Medical mysteries: Ian Liu’s back pain was horrible, but no one knew the reason

These bacteria can migrate to other parts of the body, as they did in Liu’s case, causing serious infections. Tests revealed that Liu also had cerebritis, a brain infection responsible for his worsening confusion, as well as osteomyelitis and diskitis, which were the reasons for his back pain.

Liu’s infection was caused by Streptococcus viridans, bacteria found in the mouth that are a common cause of endocarditis. Liu said that he had not undergone any medical procedures, but he had had his teeth cleaned several weeks before the back pain developed; doctors have told him there is no way to know whether that precipitated his infection. And although he said he had never been told he had a heart murmur or other defect, such a condition may have predisposed him to endocarditis, said infectious-disease specialist Marc Siegel, an assistant professor at George Washington University School of Medicine.

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“Back pain is a known presentation of endocarditis,” said Siegel, who has not treated Liu. “The lower back happens to be where the blood supply is most concentrated.” In a patient with a defective heart valve, the strep bacteria can flourish.

So why wasn’t Liu’s heart problem detected earlier?

The reasons for that are unclear, Siegel said. It’s impossible to know whether the murmur was new or had been present for some time but never detected. “A new murmur would be a pretty concerning finding,” he said, while a preexisting one might have alerted doctors to focus on Liu’s heart much sooner. “Unfortunately, younger doctors — and I include myself in this — are probably not as good on physical exam as [doctors] used to be.”

Many heart murmurs, which are detected by listening to the heart through a stethoscope, do not cause problems, while others found in adulthood may be a sign of valve disease.

Liu said that the specialists treating him initially expected he would receive 10 weeks of intravenous antibiotics, then undergo open-heart surgery to repair or replace his damaged mitral valve. But after a few days in the hospital, it became clear that his heart was failing and surgery could not wait. On Jan. 18, he received a new mitral valve made of bovine tissue.

For the next two years, Liu said, he took antibiotics to eradicate the infection in his back.

Now 47, Liu has retired from the military and works as an IT specialist for the State Department. Although his replacement valve has functioned well, it has worn out faster than doctors expected, and he is facing surgery this spring to replace it.

Liu said his illness has made him appreciate the importance of having an advocate to ask questions and push for care when a patient is too ill to do it.

“I was in such pain and on heavy painkillers, and I just wanted the pain to stop,” he said of the weeks preceding his diagnosis. He said he is especially grateful to the military doctor who helped coordinate his care once he learned he had endocarditis and to his wife for telling the neurosurgeon about his confusion.

“At the time, I thought I had done everything I could do.”

Have a medical mystery that’s been solved? E-mail medicalmysteries@washpost.com.