. He saw 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 team’s three junior doctors. Here’s another interesting thing, he told the patient and the students. If you look at the blood count, you can see that this young man has anemia – a lower than normal red blood cell count. That is rare in a man. And the blood cells he has are very, very small. Usually you only see this with a serious iron deficiency or with an abnormality in the shape of the red blood cells. Regular ones are shaped like SweeTarts candies – disc-shaped, with a notch on each side. That shape gives the cells maximum flexibility to move through the narrowest capillaries in the body. Red blood cells of a different shape are destroyed much faster. This can cause jaundice, especially if the elimination of the extra bilirubin is blocked. Let’s contact the hematology service, the doctor said, to help us unravel the mysteries of this man’s blood.
Braverman, meanwhile, was curious. This young man had medical training. What did he think of his yellowed skin and eyes? The patient looked away uncomfortably. Actually, he hadn’t noticed. During the pandemic, he moved in with his parents and worked from home. He had been quite isolated. Hadn’t been in his office. Didn’t see his friends. His parents, who were elderly, had not said a word. And he didn’t look much in the mirror. In recent years, he noticed that the whites of his eyes sometimes had a yellow tint. On that basis, he had been diagnosed with Gilbert’s syndrome, a benign condition caused by not having enough of the enzymes that break down bilirubin. People with Gilbert’s disease may have a yellowish tinge to their eyes, especially during times of physical or emotional stress, when red blood cells break down more quickly. But he never associated the yellow he sometimes saw in the mirror with bouts of abdominal pain. And he had never been so yellow.