Hits and Misses

Wednesday, after I had seen patients with all 3 residents at Setta, the intern asked me if I wanted to see one more quick case. Sure, why not? I usually stay until it’s clear they are finished with me, unless I have an appointment or meeting at lunch. The ‘quick’ case was a 22 year old woman who had been transferred from another hospital after a wrist abscess was lanced the preceding day. Before being admitted there, she had had a transient episode of loss of vision (without change in consciousness, dizziness, lightheadedness, palpations, etc.) Within a few hours of the lancing, she had sudden, complete loss of vision. The intern tells me this story as between 5 and 10 eager medical students crowd around the bed. I check her eyes - she has pupillary reflexes, but the are sluggish. We do not have an opthalmoscope, but even if we did, she has photophobia and I’m not good enough with one to see anything in a patient who’s not extra cooperative. She has tenderness of her sinuses above and below the eyes, but no swelling, redness, or warmth. She also has a particularly tender area under her jaw on the left, and maybe a slightly big L tonsil but nothing too exciting inside her mouth, and supposedly no tooth pain recently. I listen to her heart and lungs. She’s a bit tachy, but I don’t hear anything else unusual, of course, she is moaning occasionally, so it’s not the easiest cardiac exam. (She's not morbidly obese, though, so it's not the hardest either.:) ) I usually start my exam with the patient’s hands, because it’s less personal and confrontational than the face, but with a crowd of 10 observing, my routine is off. I will later learn that this was a mistake. . .

I ask the residents what the wrist abscess looked like. It was red, warm, and swollen and drained puss when it was lanced. She only had fever for one day before coming to the hospital, according to the family. They haven’t actually seen it though, because no one has unwrapped it since her arrival at this hospital. Maybe the surgeons will look at it this afternoon. (She is actually on the surgery ward, the medicine team was just consulting.) I try to model good wound-observing practices, so we unwrap it. It’s surprisingly clean and benign looking - she writhes in pain every time we move the hand, but it’s not red or warm, and no pus comes out when I remove the pieces of what appears to be rubber glove that had been used to pack it. I’m beginning to think that she’s not a particularly stoic 22 year old. I re-bandage the wound. We talk about what could have possibly caused sudden, bilateral, complete, loss of vision in this 22 year old. We talk about how sudden loss of vision is an emergency (not a quick case.) I am worried about a retropharyngeal abscess with swelling affecting the optic chiasm, or some kind of spread to the sinuses with swelling, because I can’t figure out how else to put the clinical picture together. Either way, I’m pretty certain that she needs more than just cloxacillin, so I suggest we change to ceftriaxone and metronidazole, given the potential tooth/mouth involvement. Ceftraxone will cover meningitis if this is some kind of crazy manifestation of systemic spread from the wrist abscess. I also suggest we need a CT of her head somewhat urgently, and maybe and LP.

Thursday, I am told she is getting better (she is still in the surgery room) but has not had a CT. One of the french program interns suggests that this might be a psychogenic problem, as she tested a blink reflex and found it present, though the patient claimed not to see anything. Still, without a CT (and really, probably and MRI) we couldn’t rule out a physical cause, and I was worried about the tenderness I had found, so I again asked them to push for this. I did not see her, as I did have a lunch appointment and was just barely going to be on time.

Friday, she had been moved to one of our rooms. I had David, an Australian Oncologist here with his wife, Margie who is taking over the Peds coordinator job with me. Her vision was better, maybe even normal, and she was getting ceftriaxone and metronidazole. She still hadn’t had a CT. When I had gotten home Wednesday, I started to worry about eosinophilic meningitis - it can cause a lot of swelling and intraparenchymal hemorrhage - and severe headache, which she now had. Would a contrast head CT be bad, or terrible, in that case? No peripheral eosinophil on the CBC though, so we could put that worry lower on the list. She still had a lot of tenderness under her jaw as well. I again asked about getting a CT - preferably before the weekend started. And I gently chided the residents when I saw that the bandage I had put on on Wednesday was still there, just as I had left it. . . We headed on, but were called back to the bed. Someone had noticed lesions on her hands and feet. We went back to discover that she had classic Osler’s nodes on her right hand - the one without the abscess - and splinter hemorrhages and janeway lesions on her feet. Endocarditis would explain the multiple site of infectious involvement well - I listened to her heart again - now her heart rate was normal and I heard a soft systolic murmur. Was it new, or was my exam just harder on Wednesday? Had we missed these skin findings for 3 days? Or were these new despite antibiotics? We asked the family - they had been there since before she came to the hospital. Part of me was relieved, because it means she wasn’t failing treatment, but another part was mortified that we had all missed this evidence for 3 days. So we changed the plan - EKG, echo at Mahosot that afternoon, and talking to the family about a possible need to go to Thailand for valve replacement if she had a large lesion. We would add gentamycin if she got worse again. And someone would discretely ask her and her husband about “risk factors” (IE, not in the room with 7 other patients, 5-10 doctors/med students, and her whole family.) So that is how I missed, and then (probably) found, my first classic case of bacterial endocarditis. Needless to say, David was also impressed with the incredible pathology you can see here. I am hopeful and afraid about what I will find Wednesday when I return to Setta. (Today I had to take a visiting nephrologist out to Mittaphab for introductions, and tomorrow is Women’s day, a holiday, so the residents will do short rounds then go home.)