Twenty-Nine, Male, and Dangerously Ill

A young man with fevers and groin pain leads E.R. doctors on a race to find the cause.

By Tony Dajer|Thursday, October 23, 2008

“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.”

He pointed to his lower right groin. The spot didn’t match appendicitis. Through Kevin’s boxer shorts, I pressed across the lower belly and the upper thigh.

“Does this hurt?”

“No. When I’m lying down it’s OK.”

“Benign abdomen,” I muttered to Anne and John. “Nothing there. Let’s go think.”

As we were walking out, the brown checker­board pattern on Kevin’s shorts caught my eye. His exam was not complete.

“Why don’t you guys wait outside?” I told my duo.

Turning back to Kevin, I said, “Let’s take a look. Just pull them down and stand up here, OK?”

Kevin hopped off the bed and faced me. Sitting, I felt his groin for hernias, then gently examined the testicles. As my fingers moved behind the left one, he jerked back.

“Ow. That hurts. Up here, between my legs.”

Suddenly, clarity. Anatomists call that nether region of our bodies the perineum. Pain there equals prostatitis.

“We need to do a rectal, Kevin. Sorry.”

Inserting a gloved and lubricated finger into his rectum, I felt the contour of the prostate. It was swollen and boggy.

“Wow, that really hurts, Doc.”

Everything snapped into place: the fevers, the abdominal pain, and the difficulty urinating all stemmed from an infection of the prostate. Tucked away in such a private spot, an infected prostate can cause symptoms so vague that patients think, as Kevin did, that they have the flu. Doctors, in turn, often miss the diagnosis. At the other extreme, an infected prostate may trigger life-threatening bacterial sepsis.

The size of a walnut, the prostate gland sits between bladder and rectum, encasing—and discharging its secretions into—the urethra as it exits the bladder. It lies so close to the rectal lining that prostate biopsies can be taken right through it. As to function, it’s all about reproduction: Without secretions from the prostate, sperm would never complete their dash to the ovum. Unfortunately, the prostate is hardly the pinnacle of evolutionary design. As men age, some 80 percent develop an enlarged prostate, which can press on the hollow urethra and throttle urination. More dangerous, it can turn malignant. Prostate cancer is a leading cause of cancer death in men (almost 29,000 per year). Say “prostate” and most people, doctors included, think “old man.”

Turns out, it is not old men who most often get prostatitis, the infection or inflammation of the gland. The numbers are surprising: In one large Canadian study, 20 percent of men under 60 complained of symptoms attributable to chronic prostatitis. Let’s face it, the gland lives in a dirty neighborhood. Bacteria can sneak in through the rectal wall or be sexually transmitted through the penis (chlamydiae are not uncommon visitors). Because the gland is honeycomb-like and filled with secretions, bacteria can rapidly infect it. Yet most antibiotics penetrate it weakly, so treatment for bacterial prostatitis must last four to six weeks. Misery results when small pockets of infection remain, causing persistent, frustratingly broad symptoms. In some cases, it takes repeated, painstaking milking of the gland (via a rectal exam) and meticulous culturing to identify the culprit. It might also require a patient to repeat a long-term course of antibiotics.

For Kevin, at least, we now knew where to begin. I rang up Fabio. “You owe me a dollar.”

“OK, but it better be good.”

“Prostatitis.”

“Shoot, he was complaining about the urination as I walked him down to the ER. I missed it.”

“Want me to write his prescriptions?”

“No. I’ll be right down.”

Minutes later Fabio was writing a prescription for four weeks of antibiotics. Kevin pressed an arm across his lower belly. “Boy, after that rectal exam this whole part hurts,” he said.

Fabio pointed at me.

“His fault.”

“Sorry about that,” I said. John and Anne followed me out of the room.

“Not that sorry,” I whispered. “That complaint just clinched the diagnosis.”

Tony Dajer is the chairman of the department of emergency medicine at New York Downtown Hospital in Manhattan. The cases described in Vital Signs are real, but names and certain details have been changed.

Additional fact checking by Dr. Andrew McCullough, a urologist at NYU Langone Medical Center.

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