But the most important question was raised by Dr. Simmons’s reflection: “Why didn’t I think to ask them how often they had intercourse before the workup?”
We will never know the true answer about their motives. One thing is certain in this case, however: The answer to a single question can solve a lot of mysteries. Dr. Simmons says her first question in any infertility workup, now embedded in her brain, is “When and how often do you have intercourse?” Every time she asks the question, she remembers the Matthes and still wonders what they were thinking.
*Case shared by:
Betty Ruth Speir, M.D.
Adjunct Professor of Obstetrics and Gynecology
Professor Emerita of General Surgery
University of South Alabama College of Medicine
Chapter Twenty Eight
Strange Intuition *
Late one day in October, Wilbur Cleaves called Dr. Paul Barnett’s office and insisted on speaking to the doctor. Wilbur had been a patient of Barnett’s for many years and had a close relationship with him. Except for mild, treated high blood pressure, Cleaves was in good health. The phone call was about his wife, Caroline, who just turned 47.
Caroline had just been diagnosed with a malignant lymphoma by her home doctor in Kentucky. Wilbur wanted her to see Dr. Barnett. Barnett told him she really should be under the care of an oncologist to guide her treatment and offered to make a phone call on her behalf, but Wilbur declined.
“Don’t ask me how I know,” Wilbur told the doctor. “I just know Caroline does not have any lymphoma. I somehow know it. Caroline just doesn’t look like she has any cancer.”
The two men talked a while longer, and Wilbur remained steadfast. Barnett figured this insistence there was no cancer was simply denial by an upset husband, which is not uncommon. Barnett decided to see Caroline, knowing he would have her seen by an oncologist at the same time.
When Caroline arrived to see Dr. Barnett, Barnett had the resident do the initial medical workup. He found she had weight loss of 10 pounds, low-grade fever and large lymph nodes in her neck. The chest x-ray also showed enlarged nodes behind her sternum. All blood chemistries and blood counts were normal. The diagnosis seemed firmly established, since a biopsy of a node had showed changes of a lymphoma. The only notable factor in her past history was a history of grand mal epileptic seizures beginning more than 10 years ago. Caroline had been taking Dilantin (phenytoin) daily with good control of the seizures.
Dr. Claude Wills, the medical resident, called Barnett to report his examination and history. “Looks like she’s got a lymphoma to me. However, I just read a report about pseudolymphomas being caused by Dilantin. Guess we ought to check that out.” (See Chapter Notes.)
Barnett thanked the resident and could not wait to read the reported case of pseudolymphoma caused by Dilantin. It was the first he had heard of the syndrome. As so often happens, interns and residents are reading the medical literature voraciously. Often they read of new diseases and treatments before the faculty.
Given Wilbur’s refusal to accept a diagnosis of lymphoma in his wife, Barnett suggested stopping the Dilantin first before beginning any chemotherapy. He would see what would happen to the lymph nodes. By the end of six months, all nodes returned to normal size, the fever went away and Caroline regained her weight. Young Dr. Wills had come across the key information. The diagnosis was established as “phenytoin-induced pseudolymphoma.”
Barnett’s review of the literature found two different syndromes of Dilantin associated lymph node enlargement. The first syndrome, the rarest, occurs shortly after beginning Dilantin treatment. It is now called the “anticonvulsant hypersensitivity syndrome” and is associated with fever, rash, enlarged nodes and hepatitis. It usually begins within eight weeks of beginning Dilantin treatment.
The second syndrome, as in this case with Caroline Cleaves, is called “phenytoin-induced pseudolymphoma.” It is slow to develop, coming even years after being on Dilantin. Both syndromes vanish on stopping the drug.
It is clear that the resident from his readings led Dr. Barnett to the correct diagnosis. What remains a mystery is how the husband knew to reject the diagnosis of a malignant lymphoma.
One can only wonder what tragic course would have occurred had chemotherapy been initiated.
*Case shared by:
Paul Barnett, M.D.
