A Wobbly Reservoir

A young athlete stumbles around the emergency room like an old man.

By Paul Austin|Saturday, May 29, 2004
RELATED TAGS: INFECTIOUS DISEASES

The emergency room was jammed, and 10 patients were waiting to come back from triage. Maria, the charge nurse, stared at the list of patients’ names, trying to find a way to open up some beds.

“If some can be seen in the hallway, I’ll be glad to start taking care of them,” I said. “We can start clearing out the backlog while we open up some spaces.”

“Works for me.” She asked the triage nurse to bring back a group.

The first was Joey, a blond 15-year-old who’d been having cold symptoms for six days. Good. Should be quick.

“Any other problems?” I asked, turning from the boy to his father.

“Just his runny nose and a sore throat,” his dad said.

“Anything else?”

“Nothing. Except he can’t walk.”

“Can’t walk?” Nonsense, I thought. Joey was a trim, muscular teenager.

“He’s wobbly,” his dad said.

Joey shrugged. “My feet aren’t right.”

This was looking less and less like a quick fix. “Joey,” I said, “touch my finger, then my nose.”

I wanted to see if his cerebellum, the part of the brain that handles coordination, was working normally. I expected precise movements from this fit young man, but when he reached out, his finger waggled like a palsied old man’s.

“Does he usually have problems with his coordination?”

“No,” his dad said. “He’s an athlete. Plays basketball.”

“Let’s see how his walking is,” I said. “Joey, take a few steps.”

Joey swung his legs off the stretcher and tried to walk. His feet wobbled from side to side, and he had to clutch my arm for support. This was serious.

“You can sit back down,” I said, helping him back to the stretcher. “He’s had a fever. Any other problems?”

“Well,” his dad said, “mostly this cold.”

“What about a headache?” I asked the teenager.

“Yeah, kind of.”

“Does the light hurt your eyes?”

“Some.”

“Here,” I said, “let me nod your head for you.” I gently moved his head forward and backward. Not really stiff. I was worried about meningitis, a bacterial or viral infection of the membranes surrounding the brain, but if he had that, he’d be sicker by now. Emergency room doctors tend to think of the worst things first, rule those out, and then work back toward less serious causes.

“I need to examine him,” I told his dad. “I’m going to move him to a place with some privacy.”

I pushed his stretcher past the other patients lining the hallway down to the psychiatric holding room, the only available space. Once we were out of the hall, I did a quick physical exam.

“Your neck looks puffy here.” I pointed to the sides of his neck.

“It’s always like that,” his dad said.

I was doubtful. Necks aren’t normally puffy. “Have you been feeling tired lately?” I asked.

“Yeah.”

Could it be mononucleosis? That condition results from viral infection, but movement problems aren’t common.

“Touch your chin to your chest again.” Any stiffness in his neck would support a diagnosis of meningitis. But Joey could move his head without any discomfort.

“Do you do any drugs?”

“Nah, man,” he said. “I’m an athlete.”

“I didn’t think you used drugs,” I said, “but I had to ask.”

Bacterial meningitis was the only treatable cause I could think of, but it would be unusual to appear this way. And he was too young for a stroke.

“He hasn’t hit his head, has he?” I asked his father.

His dad looked at his son. Joey shook his head.

I patted Joey on the shoulder and turned to his father. “This could all be due to a virus, but I’m not sure,” I said. “I think we should give him some antibiotics and do a CT scan and a lumbar puncture, just in case it’s meningitis. If it is bacterial meningitis, we don’t want to fool around.”

His dad shrugged. “OK.”

I found Maria. “We need to move someone else out into the hallway to make room for the kid with the cold. He can’t walk.”

Maria gazed at the board. “Room 4 can come out.”

Joey was quickly moved to room 4, given a dose of intravenous antibiotics, and then taken for a CT scan. The scan was normal. I did the lumbar puncture; the fluid I removed from his spinal column was crystal clear—no sign of immune cells fighting off an infection.

After I got Joey on antibiotics and started his workup, I called the pediatric residents from a nearby medical school who rotate through our hospital. I wanted them to evaluate Joey. After examining Joey, they arranged a transfer to the school’s medical center.

“We’re not sure what he’s got,” one of them said. “If he gets worse, that’s the place he should be.”

“We’ve given him antibiotics, in case it turns out to be bacterial.” I motioned to the sides of my neck. “But isn’t there an encephalitis you can get with mononucleosis?”

“Yeah,” the resident said. “I think so.”

Encephalitis is an infection of the brain. But Joey didn’t have sudden fever, vomiting, and drowsiness—the classic signs of encephalitis. In any case, Joey would be better off under hospital supervision.

I explained the transfer to Joey and his father, and the paramedics came to wheel him away. As soon as he was out of the department, I forgot about Joey. Patients were still waiting for beds.

A week later, I saw the same pediatric resident in the emergency room. “Good call,” she said. “EBV encephalitis.”

“What?”

“Epstein-Barr virus. Remember the kid with the movement problems? He had EBV, and it spread into the nervous system. It’s rare, but it can happen.”

“How’s he doing?”

“Better,” she said. “The resident taking care of him called and told me.”

Epstein-Barr virus is a type of herpesvirus, and humans are its only known reservoir. Because the virus spreads primarily through oral secretions, the disease it causes—mononucleosis—is known as the kissing disease. Infection is common: Ninety percent of American adults over age 25 have antibodies to it. Not everyone develops symptoms after infection, however. Those who do develop symptoms are responding to the body’s own defense against the virus. Epstein-Barr preferentially infects B cells of the immune system. When that happens in large numbers, the body’s defenders against viruses—T cells—go on the attack. The most common symptoms—fever, sore throat, and swollen lymph glands in the neck—result from the T cells’ battle against the infected B cells.

The disease leaves many patients feeling exhausted, and it can be weeks before they feel normal. Complications of the infection can include rupture of the spleen, hepatitis, decreased platelet count, anemia, inflammation of the testes, even inflammation of the heart. The virus can also spread into the central nervous system, as in Joey’s case. There are no effective medications against the virus, although steroids are sometimes used to treat a few of the symptoms. The good news is that problems resulting from Epstein-Barr are unusual, and when they do occur, they are rarely fatal.

Sometime later I called the medical center to find out how Joey had done.

“I remember him,” the resident said. “Joey Jenkins. Nice kid. We were consulted on him. As I remember, the tests indicated the encephalitis was due to EBV; they showed that his antibodies to the virus were from a recent infection.”

I heard computer keys clicking over the phone.

“Let me check his discharge summary,” she said. “Yup. Hospitalized for two weeks, got physical therapy and a trial of steroids. Improved, discharged to home, still using a walker.”

“Will he have a full recovery?” “Hope so,” she said. “He’s motivated and has a good chance if he keeps at his physical therapy.”

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