A Suspect Diagnosis
Tuesday, March 4, 2008
Whenever doctors told Ruben Galiano that his wife, Olga, had multiple sclerosis, he tried not to look as though he didn't believe them. To the former hotel cook, her symptoms resembled those he had seen in stroke patients. And the MS medication she had been taking hadn't done a thing.
But the real reason Galiano clung to his skepticism was emotional. "If she had MS it would mean she wouldn't be cured," he said. That was a possibility Galiano could not entertain about his wife of nearly 40 years.
Olga Galiano's problem surfaced about five years ago, shortly after the couple moved back to their homeland, Guatemala. They had spent their entire adult lives in the Washington area, where their children were born and raised, but Olga Galiano's mother was seriously ill and needed their help.
Soon after they settled in Guatemala City, Olga Galiano got very sick. She collapsed on the floor and in the space of a week developed double vision and an uncontrollable tremor in her head and hands. She also lost her sense of balance, and her speech became badly slurred. The first doctor who examined her ruled out a stroke, then diagnosed Parkinson's disease, which he soon changed to MS, an autoimmune disease that affects the central nervous system. A second doctor concurred with the MS diagnosis. A third physician told them he had no idea what was wrong and recommended a witch doctor.
In 2005, the couple moved back to the Washington area to be near their children and to seek better care. Galiano said his wife underwent a brain scan and other tests, and doctors at major medical centers in Washington and Baltimore agreed she had MS.
A chance referral to an astute neurologist months after they returned to the United States proved that Ruben Galiano had been right all along. The Georgetown University neurologist, fresh from a fellowship at the National Institutes of Health, said he had seen other patients with "very weird diseases that looked like MS -- but wasn't."
After four physicians in two countries agreed about the diagnosis, Ruben Galiano, who at the time had no medical insurance, said he struggled to accept what seemed an inevitability. "I thought, 'Okay, that's what this is.' So I called the MS Society because my wife wanted a Spanish-speaking neurologist." He was referred to Carlos A. Mora, an instructor in neurology at Georgetown.
At the first appointment, Galiano recalled, "I told him everything that had happened and said that in my guts, I didn't think she had MS." Mora's response was a complete surprise. "He said 'Ruben, I agree with you.' "
Mora said that he was immediately suspicious of the diagnosis for two reasons: The onset of symptoms had been uncharacteristically rapid and severe for MS, and an MRI of Galiano's brain failed to show lesions that are a hallmark of the disease.
"I had a suspicion of what I thought it was," Mora recalled, but he needed to rule out other causes, including Vitamin E deficiency, encephalitis and a retrovirus that causes a rare form of leukemia. After a repeat MRI revealed an area of atrophy but no brain lesions, Mora ordered a panel of blood tests to check for unusual antibodies.
The results confirmed what Mora had first suspected: Galiano had very high levels of anti-Yo antibodies. That signaled a rare condition called paraneoplastic syndrome, a group of degenerative disorders triggered when the body's immune system mounts a response to a cancerous tumor somewhere in the body.
Anti-Yo antibodies circulate in the blood of women with breast or ovarian cancer. According to the Merck Manual, as many as 20 percent of cancer patients show evidence of paraneoplastic syndromes, which can cause itching, night sweats and skin problems. These symptoms can complicate a cancer diagnosis because they frequently occur in sites that are distant from the primary tumor or metastases.