i wished she had meningoencephalitis

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Page 1: I wished she had meningoencephalitis

Ricardo Castro I wished she had meningoencephalitis

Received: 24 July 2013Accepted: 2 August 2013Published online: 14 August 2013� Springer-Verlag Berlin Heidelberg and ESICM 2013

R. Castro ())Departamento de Medicina Intensiva, Pontificia UniversidadCatolica de Chile, Marcoleta 367, Santiago 8320000, Chilee-mail: [email protected].: ?56 2 2354 3746

I did wish she had meningoencephalitis. I really did. Itwas one of those young and beautiful girls you encountersometimes. I’ll name her Andrea.

First in her class, smart, athletic, nice countenance, andhad just finished school. She had just crossed thethreshold to full adulthood and was in the beginning ofher studies on engineering. In fact, she was attending thesecond week of class and making new friends at college.Then the issues appeared.

Her parents thought it was part of her well-acknowl-edged responsibility and accountability. ‘‘She alwaystakes everything to its fullness,’’ they said. But someconcerning sparks appeared. She started to be exceedingly‘‘spiritual.’’ Although she was accustomed to prayer,going to church, helping the needy, and her parentsreassured me that their daughter was very devout indeed,this time it was too much. So they started to worry. Herfriends told me later that she had been ‘‘fine,’’ butsometimes said inexplicable things to them. ‘‘What kindof things?’’ I asked. ‘‘Well, sometimes she says… shesays… she is God….’’ Wait a minute, things were gettingdarker, so apprehensions gave way to unconcealed con-cern and she was taken to see a psychiatrist. After 1 h he

said to the parents that she had ‘‘an acute psychotic event,probably explained by the start of schizophrenia.’’

They were devastated. They had another son withbipolar disease and now their princess was falling into therealm of those enigmatic diseases of the mind—diseaseswhich make us stop and wonder whether they may be apsychiatrist’s invention, for many times symptoms arejust a little step away from what is normal; but what isnormality, by the way?

So she was admitted to the mental health facility of ourhospital one Friday night. The psychiatrist found outsomething unsettling on Andrea’s medical history. Shehad suffered from herpetic lesions on her mouth 1 weekbefore being admitted and had been taking acyclovir inhigh doses for 3 days and had a higher-than-normal whiteblood cell count. Smartly, she asked for non-psychiatricevaluation and admission to our intermediate unit. Thehypothesis? She could be suffering from herpes simplexencephalitis.

Everything could be better than expected. There wassome hope, but who is in need of hope? The patient? Thefamily? The doctor?

Anyway, she could recover! And I took the unlikelyprospect as mine. I acknowledge that the psychiatrist hadprimed me and I was very excited about this possibility.Perhaps we were facing a psychiatric-like disease. I couldeven publish it! Say, ‘‘Herpes simplex encephalitis as adifferential diagnosis of schizophrenia: don’t forget thevirus’’ or so. Therefore we performed cerebrospinal fluid(CSF) analyses, PCRs, and the like. As these eventshappened over the weekend, I met the patient on Mondaymorning with rather disappointing news: CSF was normaland HSV PCR was negative. All hope was lost and wehad to face the unfairness of an overt psychiatric diseasein a young lady.

As physicians, many times we want to turn around theinescapable course of the events. Somehow, someway, weget some hints that seem to endorse our innermost

Intensive Care Med (2014) 40:107–108DOI 10.1007/s00134-013-3062-1 FROM THE INSIDE

Page 2: I wished she had meningoencephalitis

longings. Otherwise unintended happenings or smart andright colleagues’ opinions that, when thirsty for hope, weregard as providential.

Then, suddenly, I came up with an idea: Perhaps, thefact she was on acyclovir the week before of heradmission could have caused the PCR results to appearnegative and perhaps she had herpetic encephalitis, butour ability to diagnose it was reduced because of aprevious use of an antiviral drug, and the clinical courseof it was softened precisely because of a suboptimaltreatment. Bingo! I talked immediately to the microbi-ology laboratory director and she informed me thateffectively sometimes herpes PCR results are negativewhen previous and recent use of acyclovir is present. Idid not pay attention to any warning she may have givenme. That was what I needed to hear so I talked toAndrea’s parents and they agreed to give it a try: Wewould treat her with intravenous acyclovir and wouldexpect her to recover from her psychotic burst and—perhaps—return no normal life and college in a coupleof weeks.

She is not a schizophrenic girl, she just has encepha-litis, and with the right treatment, at the right time….

Some days later she was transferred under acyclovirtreatment to another hospital because of health insurancecoverage issues. I submitted an epicrisis just stating thatthe patient had herpes meningoencephalitis with normalCSF due to a previous and recent use of acyclovir, andthat we were pretty confident she would recover.

I was left with some sort of triumphant feeling; I toldmy colleagues that I had rescued a patient from the psy-chiatric ward; jokes went back and forth.

Four weeks later, reality abruptly returned. Ouradmission nurse, with a worried face, represented theexecutioner: ‘‘Did you hear about Andrea? She isback….’’ ‘‘Back? Where? In the ICU?’’ She softened hervoice. ‘‘No… Andrea is back in the psychiatric ward.’’

Time has passed and I am now pretty sure that I wastotally wrong in many respects of my approach. Realityalways stood in front of my eyes, but honestly I did andstill wish that she had meningoencephalitis.

Ricardo Castro, MD MPH

Conflicts of interest The corresponding author states that there isno conflict of interest.

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