“I’m sending you a patient.” The voice on the phone belonged to Fabio Giron, a critical-care specialist and one of the smartest doctors I know. “Twenty-nine-year-old guy, headache, photophobia, fevers off and on for two weeks. Trouble urinating. Ataxic gait.”
“Bizarre,” I replied. “Start with a head CT and spinal tap?”
“Definitely. I can’t figure out if it’s viral meningitis or maybe a brain abscess,” Fabio said.
The signs were not good. Photophobia —light bothering the eyes—is a classic symptom of infection or inflammation of the meninges, the lining of the brain. Ataxic gait—inability to walk a straight line—suggests damage to the cerebellum, the brain’s coordination center. Most odd and worrisome was the difficulty urinating. That suggested a tumor or infection in the spinal cord.
The symptoms were all over the neurological map. I got off the phone and found the charge nurse. “Jeannie, Dr. Giron is sending a patient down. Possible meningitis. We need an isolation room.”
I called over my two medical students, Anne and John, to relay the story. Taking notes, they both nodded gravely.
“Your job,” I said, “is diagnosis.”
Twenty minutes later they were back.
“Well,” Anne said, pursing her lips. “We’re not sure.”
John jumped in. “He’s under a lot of stress. Three hours’ sleep a night. Taking a slew of cold remedies and stimulants to stay awake. Two weeks ago he was running somewhere, really had to urinate. When he finally went, he felt he had ‘done some harm’ to his bladder. Since then he’s had a weak stream.”
“That makes no sense.” I eyed the ceiling tiles. “You can rupture a bladder, but how can you ‘harm’ it?”
John shrugged. “As for the headaches, they come and go.”
“Any migraine history?”
Anne picked up the thread. “No. Very healthy guy. And then the fevers. They come every three days. Drench the sheets.”
In two weeks bacterial meningitis would have killed him. “Could be lymphoma. Any enlarged lymph nodes?”
“No,” John replied, “but that doesn’t rule it out, does it?”
“No.”
“Plus, he has this lower abdominal pain,” Anne added, “but there’s no tenderness when you press. Temp is 102, but the rest of the exam is normal.”
“Boy, lots going on. Let’s see if we can sort the real clues from the red herrings.”
Entering the isolation room, John and Anne donned their masks again. One look at the muscular, smiling young man sitting on the stretcher told me that he did not have meningitis.
“Masks off,” I told them. “Hi,” I said to their patient. “I’m Dr. Dajer. I’m the boss.”
He gave me a hearty handshake. “I’m Kevin. I’m the patient.”
Chuckling, I said, “I heard all about the cold remedies. Any other meds?”
Kevin ducked his head. “I know it was a bad idea, but I took some flu medication a week ago. A friend gave it to me. I figured I had the flu.”
“Don’t ever do that again,” I said mock sternly. “Seriously, those things can cause a lot of side effects. Did you have trouble walking afterward?”
Kevin thought a moment. “Not really. Just kept feeling crummy.”
“Any alcohol lately?”
“Some over the weekend.”
“How much is ‘some’?”
“I was stupid. Vodka shots.”
“Enough to get drunk?”
He winced. “Yup.”
The clues were lining up: Stress plus no sleep plus a lingering hangover-cum-migraine plus the effects of flu meds would make anyone batty.
I walked my students through the neurological exam. Kevin’s neck was supple in every direction. No sign of meningeal irritation, making meningitis even less likely.
“Now let’s see you walk heel to toe,” I told him.
He shrugged an apology. “I really scared Dr. Giron with this one. But I can do it better now.” A brief wobble, then he got heel and toe to line up.
“This urinating problem, does it burn or hurt when you pee?”
“No, but something happened when I was running that time. And that pain is back.”