Health & wellness

Boston Medical Mysteries

Why was marathoner out of breath?

This is the case of a real patient treated at a Boston-area hospital

D isn’t running the Boston Marathon Monday; he’s still recuperating. “My doctor actually told me to stop running because it was hard on the body,” said D. Up until recently, he was in great shape: He completed three marathons and several half-marathons. His exuberance in fitness carries over into his attitude. He’s a cheerful guy — in his mid-40s, quick to joke, and nonchalant in conversation. Exercise was a part of his life. He lifted weights at the gym on Monday, Wednesday, and Friday, then ran or bicycled on alternate days. He never thought that practiced routine would change. But it did.

One day, after returning home to Boston from a motorbiking trip in West Virginia, D climbed a single flight of stairs and found himself exhausted. “I was completely out of breath,” he said. “I couldn’t believe it. I felt like I was breathing through a straw.” Although he had bouts of asthma in very cold air, he’d never had any lung problems. “Never smoked,” he told me.

He told me about an excursion in West Virginia he went on before he fell ill: “Basically,” he said, “you take a motorcycle into the woods. It’s got knobby tires so you can drive over roots, rocks, stumps, tree logs.” He couldn’t remember anything going wrong during the trip. It was only after he was back home that the shortness of breath descended upon him.


The feeling began to scare him. Depriving a human of oxygen elicits a primal fear response similar to a panic attack. People who are short of breath may describe an overwhelming hunger for air. Doctors call this distressing sensation dyspnea. If the sensation occurs after physical activity, it’s called dyspnea on exertion. “I started to have lots of fearful thoughts about what this could be,” he said. “I broke down and called my primary care doctor.”

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His doctor knew him well. “He’s a fit guy,” the doctor told me. “It was unusual to see him unable to exercise.” His doctor checked his peak flow, a test used to detect an asthma attack. Negative. He then put a pulse oximeter on his index finger and had him walk around the room. Normally, oxygen levels will read near 98 to 100 percent. Upon walking, his oxygen fell to 88 percent — concerningly low for a healthy man, and a successful marathoner at that.

A chest X-ray was normal. Other than dyspnea, D had no other complaints — no fever, no loss of weight, no cough, no pain in his chest. Nevertheless, his doctor obtained an electrocardiogram. What he saw in the tracing was alarming.

The diagnosis:

A few days later, D found himself in a CT scanner. “The technician did a test scan first,” he said, then started laughing. “Turns out that was enough for her. She rushed right in after the test scan, and said, ‘You need to talk to your daughter.’ I knew something was wrong. She told me to sit in a wheelchair and not to move. I couldn’t believe it. Just an hour ago, I had been driving down the Mass Pike on my motorcycle!”

writer and critic, forecast the inevitability and randomness of how disease affects our lives: “Everyone who is born,” she said, “holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”


A radiologist called D in the scanning room. “I said, ‘What’s up doctor?’ ” D said with a laugh. “But the doctor was totally serious with me. ‘This is no joke,’ he said to me. ‘You’re lucky to be alive right now. You’ve got lungs blocked by large blood clots. If you weren’t in the shape you were in, you would have had a really big problem.’ ”

D had multiple pulmonary emboli — blood clots that usually form in the legs and travel up into the vessels of the lungs. If they are huge, they can interrupt blood flow and cause shock or respiratory failure. Smaller clots can cause breathing problems such as D was experiencing; if they are not treated, the symptoms can progress. “I went straight to the hospital and they put me on oxygen immediately,” D said. “They started me on Coumadin,” he said, naming the commonly prescribed blood thinner. “I might have to stay on it for life.”

Pulmonary emboli can happen to anyone. In D’s case, they were most likely caused by the long, 12-hour truck ride home from West Virginia to Boston after his motorcycle excursion. “Usually,” said Dr. Praveen Akuthota, a pulmonary doctor in Boston, “this happens with prolonged air travel, particularly on very long, trans-oceanic flights that last in the six-to-eight-hour range. But even just being seated for most of a 12-hour journey puts him at increased risk.”

There are other known risk factors for clot formation: cancer, structural problems in the vessels, dehydration, smoking, and certain blood disorders. But immobility, by itself, can be enough. You shouldn’t sit in one place too long, Akuthota said — whether you are at work, driving, or flying. Get up and walk around often. But even then, Akuthota went on, even if you are mobile, you can still get a pulmonary embolus.

Thankfully, D’s doctor picked up signs that something was critically wrong on the EKG — he had a pattern called right heart strain, which is seen when the heart is pumping harder than usual, sometimes indicative of a clot in the lungs.


As long as the human body remains complex, medicine will be imperfect, illnesses will strike seemingly at random. There is nothing fair about any of this. But the same flawed mechanisms that bring us into disease sometimes bring us back out again.

D thinks back to the days he used to run marathons. “During the run,” he said, “it was a mental game with myself. I had to keep telling myself I could do it, I can do this. I’ve trained and today’s the day to put it all out there.”

The words of a marathoner are the same sentiment I’ve heard from patients who have been affected by illness; these are the words every fighter carries close to his heart.

Do you have your own medical mystery? Dr. Sushrut Jangi of Beth Israel Deaconess Medical Center can be reached at