The voice on the phone was crisp and efficient. The 75-year-old woman listened, speechless. Her much-anticipated surgery to repair the crumpled vertebra in her lower back was canceled. The caller informed her that her chest X-ray, a routine pre-procedure test, was abnormal. She should see her doctor, and when her X-ray was normal, she could reschedule the operation. She summoned a polite response and hung up the phone. She could feel her heart racing and sat down.
She had had a cough for two years. It started not long after the pandemic descended on New York City and down the length of Long Island, even into the sleepy village of Quogue where she had moved to at the end of a busy career in Manhattan. After hacking away for several weeks — longer than any normal cough should last — she went to see her primary-care doctor. The doctor immediately tested her for Covid and sent her for an X-ray. When both were normal, doctor and patient were reassured. Her doctor suggested she get rid of her feather pillows and down comforter, in case they were causing an allergic reaction, and she did. It didn’t help. Occasionally she considered going into the city to see a pulmonologist but knew the doctors there would be drowning in Covid cases. People were dying, and all she had was a cough.
But a year and a half later, she still had the cough. It was her constant companion, with her all day long, and according to her daughter — who moved back in with her when the pandemic struck — it was there all night as well. And it was a disgusting-sounding cough, as if she was coughing up something awful. Even worse, over the past couple of months she noticed that exercise was harder. She used to be a big walker — she and her dog could stride for miles on the beach and through the village. Now even a short walk could leave her out of breath. Not gasping but winded in a way she had never been from simply walking. Sometimes just making her bed would make her breathe a little harder than she should. Sure, she was 75, but she was a healthy 75. At least she thought she was.
Doom-Scrolling the Internet
It was when she noticed that she’d lost weight — more than 20 pounds — that she became worried. That’s when she went to see an ear, nose and throat specialist, who examined her and put a camera down her throat. Everything looks fine, he told her. He thought it could be reflux and prescribed a medication for heartburn. When that didn’t help either, she just let it go.
But now, just a few months later, this routine X-ray showed that there was something wrong with her lungs. She called her primary-care doctor once more. The doctor looked at the X-ray and immediately ordered a CT scan of the woman’s chest. The results were posted in her electronic medical record within a day. The patient scanned them anxiously. She didn’t understand a lot of the language, though it was clear the scan wasn’t normal. She used the internet to try to understand what she was reading. Each page she read led to more searches and newer and stranger terms. Did she have interstitial lung disease? And exactly what was that? Finally, she found a sentence that put an end to her search: “The most common form of interstitial lung disease, idiopathic pulmonary fibrosis (I.P.F.), has a life expectancy of approximately three to five years.”
Terrified, she called her old doctor, who had taken care of her for years when she lived in New York City. “Am I going to die in three to five years?” she asked her, as calmly as she could. She read the CT scan results to the doctor. She too was concerned by the radiologist’s findings and suggested the patient see a pulmonologist. She knew a good one: Dr. Lester Blair at Weill Cornell Medicine in New York City. The older woman thanked her, then called his office immediately. She got an appointment for the following week.
It was a crisp, cold February day when the patient drove to the Upper East Side to see Blair. The doctor knocked on the exam-room door, then entered briskly. He was tall and thin and looked to be in his mid-60s. He introduced himself and got right down to business. He asked: Do you have a bird? She was stunned by the question. Why in the world would that matter? And how did he know? Because, actually, she did. Or rather, her daughter did. She brought a parakeet home with her when she moved in at the start of the pandemic. Blair nodded. And who cared for the bird? Well, she did. She had birds years ago and enjoyed taking care of them. She changed the food and water and cleaned the cage every day. She did the same for the birds that visited the feeders outside her windows. Blair nodded again.
It’s possible that her daughter’s bird was causing the cough, Blair explained — it was possible that she had developed a type of allergy to birds called hypersensitivity pneumonitis, one variant of which is known as bird fanciers’ lung. It was first identified in 1965 in pigeon breeders but is now recognized to be one of the most common causes of this kind of lung disease, possibly affecting thousands of bird owners. But there were other possibilities that they would have to test her for as well. In the meantime, she should consider finding a new home for the bird and getting her house cleaned to get rid of any allergens left once the bird was gone.
After a brief exam, Blair sent her to the lab, where tube after tube of blood was taken. She was to follow up with one of his colleagues — Dr. Kerri Aronson — a pulmonologist who specialized in this kind of lung disease.
Questions and Questions and Questions
The bird was still living with the woman when she returned to see Aronson. When the doctor introduced herself, the patient repeated the story once more. The cough started a few months after the bird moved in. She had birds before and this had never happened. But, she added, she took Blair’s advice and the bird would be going to a new home in a couple of weeks. Then Aronson asked her about other possible exposures. Had she ever been a smoker? No. Had her house suffered water damage or had a mold problem? Never. Did she have a Jacuzzi? Had she ever lived on a farm? The list went on and on. She had none of those exposures. Just the bird.
Blair had tested the woman for evidence of sensitivity to various bird allergens. They were all negative. Was it really the bird? He had also ordered tests to look for other causes of this kind of lung disease. Nothing showed up there either. So what was it? Despite the negative tests, Aronson still thought the bird the most likely culprit. But there was one more test to be done before she started treatment — a test to look at her lungs from the inside. In this procedure, a tiny camera would be introduced into her lungs. A sterile liquid would be sprayed into the airways then sucked out. The retrieved liquid would be examined for evidence of inflammation and to detect any viruses or other bugs.
That test, called a bronchoalveolar lavage, was done 10 days later. The liquid suctioned out of her lungs was teeming with inflammatory cells. But there were no viruses. No bacteria. No fungi. With everything else ruled out, Aronson started the patient on a high dose of prednisone to calm what still seemed most likely to be an allergic inflammatory process. The prednisone was like magic. Almost immediately the patient noticed that her cough quieted and that her breathing was easier. By the time she returned to see Aronson two months later, she felt great. She still had the occasional cough but it was getting better all the time. The scans took longer to improve, but her most recent one, this spring, showed only a scattering of abnormal patches, which are probably scars.
I asked Aronson about the inconclusive test results. She said that the patient’s story of a cough that started months after the bird moved in, along with the typical CT scan, seemed more important than the test results. And her improvement once the bird was out of the house was reassuring. No test is perfect, she reminded me.
The patient is thrilled that she was finally able to have her much-needed back surgery — and that she is now able to enjoy her walks again. She isn’t doing the kind of mileage she did before the bird moved in — but then, she and her dog are a couple of years older. And as they walk, they still enjoy watching and listening to the birds — from a very safe distance.