Associate Clinical Professor of Medicine
Department of Medicine
Vanderbilt University School of Medicine”.
Chapter Twenty Nine
“Extratebreastrial” Communication *
Tiffany Snopes, a 31-year-old woman, was first seen in the Surgery Clinic of University Hospital complaining of problems with her breast implants.
Dr. J. Willis Malone, a plastic surgeon, asked Ms. Snopes to describe the problem.
She rambled on for the better part of 10 minutes about her insomnia and unwanted weight loss, then began describing — in great and unnecessary detail — her long trip to Singapore three years ago where she had the implants inserted. Her tale went on for at least 15 more minutes, chock full of digressions and trivia that no one, especially this busy doctor, wanted to hear.
Dr. Malone interrupted politely, “Please, Ms. Snopes, could you tell me what the problem is?”
She paused and blinked for a moment, as if trying to understand the question.
“Well,” she finally said with some indignation, “I haven’t had one moment’s peace since they put those things in me. I cannot sleep. I cannot think. It is incessant. I want them removed now.”
“Can you describe the problem?” he asked. “Is it pain? Do they hurt you? Are they too small or too large? I need more information before I can help you.” Malone was getting frustrated.
“All night long they go on,” she continued, hardly taking a breath. “It’s those Martians. My breast implants are audio devices for the Martians. Didn’t I tell you that? They talk to each other all the time. Sometimes they yell and wake me up. I can’t stand this anymore. I want these implants out so I can get some peace and quiet!”
Malone stood there dumbfounded. At first he thought someone had put her up to this as a joke. It was beyond outrageous. But he could clearly see she was very serious and very upset. He had never encountered anything like it. The woman was obviously delusional and paranoid.
The more he listened and questioned her, the more he was convinced these delusions and paranoia were highly selective and limited. She was not worried about a whole host of things, as is often the case. Her paranoia was focused exclusively on aliens using her breast implants as communication devices.
Malone called in Dr. Sidney Mayhand for psychiatric consultation. After lengthy interviews with Ms. Snopes, Mayhand was convinced there could be no psychological progress until the implants were removed. He told Dr. Malone he had seen people with very limited delusions like this before, but none had centered on breast implants.
“She is refusing any kind of psychiatric treatment or drugs until the implants are removed,” Mayhand said. “I know it is heterodoxy, but I suggest you comply with her request and remove the implants.”
“Are you nuts?” Malone replied. “Me? Remove implants from a psychotic woman? I can imagine the jury now. There’s no telling what a lawyer would try to get out of me for that. They would have a field day!”
Dr. Mayhand tried once again to convince Ms. Snopes that medications would stop her delusions, but she adamantly refused to take them. She didn’t need them, she said. All efforts to convince her otherwise fell on deaf ears.
Running out of options, Mayhand and Malone asked to meet with the hospital’s ethics committee and attorneys to discuss the situation. After careful consideration, all parties supported a plan to remove the implants as the only treatment that might give the patient relief, noting in the record that her general health was deteriorating from the insomnia and weight loss. Legal consent forms were drawn up and signed by witnesses, the patient herself
and an uncle, who was her only living relative.
Dr. Malone, still reluctant, scheduled surgery. In her terms, she demanded “American breast implants and get rid of these Singapore things.”
After the procedure, Ms. Snopes woke from the anesthesia. Immediately, she seemed a different person, smiling and happy. When Dr. Malone made his first post -op visit, she was sitting on the edge of her bed.
“Oh, thank goodness!” she exclaimed when she saw him. “It’s the first time in over two years those voices have shut up. Thank you, thank you so much.”
Malone told her he was glad she had relief and took the opportunity of her good humor to remind her of the promise she made to continue to see Dr. Mayhand for psychiatric treatment. “Now don’t go back on your word,” he said.
“But Dr. Malone,” she said, still smiling, “you cured me. I don’t need any more treatment. You fixed it!”
