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Posted by Dr. Sushrut Jangi July 16, 2013 12:17 PM
This is the case of a real patient. After reading the description of the case, I invite you to guess the patient's diagnosis in the comments section below. The answer will be posted Friday.
Over the past century, chronic diseases - diabetes, high blood pressure, and cancer - have become more common, while sudden, thunderclap illnesses are less frequent. But when an acute illness does occur, a comfortable landscape is jarringly altered: one moment, your sister, mother, husband is sitting beside you at the dining table, and the next, he or she is unconscious, in a hospital gown, in an unfamiliar bed. Such illnesses don't give anyone time to prepare for change; we are forced into circumstances, and the repercussions can last far longer than the course of the disease. Just ask Wendy.
One Monday morning, 42-year-old Wendy woke up and found she couldn't walk. Wendy and her husband Bruce lived in one of those pretty oceanside towns that dot the rocky arc of the North Shore of Massachusetts. They had a wonderful, happy life. Wendy worked downtown, her office high up in the glassy Hancock Tower that gave her an expansive view of Boston. A summertime tennis player, a wintertime skier, and a year-round active mom (she had a seven-year old son, a three-year-old-daughter) Wendy considered herself lucky, blessed, healthy.
But one day in spring, Wendy came down with some kind of flu. "I spent that weekend resting," Wendy would say later, but Bruce noted that she had barely gotten out of bed at all. The lethargy was unlike her; Bruce thought it would pass. By Sunday night, however, things had only gotten worse. She had developed intermittently high fevers, her forehead was clammy, and Wendy had begun to say things to Bruce that were increasingly non-sensical. He wondered if she was hallucinating. "If you're not better by tomorrow," Bruce had said, "we're taking you to the hospital."
On Monday morning, Wendy called to her husband, in shock at the inability to coordinate her legs. Devotedly, Bruce helped her to dress. Then, he lifted her out of bed onto his back and carried her downstairs. As he carried his wife out to the driveway, his concern doubled. "Is that a new car?" Wendy asked him, when she laid eyes on the old Buick they had owned for years. He drove her straight away to the hospital downtown.
Wendy was rushed into the emergency room, where physicians inserted a long needle into the space between her lower vertebrae to test the fluid around her spinal cord. They were hunting for the source of her fevers and paralysis, wondering if her brain harbored infection. Soon enough, the laboratory called back with the results. Her spinal fluid was full of white blood cells - markers of inflammation -- but in Wendy's case, the doctors found no bacteria. Nevertheless, they started her on antibiotics. "Which ones?" Bruce asked the doctor, who replied: "All of them."
Over the next few days, despite the cocktail of antibiotics, Wendy's condition deteriorated. When her name was called, she woke only briefly, babbling incoherently. Soon, she stopped following instructions altogether. Her lower legs remained immobile. Four days since that Monday morning, she stopped opening her eyes, unable to wake.
As the doctors stood around Wendy's bed in the intensive care unit, they had reached a standstill: her diagnosis was in question, treatments had no demonstrated effect, and Wendy's life hung in the balance. Such standstills, which occur often in medicine, require reframing the story. Crazy ideas are entertained. Old clues are reviewed under new light. At the suggestion of one of the neurologists, the team decided to repeat an MRI of her head. What had been an ordinary scan the first time around had transformed into a new film: a brain scattered with white blotches that heralded a promise of a diagnosis and a change in Wendy's treatment.
Can you help out Wendy's medical team? What was her diagnosis, and what was the treatment?
Below: MRI similar to Wendy's, which shows white hyper intensities
in the brain. Photo courtesy Dr. Dapaah-Afriyie, Miriam Hospital,
The author is solely responsible for the content.
About the authorSushrut Jangi is an internist at Beth Israel Deaconess Medical Center and an editorial fellow at The New England Journal of Medicine. More »
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