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When Darkness Prevails

You Be the Doctor

"Ever tried. Ever failed. No matter. Try again. Fail again. Fail better."

Worstward Ho, Samuel Beckett

Light sensitivity

Any time physicians dwell in the land of causality, they exist in treacherous terrain.

Connecting the dots between a specific event and subsequent illness or injury is often tethered by only the most tenuous sliver of time. You cannot assume that temporal correlation equals causation.

Nausea and vomiting after supper? More likely due to contaminated food eaten much earlier in the day than food recently consumed.

Both empiricism and the laws of nature have to be respected by physicians as they attempt to explain the why of a diagnosis.

A potential diagnosis reaches its highest validity when doctors have an exact etiology, the explanatory epitome of why one suffers from a particular affliction.

Still, there are times when even the best diagnosticians come up wanting in their quest for a clear explanation.

The late Emory poet-cardiologist John Stone wrote, "There may be no answer . . . and you will look smart and feel ignorant . . . and whole days will move in the direction of rain."

A patient evaluated at the Emory Special Diagnostic Services clinic highlights this occasional failure to diagnose and explain.

The patient, who was in her 50s, had undergone aesthetic laser treatment of the "baggy under-eye area" two years earlier.  

Despite the limited surface area initially targeted, the procedure soon led to extensive skin irritation, with involvement spreading from the original site. Repeated episdoes of flushing and other debilitating systemic symptoms soon ensued.

Her life had become a solar nightmare. Transient exposure to sunlight caused her skin to burn, and her eyes to become intolerant of light. Now a nocturnal being, she travels only at night, her existence confined to the shadows.   

The laser therapy seems to have been the temporal and probably causal culprit.

As to the why, however—the etiology, the reason, which could lead to effective treatments for her suffering—ignorance reigns.

What if the laser procedure had nothing to do with her symptoms? This possibility must be considered. Perhaps it was an unrecognized, pre-existing autoimmune condition, predisposing her to the reaction. It could have been autonomic problems, a virus, hormones—a host of other underlying possibilities presented themselves.

Extensive consultation with specialists, laboratory testing, and radiologic imaging were not enlightening.

Even if it was the laser, what made the therapy so devastating for this patient while other patients recovered quickly and completely?  

So while the physician may deduce that the patient’s face was red and inflamed due to the laser treatment, many unknowns remain: Why did the laser provoke such a reaction? Why did it spread? Why will it not go away? And why did it generate such diffuse symptoms?

We’re still searching for answers. And the patient, like her diagnosis, continues to struggle along in darkness.

This case is shared by Clyde Partin, director of the Emory Special Diagnostic Services (ESDS) clinic, which can be reached at diagclinic@emoryhealthcare.org.

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