The doctor’s words hung in the air, heavy with uncertainty. “I don’t know where to go from here,” he admitted to Lashay, a pale 14-year-old, and her increasingly anxious mother. Lashay had been admitted to Intermountain Primary Children’s Hospital in Salt Lake City nearly a week prior. Her body had betrayed her for two long months, rejecting every attempt to nourish it. Food and drink, regardless of type, returned shortly after consumption, sometimes immediately, sometimes after a torturous delay. Nearly ten pounds had vanished from her frame. The symptoms were as baffling as they were alarming. No nausea, no sharp abdominal pains, no diarrhea – just relentless vomiting. A persistent, dull headache and a sensitivity to light were her only other companions. Her mother’s fear grew with each rejected meal; was her daughter starving?
Help us solve this medical enigma. What is the Lashay Diagnosis?
The Costa Rica Vacation Incident
The ordeal seemed to trace back to a family vacation in Costa Rica, just after Thanksgiving. Lashay, her parents, and sister, eager for adventure, spent their first day hiking through the lush coastal forest of Manuel Antonio National Park. An active family, vacations were synonymous with sports and exploration. Suddenly, a large raccoon darted onto their path, launching itself at Lashay’s foot. A scream pierced the tranquil forest as the raccoon scrambled away. Lashay’s foot wasn’t bleeding, but a scratch, a break in the skin, was visible. No deep puncture, just a superficial wound. They cleaned the area with alcohol, comforting the shaken girl. The raccoon incident quickly receded as they immersed themselves in the beauty of their vacation – swimming in crystalline rivers and the vast Pacific, white-water rafting, exhilarating ziplines through the forest canopy, and more hiking.
The raccoon encounter seemed insignificant, a fleeting vacation mishap. But back home in their quiet Utah suburb, it resurfaced. Both Lashay and her mother fell ill with gastrointestinal distress. Her mother experienced diarrhea and headaches. Lashay, too, suffered headaches, but hers were accompanied by violent episodes of vomiting. While her mother recovered in days, Lashay’s condition spiraled. Then, a chilling thought struck her mother – the raccoon scratch. Why would a nocturnal animal attack in broad daylight? Rabies. The terrifying word echoed in her mind.
Driven by fear, she rushed Lashay to her pediatrician, who shared her concern. He immediately directed them to the emergency department, where doctors could assess the necessity of rabies prophylaxis.
Download the records from the first E.D. visit.
Return to the Emergency Department: The Vomiting Persists
A week later, Lashay was back in the E.D., not worsened, but certainly not improved. The relentless vomiting continued – multiple times daily, triggered by even sips of water. Yet, nausea was absent. Strangely, she was also constipated, a stark contrast to typical gastrointestinal upset. Beyond the persistent vomiting, she presented with minimal symptoms. A physical exam revealed nothing significant.
Download the records from the second E.D. visit.
Vomiting without nausea raised a red flag – potential increased intracranial pressure. The E.D. doctor conducted a thorough neurological examination. It was normal. Her abdomen was soft, non-tender. Intravenous fluids were administered, and blood tests were drawn. Again, all results returned within normal limits. “Why is she still vomiting?” her mother pleaded. The doctor offered a possible explanation: gastroparesis, a delayed stomach emptying, perhaps a lingering effect of the virus they’d had post-vacation. Gastroparesis can persist for weeks, he explained, but usually resolves spontaneously. Lashay was given Zofran, an antiemetic, and discharged with instructions to hydrate and follow up with her pediatrician. (Review the second E.D. visit notes here.)
Download the first outpatient studies.
Lashay’s pediatrician referred her to a neurologist, who also performed a detailed exam and ordered an MRI. Both were unremarkable. Next, an infectious-disease specialist was consulted, initiating a battery of tests – blood, stool, and urine – to identify any infectious agents. Giardia, a common waterborne parasite causing diarrhea, was ruled out. Other parasitic infections were also eliminated. Helicobacter pylori, a bacterial cause of gastritis and vomiting, was negative. Celiac disease was excluded. Pregnancy was not a factor. Liver, pancreas, and kidney function were all normal. (See the reports from these initial outpatient studies here.)
Hospitalization: Still Sick and Still Searching for a Lashay Diagnosis
Throughout this medical odyssey, Lashay’s vomiting persisted, multiple times daily. Dehydration became a growing concern for the infectious-disease specialist, prompting her readmission to Primary Children’s Hospital for an expedited diagnostic workup.
Lashay spent four days in the hospital undergoing extensive evaluation. A team of specialists convened: the admitting infectious-disease specialist, a second neurologist, a gastroenterologist, and a psychologist. Due to new onset dizziness upon standing, a physical therapist was also consulted. The infectious-disease specialist repeated blood and stool tests, again yielding normal results. A spinal tap was performed; the cerebrospinal fluid was normal. The gastroenterologist performed an endoscopy, revealing only a few white blood cells at the base of the esophagus, potentially indicative of chronic reflux, but otherwise normal.
Download the records from the first hospital stay.
By the fourth day, the medical team remained without answers. The pediatric gastroenterologist, who diligently checked on Lashay each evening, sat by her bedside, his usual optimism replaced by a somber demeanor. He reviewed the exhaustive investigations, the normal results from every specialist. He confessed his uncertainty about the next steps.
Lashay’s mother listened, her distress mounting. She sensed the doctor’s resignation, a feeling of being abandoned. If nothing more could be done, she declared, she would take her daughter home. (Review notes from this first hospital stay here.)
