The Challenge: A young woman develops a headache along with nausea and vomiting. Days later, she lapses into a coma. Can you figure out why?
Every month, the Diagnosis column of The New York Times Magazine asks Well readers to solve a diagnostic mystery. Below you will find the details of a case involving a young woman with a headache that felt something like her usual migraine at first but then took a very unusual course. I have provided records from the hospital where the diagnosis was made. As usual, the first person to solve the case gets a signed copy of my book ?Every Patient Tells a Story? and the pleasure of figuring out a case that stumped a bunch of very smart doctors.
The Patient?s Story:
The young woman lay sprawled across the hospital bed when the nurse entered the room. She called out the girl?s name quietly, and when there was no answer, she hurried to the bed.
The athletic 23-year-old woman lay with her eyes closed. One side of her face twitched, pulling her expression into a transient lopsided frown, then relaxing, then scrunching again into a unilateral grimace of pain. Her arms and legs jerked with the same random frequency.
The nurse called the young woman?s name again and shook her. When the patient opened her eyes but didn?t seem to see her, the nurse reached for her phone to call a condition C ? hospital shorthand for a patient exhibiting a troubling change in status. By the end of the day, she would be completely unresponsive and hooked up to a machine in order to breathe.
The Patient?s History:
The young woman had been healthy until a couple of weeks earlier. Then, early one June morning, she awoke with a headache. She?d had migraines for as long as she could remember, but this one was a little different, a little worse. Her entire head seemed to pound with every beat of her heart. And the right side of her face felt completely numb. That was new. She also felt achy all over, and nauseated ? as if she had both a migraine and a stomach bug.
She pulled herself out of bed and fixed herself a cup of hot tea. She had taken only a few sips when she felt her stomach heave. She barely made it to the bathroom before she vomited. She resigned herself to a day of stomach bug. She could barely hold anything down, and she slept for most of the day.
The next day she felt just as bad. And the next day, and the next.
When it seemed as if it would never end, she went to the emergency room. She was diagnosed with viral gastroenteritis, given intravenous fluids and sent home with anti-nausea medicines.
The drugs didn?t help.
Over the next week and a half, she went to see her doctor three times. Her headache was unrelenting. She had a fever. And everything she ate or drank seemed to come right back up. In five days, she lost five pounds.
?How can this be just a virus?? she asked her doctor.
He tried to reassure her. Even though her symptoms were lasting longer than usual, it was still probably just a virus, he said at her first visit. And then again at her second.
When she came back a third time, he sent her to the hospital to try to figure out what was going on. Maybe this wasn?t just a virus after all.
Lots of Tests, but No Diagnosis:
The patient spent six days in the community hospital. During that time, she had many tests done and many abnormalities were noted, but no diagnosis seemed to fit.
A spinal tap suggested she had some kind of infection in her brain ? either meningitis (an infection or inflammation of the sac that surrounds the brain) or encephalitis (an infection or inflammation of the brain itself). But no bacteria were found in her spinal fluid, in her blood or in the profuse watery diarrhea that continued to plague her.
An M.R.I. of her brain was unremarkable. You can view the M.R.I. scan to the right.
A CT of the patient?s chest, abdomen and pelvis showed only a tiny cyst on her right ovary and a dermoid cyst on the left.
Because the patient lived in a heavily wooded area, she was tested for Lyme disease and other tick-borne illnesses. Negative. She was tested for H.I.V., herpes, Epstein-Barr and coxsackie viruses. While the results of those tests were still pending days after her admission, the doctors caring for her thought those diagnoses were unlikely.Could this be an autoimmune disorder, like lupus? Initial blood studies were negative.
Was this some kind of cancer? The cells in her spinal fluid were abnormal. Were these the hallmark of leukemia, or more benign markers of inflammation?
A Turn for the Worse:
As the doctors searched for a diagnosis, the patient continued to worsen. The headaches and body aches were unbearable, even with the high doses of narcotics she was given. Then she started seeing double and developed a tremor.
After six days, the decision was made to send her to the large tertiary care teaching hospital at the University of Pittsburgh Medical Center. Maybe there they would be able to figure out what was wrong with her.
You can read more about the patient, including the pertinent data from the original hospital stay, in the overnight admission note, the longer admission note, the infectious disease consultation report and the M.R.I. and CT reports, below.
At the Teaching Hospital:
It was early evening before Dr. Neil Busis, the chief of neurology at the University of Pittsburgh Medical Center, Shadyside, had a chance to see the young woman. Once he?d reviewed her chart and the studies that had already been done, he went into the patient?s room to meet her. She certainly looked sick.
She was pale, and her long brown hair was stringy from too many days in the hospital. Her right cheek seemed somewhat flatter than the left. Her pupils were pinpoint, though pinpoint on both sides ? probably from the narcotics she had received. She seemed sleepy and spoke in a slow monotone as she repeated her story once more.
She was 23, she told the doctor. She worked as an X-ray technician. She had a long history of migraines. It started with a headache that felt something like her usual migraine, though she also had a fever, nausea and diarrhea. And somehow, it just never went away.
Listening to her, it was clear to Dr. Busis that the young woman was a little confused. The story was a bit jumbled; the dates perhaps not quite right. But he got the gist.
Yes, she smoked on occasion. Yes, she drank on occasion, maybe once or twice a month. She had never used drugs. She?d had many tick bites from the woods around the house where she and her fianc? lived, but none recently. She had no pets; no recent travel. The only medication she took regularly was a birth control pill.
A Closer Look:
On exam, the patient didn?t have a fever, but her heart was beating rapidly. She complained about double vision, and when Dr. Busis looked closely, it was clear that her eyes were not moving normally.
When he had her look over to the right, the left eye moved normally to the right corner near her nose, but the right eye was only able to get part way to the outer right corner. When asked to look to the left, the same thing happened; the right eye could move to the corner near her nose, but the left couldn?t get all the way left. In addition, the right side of her face was a little droopy.
When asked to remember three words after five minutes, something most people can do easily, she was only able to remember two. And, when asked, she didn?t know what year it was.
At this point, Dr. Busis was able to make a diagnosis. Can you? All the patient data available to Dr. Busis is available to you above.
Solving the Mystery:
It was the following day when the nurse found the patient unresponsive on her hospital bed. What was causing her condition? And why was she getting worse?
The first person to make the diagnosis gets a copy of my book, and the pleasure of solving a difficult puzzle.
Friday May 3 4:54 p.m. | Updated Thanks for all your responses! You can reader about the correct diagnosis, and the contest winner, at ?Think Like a Doctor: An Unusual Headache Solved.?
Rules and Regulations: Post your questions and diagnosis in the comments section. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.
Source: http://well.blogs.nytimes.com/2013/05/02/think-like-a-doctor-an-unusual-headache/
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