Ms. Snopes went home on the third post-op day, staying longer than usual to allow for some follow-up. She refused to see Dr. Mayhand. She was never seen again. No one ever knew how long her delusions or paranoia remained in remission. All they knew for sure was that she remained free of the alien voices for those three happy days.
*This case was shared by a colleague who wishes to remain anonymous.
Chapter Thirty
The Honeymoon
By Sidney R. Block, M.D.
“I can’t breathe”, is what Martha actually said, but in the middle of Stage IV sleep, what I heard (or thought I heard) was, “I can’t sleep.” As I slowly stumbled up the cognitive staircase to awareness but not yet at the step of comprehension, she repeated, “I can’t breathe”, and, now in Stage I, I dreamed she was saying once again, “I can’t sleep.” “So,” I warned myself in my preawakened stupor, “this is what marriage is all about: she can’t sleep and I need to be told about it.”
It was the second night of our marriage, the first having been spent in the Honeymoon Suite of the Plaza in New York City, and even that notwithstanding we had managed a reasonably restful number of hours of sleep before arising and leaving the next morning for a villa on the coast of Bermuda which offered wonderful views, great privacy and a breakfast served on our patio overlooking the Atlantic Ocean.
“I can’t breathe”, Martha now strained to implore with greater urgency, and now fully awake, I also could discern her anxiety and evident respiratory distress. Sans stethoscope, I had to listen to her chest, an exercise which during a honeymoon should have been a pleasurable effort. Hearing only a mild tachycardia and no adventitious sounds and everything else between her heart and my ear seeming to be in perfect order (in retrospect I should have sat her up first and put my ear to the back of her chest—-but, again, it was our honeymoon, and though accordingly I have ever since forgiven myself, she has not), I helped her sit up and lean forward which seemed to help. I tried to be of further assistance by propping her up even more with the available pillows. She didn’t worsen but she also didn’t improve much, and we remained awake and concerned until daybreak.
After getting out of bed and sitting on the patio waiting for breakfast to arrive, there was evident improvement in her respirations and we relaxed a bit. The maid arrived with a large tray full of fresh coffee, pastries, eggs and fruit, and after setting our table, looked at us and noted that though we looked tired (as well we should have been on the second night of our marriage), we did not look as happy as she would have expected.
The maid inquired about how we had spent the night.
Martha replied, “Not well; I had trouble breathing.”
“Oh, do you have any allergies?”
“Only to feathers.”
“Well then, just let me take those down pillows and replace them for you,” and she left to do just that.
My wife gave me a look, a look that included a wry smile (a look that I have come to know much better over the last 43 years). “A lot of good it did me, did it, marrying a doctor!”
Story told by:
Sidney R. Block, M.D.
Northport, Maine
Chapter Thirty One
A Case of Overkill *
May Cusins was a 78 year old woman admitted for pneumonia. This was her third admission for pneumonia in the past year.
Dr. Allen Kaiser, an infectious disease consultant, had been asked to see Mrs. Cusins to see if he could uncover any cause for her repeated bouts with pneumonia. Lung scans and a bronchoscopy on a previous admission had been unrevealing.
Dr. Kaiser, with his team of a medical resident, an intern, and three junior medical students entered the room. He introduced the team to Mrs. Cusins.
“Mrs. Cusins, your doctor asked me to see you about your pneumonia. We need to ask you some questions. “
“Well go right ahead.” Mrs. Cusins had no teeth so she gummed her mouth up and down as she talked.
“Do you live in town?” Kaiser asked.
“Oh no. I live way up in the country. Out from Jamestown. Live in a trailer with Hunt. He’s my husband. Been married 61 years.”
“I see. I need to go down a list of things. Any dust around your place?”
“Nope.”
“Any blackbird roosts nearby?”
“Nope. Aint’ no trees.”
“Use any insecticides?” Kaiser was moving from one inhalant to another.
Mrs. Cusins looked puzzled, hesitated, then said, “Don’t think so.”
“Are you sure?” Kaiser pressed on, not certain she understood the word. With no response, he asked, “Got in any insects in your trailer?”