Seeking a Second Opinion for Lashay’s Condition
Back home, Lashay’s vomiting escalated to 10-15 times daily. Desperate, her mother sought a second opinion at the University of Utah Health Medical Center. However, the new provider referred Lashay back to Intermountain Primary Children’s Hospital.
A fresh team of doctors shifted focus to functional gastrointestinal disorders, conditions arising from GI tract dysfunction rather than identifiable pathology. They reasoned that extensive prior testing had largely excluded organic diseases.
Functional disorders, they explained, can be triggered by initial events like infections, but persist even after the trigger resolves. Cyclic Vomiting Syndrome (CVS) was considered. CVS, primarily affecting children, involves episodes of intense nausea and vomiting interspersed with periods of wellness. These episodes are often provoked by stressors and follow a predictable pattern for each individual. Migraine headaches are frequently associated; many CVS patients have a family history of migraines and may develop them themselves. CVS management often mirrors migraine treatment, using daily preventative medications or abortive medications during attacks.
The pediatric gastroenterologist agreed on a functional etiology but doubted CVS. He observed Lashay’s vomiting lacked forceful retching; instead, it appeared as effortless regurgitation of stomach contents into her mouth. This suggested Rumination Syndrome. In rumination syndrome, stomach and esophageal muscles contract abnormally, pushing recently ingested food back up the esophagus and into the mouth, where it’s either spat out or reswallowed. The cause remains unclear, but links to psychological factors like mood disorders and physical factors like constipation exist.
Rumination syndrome treatment is primarily behavioral. Patients learn to recognize the abnormal muscle contractions and use deep breathing to inhibit the backflow. If behavioral therapy fails, smooth muscle relaxant medications can be considered. (A later test measuring stomach muscle contractions appeared to support this diagnosis.)
Download the records from second hospital stay.
Lashay agreed to behavioral therapy for rumination. Initially, it offered slight relief. Recovery, they cautioned, could take weeks or months, and symptom recurrence was possible, even years later. (Review the notes from the second hospital stay here.)
Continuing the Search for Lashay Diagnosis
Discharged with medication to accelerate gastric emptying and rumination management strategies, Lashay continued therapy. However, the relaxation techniques yielded minimal improvement, and she discontinued them after a few weeks.
Lashay’s mother remained unconvinced by the rumination diagnosis, tirelessly seeking answers. She regularly took Lashay for intravenous fluids to combat dehydration and the now near-constant headaches and increasing lightheadedness. A new gastroenterologist prescribed multiple courses of Flagyl, an antibiotic for intestinal infections, which seemed to temporarily help. However, the benefit vanished upon stopping the antibiotic, suggesting infection was unlikely.
Ultimately, Lashay was referred to a specialist in Postural Orthostatic Tachycardia Syndrome (POTS), a disorder of the autonomic nervous system – the system regulating involuntary bodily functions like heart rate, blood pressure, and digestion.
POTS often involves impaired blood flow to the brain upon standing. Normally, the nervous system swiftly adjusts to maintain blood flow to the brain when standing by constricting leg blood vessels and increasing heart rate. In POTS, this system malfunctions, causing delayed cerebral blood flow, leading to lightheadedness, nausea, and even fainting.
The POTS specialist assessed Lashay’s blood pressure and heart rate supine and standing. In healthy individuals, heart rate might transiently increase, and blood pressure might slightly decrease upon standing, quickly normalizing. Dehydration can cause sustained heart rate elevation and blood pressure drop. In POTS, standing causes a significant heart rate increase with stable or decreased blood pressure. In Lashay’s case, both heart rate increased, and blood pressure decreased. Suspecting dehydration, the doctor administered IV fluids and repeated the test. The results were similar – heart rate surged, blood pressure plummeted. Despite these findings, POTS remained a likely consideration.
Download the notes from the POTS doctor.
POTS treatment aims to maintain blood pressure upon standing, often involving high-salt diets or salt tablets, compression stockings, and exercise. Leg muscle contractions aid blood return to the heart and brain. Lashay diligently tried these treatments for nearly a year, but they offered little relief. Only intravenous fluids provided consistent, albeit temporary, benefit. (See the initial POTS doctor note and testing here.)
Download the medical clinic assessment.
Another doctor in the same practice diagnosed Mast Cell Activation Syndrome (MCAS). MCAS involves inappropriate mast cell activation, causing allergic-like symptoms such as hives, flushing, blood pressure drops, and sometimes nausea, vomiting, and POTS. Lashay was started on potent antihistamines and asthma medications, also targeting mast cell activation. These, too, proved ineffective. (Review the MCAS doctor’s note here.)
Now 17, Lashay has endured this for nearly three years. Currently, she takes only pain medication for severe headaches. She manages small meals and has learned to reswallow regurgitated food to maintain her weight. Intravenous fluids remain crucial, administered three to four times weekly. She attempts light exercise despite neck and back pain hindering movement. Lashay remains uncertain about her condition and future.
What is your Lashay diagnosis? Could it be cyclic vomiting, rumination syndrome, atypical POTS, or something else entirely? What diagnostic avenues should Lashay and her doctors explore next?
Share your diagnostic insights below, outlining your reasoning. The diagnostic process is often as illuminating as the diagnosis itself. All responses will be carefully reviewed, and promising suggestions will be shared with Lashay and her primary care physician.
An update will be posted soon.
What’s Your Diagnosis for Lashay?
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