Medical Mystery: The cause of this man’s suffering was hiding in plain sight

In December 2010, Cid Lopez was visiting an airplane hangar with his employer, who owned a Cessna. While walking around the plane Lopez, blinded by the glare of the late afternoon sun, smacked forehead first — hard — into the low-slung wing.

“I fell to the ground, but didn’t black out,” he remembered.

A week later, the medical malpractice lawyer began feeling “hung over.” Returning from his daily five-mile run, Lopez started trembling and felt so weak he had to lie on the bathroom floor. His wife brought him a glass of orange juice. Within minutes, he seemed to have recovered.

But a few weeks afterward Lopez, now 44, suddenly became dizzy and extremely nauseated while drinking a beer. He stopped drinking alcohol, but the hung-over feeling persisted, accompanied by a headache, shakiness, vomiting and diarrhea.

His primary-care doctor at the time, Lopez said, was dismissive, telling him he was “anxious” and “working too hard.”

During the next six months, Lopez, of Albuquerque, consulted an ear, nose and throat specialist who ruled out labyrinthitis, an infection of the inner ear that causes vertigo and nausea. An ENT expert in Los Angeles suggested he might have chronic fatigue syndrome.

At the recommendation of his internist stepfather, Lopez underwent a brain MRI. A neurologist told Lopez he had an acoustic neuroma, a benign brain tumor, then abruptly changed her mind and said the scan showed nothing.

One New Mexico gastroenterologist suggested that Lopez’s wife, a nurse, might be intentionally poisoning him, but failed to order toxicology tests for the flabbergasted Lopez.

In 2014, another gastroenterologist recommended removal of Lopez’s gallbladder, citing his ­45-pound weight loss, coupled with the results of a scan that seemed to indicate biliary dyskinesia, a disorder in which bile drainage is impaired. The operation only left him feeling sicker.

Yet another gastroenterologist diagnosed postcholecystectomy syndrome, a complication of gallbladder surgery that causes severe nausea and diarrhea. She referred him to a prominent out-of-state medical center for a comprehensive GI workup.

Lopez spent a week there in 2015. Doctors weren’t sure what was wrong, but told him he appeared to be unusually sensitive to certain foods. Lopez noted that although he craved salt, he became violently ill after eating salty foods such as popcorn. Doctors prescribed a diet sometimes recommended for irritable bowel syndrome as well as a drug to slow digestion; neither helped.

In 2016, Lopez decided to stop seeing doctors for a while. Too sick to attend his children’s school events or eat dinner with his family most nights, he routinely came home from work and fell into bed.

“At times, I thought I was going to have to close my practice,” he recalled. “Losing my work would have been the final nail in the coffin.”

In July 2017, a seemingly promising new explanation emerged after Lopez and his wife traveled to a major teaching hospital in California.

Several tests, including a spinal MRI, showed a possible chronic leak of cerebrospinal fluid from the dura, the outer membrane that surrounds the brain and spinal cord. Experts told Lopez they believed the leaks were the result of his 2010 accident with the Cessna. They recommended a series of epidural blood patches, in which a small amount of blood is injected into the epidural space in the spine to plug the leak. For weeks after the procedure he was violently ill.

A December 2017 meeting with a client, Albuquerque neurologist David R. Smith III, changed everything.

Smith noticed that Lopez looked very ill. His skin had the grayish pallor common to cancer patients and he had lost so much weight that his cheeks were sunken. What, Smith gently inquired, was wrong?

After hearing Lopez’s story, Smith offered to review his medical records.

As he paged through Lopez’s records, Smith was struck by the absence of a positional headache, pain that improves when lying flat. It is one of the most common symptoms of a spinal fluid leak. And when he looked at the MRI, the neurologist did not see a leak.

Lopez told Smith, as he had the doctors he had seen, that his symptoms started after he hit his head. “He said he was fine until then,” Smith said. “To me it seemed logical to start there.”

Lopez mentioned that he had recently told his internist that he was getting up six or more times each night to urinate. Smith suspected the cause might not be his prostate, the most common origin of such a problem, but rather dehydration that can result from an electrolyte problem.

Reviewing his lab tests, Smith spotted a slightly but persistently elevated sodium count in the years after the accident — but not before. He calculated Lopez’s serum osmolality, which measures the concentration of sodium ions and other substances in the blood. Smith’s calculations showed that it, too, was elevated.

Smith suspected that the blow to Lopez’s head might have damaged his pituitary, the pea-sized gland at the base of the brain, which serves as the body’s metabolic control center. A traumatic brain injury can cause hypopituitarism, a condition in which a hormone deficiency impairs normal function. One of the hormones released by the pituitary is antidiuretic hormone (ADH), which regulates fluid balance.

The neurologist theorized that Lopez’s damaged pituitary had caused central diabetes insipidus, a rare disorder in which the kidneys remove too much fluid.

Lopez was initially skeptical.

But he was desperate enough

to ask his primary-care doctor to order osmolality and urine tests. Though dubious he could have such a rare condition, he ordered the tests, followed by a second round. All were abnormal, but the doctor remained unconvinced.

Lopez pushed for a referral to an endocrinologist. He, too, was skeptical, but ordered additional tests that yielded the same result, along with a scan that ruled out a pituitary tumor.

Smith’s meticulous analysis had led to the diagnosis of diabetes insipidus which essentially had been hiding in plain sight.

Lopez began taking a form of vasopressin, the replacement hormone he will need for the rest of his life. Slowly but steadily, he began to improve.

“I feel 80% to 90% better,” Lopez said recently. He carefully monitors his salt intake to prevent sodium overload, must avoid becoming overheated — he no longer runs — and cannot consume alcohol or caffeine, which are too dehydrating. He also takes expensive medication to treat the consequences of his unnecessary gallbladder surgery.

Lopez is trying to make up for the years he lost with his children, who are now 5, 12 and 14. He deeply regrets that his stepfather, who he said was consumed by trying to help him, did not live to see the outcome. He died in 2015.

Lopez thinks if it were not for his work as a malpractice lawyer, "I would never have met the person who diagnosed it.” He said he worries about others who are suffering and lack support or resources. “I represent people like that all the time,” he added.