“Aint no insects but it’s full of roaches. Some of ‘em an inch long.” she responded.
“What do you do about the roaches?”
About that time, Mr. Cusins came into the room. Mrs. Cusins said, “Hunt, tell ‘em about the roaches.”
“Hell every time she gets out the cans of ‘Real Kill’, I have to run out the trailer. She don’t use just one can. She uses 2 cans.”
Kaiser turned to his team and smiled. “Real Kill, like all insecticide sprays contains pyrithrene or a derivative molecule. It is neurotoxic to all insects. Also toxic to the lungs of humans if they are allergic or sensitive to it.”
Hunt Cusins turned to his wife. “I told you one can was enough. I knowed those 2 cans was too much.”
Kaiser said, “Sooner or later if you keep asking, you will get the answer. Patients like Mrs. Cusins often know the answer but we have to teach each other our names for things. Takes a bit of patience. Everything has a cause.”
*Case shared b:
Allen Kaiser, M.D.
Chief of Staff
Vanderbilt Health System
Professor of Medicine, Vanderbilt University
Chapter Thirty Two
Some Mysteries
Remain Mysteries*
Alfred Lee Henderson always came to clinic with his wife. Both were over dressed and looked a bit out of place in the clinic waiting room.
Alfred Lee wore two tone black and white wing tipped shoes – Spectator shoes. His suit was black with cream pin stripes, as was his matching vest. He tied his tie in a large Winsor knot. He looked like a movie version of a Wall Street Banker.
His wife, Sarah Elizabeth, was beautiful with long brunette hair swept to one side of her head. She was nearly six feet tall. Whenever the two walked into the clinic waiting room they drew the full attention of waiting patients. An audible hum rippled across the group.
Dr. Allen Kaiser, an infectious disease specialist, was seeing Alfred Lee Henderson for the first time. Both Henderson and his wife were waiting in the small exam room when Kaiser entered. Henderson had been referred to Dr. Kaiser by a primary care provider who had been treating Mr. Henderson for several months for recurring abscesses on his arm. He now required a PICC line (Peripherally Inserted Central Catheter) for IV antibiotics. New abscesses continued to appear and the frustrated primary care provider referred him to Dr. Kaiser for advice.
There were many reports in
Henderson’s medical record of the cultures of the abscess pus. The large number and variety of types of different microorganisms (bacteria) was something Kaiser had not seen before. Usually abscesses grow out a single organism such as staphylococcus. In Henderson’s case, there were half dozen different bacteria. Some were not classifiable, simply labeled “gram positive rod, not classifiable”.
All of the extensive laboratory test results were normal. Efforts to examine the immune system, including a HIV test were normal.
Dr. Kaiser had difficulty drawing either Henderson or his wife into any sort of dialogue. They either answered with one syllable or they nodded their heads in yes or no responses. He did glean with some difficulty that Henderson worked in a bank in a small town in Alabama. No, he was not an officer in the bank. Yes, he was a clerk and book keeper in the bank. (Kaiser was a bit surprised, expecting Henderson to be at least an officer in the bank.)
Kaiser got nowhere is searching for unusual contacts with plants or wild animals as a source of infecting agents. Henderson said his daily activities were unchanged from the time before the abscesses began.
After half an hour, Kaiser, drawing a blank, ended the interview. His physical examination found a dozen or more abscesses from the shoulder to the top of the hand. They were only on the left arm and hand. He did note that Henderson was right handed. The rest of the physical examination was normal.
Puzzled by his failure to make rapport with the couple, Kaiser reviewed the social worker notes. There he found that the couple, although still married, no longer lived together. No reason was given for living apart. Both always attended the clinic together. The social worker also had difficulty drawing the couple into conversation.
Henderson returned to clinic in one week. Dr. Kaiser had formulated his plan. He engaged the head nurse to come with him into the exam room as a witness. Fearing some anger and even possible retribution for what he was about to say, he placed a voice recorder in his coat pocket and turned it on.
Fascinomas- Fascinating Medical Mysteries Page 9
