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The Case of the Decoy Pigeons

You Be the Doctor

pigeons

One day in June, a 63-year-old retired telephone lineman developed a fever and cough.

He was plagued by the fever for months. Several hospitalizations, with numerous cultures, labs, CT scans, MRIs, and various endoscopies, had yet to yield a cause.

Of particular interest was the patient's love of homing pigeons. Each day he looked forward to feeding them in his attic room. Upon his arrival, 30 excited pigeons would fly around, whipping the bird droppings into a diminutive aerosol tornado. Every few months he would enter the aviary and clean the accumulated guano, never wearing a mask to protect himself.

Desperate for an explanation and some relief, he came to Emory's Special Diagnostic Services clinic in September. "In his book Infections of Leisure, editor David Schlossberg mentions 'pigeon breeders disease,' psittacosis, as one of several zoonotic diseases pigeons harbor and transmit to humans," says Clyde Partin, director of the clinic. "But this man had been checked for those diseases. The fevers continued with inordinate tenacity."

Despite his fever and cough, the man appeared tired but not acutely ill. "Back in radiology, I carefully reviewed some lymph nodes that had been seen in his posterior abdomen on a PET scan," says Partin. "We all agreed these nodes were not significant enough to warrant biopsy."

The pigeon enthusiast, however, returned to the clinic several weeks later looking much more ill, with a persistent cough, weight loss, diminishing appetite, an odd sensation with swallowing, and mild anemia.


In his book Infections of Leisure, editor David Schlossberg
mentions 'pigeon breeders disease,' psittacosis, as one
of several
zoonotic diseases pigeons harbor and transmit to humans."
Dr. Clyde Partin
Director of the Emory Special Diagnostic Services clinic

"During the second visit, right in front of me, he began to shiver and spiked a fever," says Partin.

The nurse checked his temperature—103.6.

"I had carefully reviewed his data and concluded that he had neither malignancy nor underlying infection to account for his fever, so most likely it was an inflammatory process," Partin says. "I needed to be decisive in the face of his deteriorating status. Seeing how miserable that fever made him feel, on top of his general debilitation, convinced me to move forward."  

Only one of numerous white counts taken had been slightly elevated. The patient had developed headaches with his coughing fits, but at no other time. His joints were not hurting but his sedimentation rate was up to 119, suggesting that inordinate inflammation was present.

Any thoughts, careful reader, as to what the diagnosis was?

"Taking a deep breath and hoping that he truly had no infection, I made a diagnosis of polymyalgia rheumatica (PMR), a diagnosis I had originally rejected due to how high his fevers were going," says Partin. "But when I researched it, I discovered it was possible to have fevers that high with that diagnosis."

Partin decided to give the patient prednisone—a bit of a risk since, if he was wrong and the patient actually did have an infection, the steroid would suppress his immune system and the infection could get the upper hand quickly and violently.

Two days later Partin called the patient, who reported that the fevers had disappeared and he was feeling much better. The rheumatology consultant who saw him later in the week made a slight adjustment to Partin's diagnosis, believing that temporal arteritis—a cousin to polymyalgia rheumatica—was more likely. "Some of the atypical symptoms of PMR the patient exhibited were due to the inflammatory effects on the arterial supply to his upper airway," Partin says.

Six months later, the patient felt great. After having given away most of his pigeons, he was back to breeding them again. Partin suggested that, from now on, he wear a mask around the pigeons—just to be on the safe side.

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