Sunday, August 31, 2008


Imagine being a recently married young woman and coming home from a night shift at a fast food restaurant to find your husband sitting in bed covered in poo and not able to remember anything or answer any questions.

 Yeah, I'd be a little concerned, too.

Such was the patient that I had last week. And a strange presentation it was, too. He could remember his wife's name and his birthday, but he would get easily confused and answer questions inappropriately. Grips were equal, no nuchal rigidity was noted, and I couldn't elicit a positive Kernig's sign (although later I realised that I don't think I did it properly), pupils reacted as expected, sensation was intact (in fact as we were cleaning the poo off his feet, he was complaining about it tickling). He was oriented to place - kind of (he could state that he was in an ER, but not the city or country. He could say his full name, but with a question in his voice each time. He had no concept of time. But then there were the signs that maybe he was faking it (although it would take a really devoted faker to lay in poo), such as the times when he would seem totally lucid, like when I would explain what was going to happen next. His medical history was unremarkable except that he had been complaining of bad headaches over the past 10 or so days. The wife said that she hadn't brought him in because they didn't want to pay for an ER visit and she thought it was "one of those things that you just sleep off."

After the requisite Head CT and chest xray and EKG and labs, the doc got set up to do a lumbar puncture, but got nowhere with it, because he would alternately be cooperative and oriented and then confused and combative. Ultimately he was sent down to radiology for a fluoro guided LP.

The doc and I had a little debate about what it could be because the presentation didn't fit any diagnosis very well. The vice-grip headaches for days preceding his arrival seemed to point to meningitis, but with no fever, photophobia or nuchal rigidity, we were skeptical. The AMS in an otherwise healthy young man indicated possible head bleed or tumor, but there were no hematological changes and his CT came back clear. His tox screen was negative and according to the wife he didn't drink or do drugs anyway. He denied any pain the entire time he was with us. It was unlikely to be a drug reaction or serotonin syndrome as he took no home medicaions. And finally, he had no known psychiatric history.

So we waited.

I took advantage of some time to get away from the room to go answer the urgent call of my 19 year old nausea patient who was kind enough to put away her cell phone and Doritos long enough to tell me that she wanted to go home because she'd been here forever (3 hours) and I hadn't even been in her room to see her in the past hour. I resisted the urge to go medieval on her heinie and lecture her about the 75 year old AMS (turned out to be from low blood-sugar) I had next door and the young man I've been talking about, both of which rank significantly higher on my list of priorities than a 19 year old princess with an attitude who has demonstrated no actual sign of disease, and who would eventually be discharged with a diagnosis from the doctor of "there's a bug going around." But at least she took up a room and kept me from getting anything more demanding while I tried to sort my real patients' problems out.

Finally, we got word from the lab on the CSF studies: Meningitis... not bacterial or viral; but fungal. Yeah, fungal. I've looked around a little since, and found some information on it, but I have to say that neither I nor any of the other nurses I was working with had ever even heard of meningitis caused by a fungus.

I took time the next day to go up to his room and see how he was doing, expecting to see him looking and feeling better. I have to say I was quite disappointed to find essentially the same person that I had last seen 24 hours earlier. For his wife's sake I tried not to let my surprise show, but it was there nonetheless. Fungii can be hard to treat. For his sake, I hope they didn't wait too long to come in.

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