Five Doctors, Stumped
Explanation for Woman's Fast-Growing Tremor Turns Out to Be Elementary

By Sandra G. Boodman
Washington Post Staff Writer
Tuesday, May 6, 2008

A. Bruce Munro wonders how things might have turned out if he hadn't lost it and dialed 911.

The retired obstetrician had watched with mounting alarm as his wife, Bettie, seemed to get sicker by the day. For decades her health had been stable, regulated by medicines she took to control her cholesterol, blood pressure, Type 2 diabetes, a thyroid condition and a mood disorder.

But in March 2006, Bettie Munro had developed a tremor that became very bad very fast. Doctors assumed she was suffering from a rapidly progressive case of Parkinson's disease, but the neurologist treating her was baffled about why the increasingly potent drugs he prescribed didn't seem to help.

On Dec. 22, 2006, while Munro was getting his wife dressed for the day, he snapped. She had fallen three times and could no longer feed herself. "I thought, 'This is it, I can't handle this at home,' " Munro recalled. He picked up the phone and called for help. An ambulance whisked Bettie Munro from their house in a Loudoun County retirement community to Inova Loudoun Hospital.

Less than an hour later, a doctor stepped into the waiting room with stunning news. Bettie Munro didn't have Parkinson's disease -- or any other neurological ailment. The cause, so basic a resident should have suspected it, had managed to elude the four experienced doctors caring for his wife -- and Munro himself.

"The one smart person in all this was the ER doctor," said Bruce Munro, who recently celebrated his 80th birthday. "Five doctors learned a lesson that won't be forgotten."

Now 77, Bettie Munro, who spent three weeks in the hospital and a rehab center, has recovered completely. She says she remembers little of her nine-month ordeal. (Memory loss is a symptom of the problem.) Mostly she recalls feeling perplexed about her repeated falls.

The first occurred in March, around the time she was recovering from a stomach virus. She was taking her son and daughter-in-law to lunch when she fell in the restaurant parking lot for no apparent reason. She didn't lose consciousness or hurt herself and insisted she was fine. Soon afterward she developed a tremor in her hands and consulted a neurologist.

The neurologist said he thought the problem might be Parkinson's and suggested she take a drug to control the tremor. Munro decided against it: Her symptoms were mild, and she was already taking more than half a dozen medicines.

But three months later, she returned to the neurologist. Her tremor had gotten worse, and she agreed to start taking a drug used to treat Parkinson's.

Over the summer, her gastrointestinal problems persisted. Concerned, a gastroenterologist ordered several tests and then performed a colonoscopy. He found nothing unusual.

In August, she saw her psychiatrist for a routine appointment. About the same time, the neurologist discontinued the first drug, which was costing the couple $500 a month, and prescribed two less-expensive medications in an attempt to control the worsening tremor.

But he could not explain why Bettie Munro's tremor had become so bad.

By December, Bruce Munro said, his wife was "shaking uncontrollably. She'd get up in the middle of the night to go to the bathroom and be unable to find the bed. Or she would try to sit on the edge of the bed, miss, and fall on the floor."

In mid-December her internist saw her. He checked her cholesterol and blood sugar levels and recommended that the couple seek a second opinion from a neurologist. Maybe, he suggested, they should consider a procedure called deep-brain stimulation, surgery that involves implanting a pacemaker-like device in the brain to reduce involuntary movements.

Less than two weeks later, Bruce Munro, who has had open-heart surgery and was feeling overwhelmed, called 911.

He still vividly remembers the ER doctor's first words: "He said, 'She's got a lithium level of 2.1,' " Munro recalled. "I knew that was toxic." A normal level is between 0.5 and 1.2 millimoles per liter.

At high levels, lithium, which is used to treat mood disorders including manic depression, can cause tremor, convulsions, confusion, memory problems, coma and even death. The drug has a narrow therapeutic range: A bit too much can be toxic and too little can be ineffective, which is one reason people taking it receive blood tests to check their levels.

Bruce Munro was flabbergasted, then chagrined. Despite multiple work-ups, nobody had thought to order the simple but essential blood test. Normally, Bettie Munro had her level checked about twice a year; her most recent test had been performed several months before her first fall. Gastrointestinal illness is known to increase the concentration of lithium in the blood, especially in elderly patients. The Parkinson's drugs she took boosted the concentration even further, her husband said.

The symptoms of Parkinson's disease and persistent intestinal problems were in fact indicators of lithium intoxication. Her therapeutic dose had become toxic.

"Everyone knew she was taking lithium, but nobody thought to check it," Munro said. "If they had, they would have figured out what was going on" and saved about $100,000 he estimates the tests and hospitalization cost.

Munro's case is not unusual. In 2001, Italian doctors writing in the Journal of Clinical Neuroscience reported the case of a 72-year-old woman who had been taking lithium and suddenly developed severe Parkinson's symptoms after a stomach virus. She was hospitalized with a lithium level of 3.7; within a few days, after her lithium was discontinued, her tremor and other symptoms disappeared.

Two days after Bettie Munro was admitted to Inova Loudoun Hospital, she was able to feed herself and walk using a walker. She was transferred to a rehab facility for a few weeks, just in time for a severe outbreak of norovirus, the highly contagious intestinal virus, which she contracted.

A few weeks later she was back home, fully recovered. "I feel great," she said. "I'm back to where I was."

Bruce Munro said that when he informed his wife's doctors that her problem had been lithium intoxication, they expressed surprise. One physician said he thought another had checked her level, so he didn't bother.

"It's the simple things," Munro noted, saying he wishes he'd thought of it.

Bettie Munro is philosophical. "Having five doctors -- a psychiatrist, internist, Bruce, a neurologist and a gastroenterologist -- well, I thought they knew what they were talking about."

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