Why did this patient turn so yellow?

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the yellow stuff

In the morning, the man was feeling better: the stuck gallstone must have come loose and moved on. He was sitting up in bed, reading his phone, when he noticed a small group of doctors gathering outside his door. A young woman gave what he recognized as a description of her own presentation to the emergency room. Then an older doctor began to talk 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. There is normally a constant low level of this dark colored waste created and eliminated as 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 break down, causing more bilirubin to be produced. In the case of this patient, 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 can be a bit yellow, which is where jaundice is most easily seen, but this man was visibly yellow all over. He had much more bilirubin than would be expected in a blocked gallbladder. Our job, he explained to the trainee doctors, is to find out why.

“Do you think I’m hemolyzing?” the patient yelled from his bed. Silence fell as all faces turned to him. They knew that hemolyze was the destruction of red blood cells. But this was not a word that patients normally used. The patient got out of bed and walked to the door. He could see the unspoken question in his eyes. He went to medical school, he told the group, though he never practiced.

Dr. Peter Braverman introduced himself and the three physician trainees on the team. Here’s something else interesting, he told the patient and the apprentices. If he looks at the blood cell count, he can see that this young man has anemia, a lower than normal number of red blood cells. That is rare in a man. And the blood cells that he has are very, very small. This is usually seen only with severe iron deficiency or some abnormality in the shape of the red blood cells. The regular ones are shaped like SweeTarts: disk-shaped, with an indentation on each side. That shape allows the cells maximum flexibility to move through the narrowest capillaries in the body. Red blood cells with any other form are destroyed at a much higher rate. This can cause jaundice, especially if the removal of extra bilirubin is blocked. Let’s go to the hematology service, said the doctor, so they can help us decipher the mysteries of this man’s blood.

Braverman, meanwhile, was curious. This young man had medical training. What did he do with his yellow 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. He hadn’t been in his office. He hadn’t seen his friends. His parents, who were elderly, had not said a word. And he didn’t look at himself in the mirror much. In previous years he noticed that the whites of his eyes sometimes had a yellow tinge. Based on that, he had diagnosed himself with Gilbert’s syndrome, a benign condition caused by not having enough enzymes that break down bilirubin. People with Gilbert’s disease may have a yellowish cast to their eyes, especially during times of physical or emotional stress, when red blood cells break down more quickly. But he never related the yellow that he sometimes saw in the mirror with episodes of abdominal pain. And he had never been so yellow.