The first case of the novel Coronavirus (COVID-19) in Chicago was reported in January. Fortunately, it didn't reach our hospital, but it still scared a lot of people. In the days following the first reported case in Chicago, our attending received many calls and pages from other services because of paranoia about the virus. One patient in our hospital tested positive for the Coronavirus strain HKU1, which scared a nurse, prompting the primary team to contact us. Our attending abated their fears, relaying that the patient is extremely unlikely to have the Wuhan Coronavirus because 1) our Resp PCR viral panels can't detect the novel strain and 2) the patient had no recent travel history or contact with someone who recently traveled to Wuhan, China. Many other teams also contacted our attending and fellows to share concerns about their patients who recently traveled to Southeast Asia and returned with a cough as well as other flu-like symptoms. We told them that the main focus was on individuals who had been to specifically Wuhan, China and returned with flu-like symptoms.Unfortunately, the Coronavirus epidemic has unearthed xenophobia. One of my colleagues shared with our team a story about a schoolteacher in one of the IL suburbs asking if she should be worried because there are Chinese students in her class. ("Are you kidding me?" was our response). One hospital employee made the comment, "They always have these weird diseases starting over there." Currently, I'm in Ecuador for an international medical elective and one of the students also completing the program (from another medical school and whose family is Vietnamese) shared that a few people stopped him to ask if he was from China and/or if he had "la virus". There have been no reported cases of the novel Coronavirus in Ecuador, but many people are still scared. So much misinformation is floating around on the internet which seems to be feeding into the fear and xenophobia across the globe.
Infectious Disease is a fascinating field. It is a subspecialty of Internal Medicine and the fellowship is two years in length. I decided to enroll in this elective because infectious disease is an area that will certainly come up again in my training and career as a neurologist, and I didn't feel very comfortable with microbiology, antimicrobials, and some other intricacies of infectious disease management (i.e. best antibiotics used to treat hospital-acquired pneumonia, infective endocarditis, or pyelonephritis; the antibiotic progression to follow if a patient has an allergy to a specific first-line medication; remembering all of the side effects of antimicrobials; etc). One of the other interesting things about ID is that it has a global component (i.e. the novel Coronavirus is currently the best example, but there has also been the Ebola virus, SARS, and H1N1 pandemics, etc to name a few). This global component of ID demands that ID specialists have a good grasp of any outbreaks that may affect many people worldwide.
---
I will close out this entry by sharing one interesting patient encounter on the Infectious Disease service. To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of this encounter have been modified to protect the patients and their families.
Towards the end of my four weeks on the rotation, the Neurology team consulted us on a 28-year-old male patient with a history of IV drug use who came into the emergency room with altered mental status, but a few hours prior (per his fiance) demonstrated symptoms of a stroke: right-sided weakness, dysarthria (difficulty of speech), and confusion. Let's call him "John". John's case had the greatest emotional and educational impact on me during my time with ID. Neuro obtained a CT which showed a subacute infarct with hemorrhagic conversion. He was admitted to the NeuroICU for further management.
John's fiance and her mother were present at the bedside when we went to see him for the first time. She told us that he hadn't used in over a year, although his urine tox screen came back positive for cocaine and opiates. The initial physical examination was remarkable for significant somnolence, a tricuspid murmur, and the peripheral stigmata of infective endocarditis: splinter hemorrhages, Janeway lesions on several fingers (small, painless erythematous lesions on the palms or soles), Osler nodes on several fingers (tender raised lesions on finger or toe pads), and palpebral conjunctival hemorrhages.
 |
| Photo from here |
On the second day of John's stay in the NeuroICU, I went to examine him and provide updates to his fiance. She also had a history of IV drug use and had been on methadone for the past year. She shared quite a bit with me about John, including some cute quirks in his personality, how he saved her life in the past, the recent death of his mother which left him broken, and how his only "real family" consisted of his fiance and her mother. She was desperate to know if he would recover after this hospitalization. I had no idea what the exact outcome of John's hospitalization would be, so I simply told her that we were doing all that we could to provide him the best care possible, and that hopefully things would move uphill from here. She thanked me for staying to chat with her. Unfortunately, John remained somnolent and minimally responsive that day.
When I went to visit John on the third day of his hospitalization, I saw through the glass door of his room that he was wide awake. I was so ecstatic that I nearly ran past the rounding Neuro team, quickly squirted the hand sanitizer on my hands, and rushed into the room. "Hi John!" I exclaimed with a big smile. He smiled right back. I smiled at the nurse too, wanting to shout, "Are you seeing this??! For the past two days we basically couldn't get him to wake up!"
"How are you John? How are you feeling?" I asked. His fiance wasn't at the bedside.
His smile was replaced with a subtle frown and a quick upward nod of the head as if he were asking, "What'd you say?"
"I'm Deborah," I told him, placing a hand on my chest, then his shoulder, "I'm one of the medical students on the Infectious Disease service. I'm here to check in on you and see how you're doing."
He stared blankly at me with his big blue eyes and did another quick upward nod of his head. I thought he simply couldn't hear me with all of the machines going in the room, so I repeated what I said in a louder voice. This time, he didn't made the gesture for me to repeat myself and instead didn't reply to me. "Oh no no no no no," I thought, my heart dropping. He couldn't understand me.
I placed my hand in his. "John, squeeze my hand," I said. He continued to stare at me. "Can you show me two fingers?" Again, no response or indication that he'd understood. I wanted to bury my head in my hands. His initial exam in the ED did not mention receptive or expressive aphasia (perhaps because he was too altered for this to be properly evaluated). Was I too optimistic that he would make a remarkable recovery?
I relayed my findings to our team during rounds. Our recommendation plan consisted of continuing the nafcillin for John's infective endocarditis and consulting Cardiothoracic Surgery for evaluation of removal of his infected valve and/or surgical debridement of the vegetations (which he did have). Although John's global aphasia did not improve, things were moving in the right direction with his treatment and CT Surgery's potential plan to proceed with surgery, until the nurse discovered a couple of days later a significant change on John's neuro exam: his left pupil became dilated with minimal response to light. A stat CT was ordered, which showed a large new intraparenchymal hemorrhage (IPH) on the side of John's brain opposite to where the original stroke occurred. Neurosurgery felt that he was not an ideal candidate for surgery in the setting of his systemic septic embolic infarcts. The mechanism of this bleed could have been due to a septic embolism (arising from the infected valve vegetations in his heart) vs a possible ruptured mycotic aneurysm. He was officially declared brain dead two days later.
I was devastated. "He was only 28 years old," I kept thinking. "And he was just smiling at me a few days ago!" I couldn't believe it. No one could have predicted the massive IPH that he suffered a couple of days later. How awful. Addiction is an awful disease. Unfortunately, John's history of IV drug use led to the development of tricuspid and mitral valve vegetations in his heart (which we believe dislodged and traveled to the brain, causing his initial stroke) and possibly a mycotic aneurysm which may have ruptured, causing the large bleed on the other side of the brain. My heart goes out to John, his heartbroken fiance, his fiance's mother, and his father, who was the one who decided to discontinue all life-saving measures for John and transition to comfort care.
I will never forget about John. I didn't know him for a very long time, and sure, he had fascinating pathology, allowing me to learn so much about infective endocarditis from his case. However, what's most important to remember is that he was a human being whose disease of addiction stripped him of a healthy and fulfilling life. Addiction is taking the lives of many people in our country. We desperately need to attack this public health problem in a more humane and practical way.
