By Daphne Sashin
HUP unit secretary Veronica “Ronni” Elena rejoices for her good health with Todd Hecht, MD, Max Itkin, MD, and colleagues who supported her when she was sick.
Veronica “Ronni” Elena, an award-winning unit secretary at the Hospital of the University of Pennsylvania (HUP), has always had a joke, song, or hug for her co-workers and patients – anything to make the day a little brighter. But last year at this time, she was feeling pretty bleak.
The problems started in August 2021, when Elena returned home from a trip to Wildwood, New Jersey, her most favorite place in the world. Even after giving herself a couple days for her 54-year-old body to recover from eating “everything up and down the boardwalk,” Elena couldn’t leave the bathroom.
Her severe gastrointestinal discomfort persisted for months, and even as she managed to continue working, her stomach and feet swelled with fluid, her hair fell out, and her nails stopped growing. Concerned nurses and other co-workers on the cardiac intensive care unit, where she has worked the past eight years, brought her protein shakes and came to her West Philadelphia home to check on her.
“My colleagues were so worried about me,” Elena said. “I’m coming in wearing extra-small stretch pants, but a 3X shirt, and my belly is sitting all the way out with this fluid ... Those people tried to make me happy when I thought I was going to die.”
No one could determine the cause. Finally, in March 2022, Elena’s coworkers were so concerned about how unwell she looked that they brought her down to the Emergency Department. Upon admission, she heard a comforting voice: hospitalist Todd Hecht, MD, whom Elena had met more than a decade earlier when they both worked on Silverstein 11, and stayed friendly with ever since.
After reviewing her symptoms, the physician was perplexed.
“She was very much a mystery case,” Hecht said. Tests ruled out heart failure, cirrhosis, and kidney failure – typical causes for abdominal and lower extremity swelling – along with cancer and gastrointestinal disorders.
HUP unit secretary Ronni Elena, left, calls hospitalist Todd Hecht, MD, right, her “angel.”
Whatever the cause, Hecht and internal medicine resident Lara Sokoloff, MD, confirmed that it was leading Elena to suffer protein losing enteropathy (PLE), a rare and potentially life-threatening condition where protein leaks into the GI tract. PLE can sometimes be caused by a disorder of the lymphatic system, an essential part of the body’s immune system composed of tissues, organs, and vessels that work together to fight infection. So Hecht called interventional radiologist Max Itkin, MD, director of Penn’s Center for Lymphatic Disorders and no stranger to medical mysteries, to explore whether her lymphatic system might be involved.
Itkin and his team conducted specialized testing to better visualize Elena’s lymphatic system, which showed that her thoracic duct – the main vessel in the system – was partially obstructed and causing the back-up of fluid into her stomach. Itkin initially performed two minimally invasive procedures to open the duct, which offered temporary relief of her symptoms. Ultimately, in July 2022, Elena underwent a thoracic duct bypass surgery pioneered by Itkin with plastic surgeon Stephen J. Kovach, III, MD, to reroute the lymphatic system for patients whose thoracic duct symptoms don’t resolve with minimally invasive treatment. While they had performed the surgery in other cases of thoracic duct obstruction, Elena was the first to have the surgery to address PLE.
Within days, Elena’s GI symptoms subsided and she began to put on healthy weight. The doctors still don’t know what caused her lymphatic duct obstruction, but Elena is elated to feel well again.
“Since having the lymphatic duct bypass, I go out with my friends, I travel, I’m doing my own laundry again, I’m cooking again, and I’m eating now,” Elena said. “At my lowest, I thought I was going to die. I am so grateful that I’m a Penn employee and that these doctors saved my life. Now I get to see my grandson, I get to be with my family, and I get to go to work and do what I love.”
Hecht and Sokoloff plan to share the case in a poster presentation at the Society of Hospital Medicine conference this month in Austin, Texas. They hope that in hearing Elena’s story, more hospitalists and residents nationwide will consider lymphatic obstruction as a potential cause of symptoms like hers.
The case has given both Elena and Hecht – who has spent his entire career here, since attending medical school at Penn – renewed pride in their work at Penn Medicine.
“We care about our staff, and we have expert clinicians and specialists with world-changing technology at their fingertips,” Hecht said. “I love Ronni’s excitement about this. She's really back to her normal self ... It's a wonderful story, and I'm so happy for her.”