I’ve never posted on a February 29th before!
Just so you can keep track of my arbitrary temporal preferences:
-Leap year = awesome.
-Daylight savings time = still mind-numbingly idiotic.
You’re welcome.
Happy February 29th!
Hey! What’s Green With Red Wheels?
Think about that while I tell you about my fever dude! Remember my fever dude? The one that I was all like, damn, he has lymphoma?
Well, we have a follow-up! Yes, I know it’s been forever. It takes a while to write long posts these days, since I can’t really just sit down and do it in all one chunk anymore. When I even have a chance to sit down.
Anyway.
Before I give you the update, I’m going to start out on a complete tangent by telling you why I hate and adore House (yeah, the medical TV show.) (I bet you were wondering when I would get around to reviewing medical TV shows, and Marina has been campaigning for House commentary for a while now…) (I swear this is relevant, I swear.)
House actually drives me crazy. I love it and hate it and love it and hate it and love it and hate it and love it. I don’t actually watch it all that often, although I sometimes feel like I should start at the beginning and watch all the way through because there’s clearly interesting character development going on. But I watch it sometimes when I’m visiting my mom, and I love it every time I see it. And hate it. And here’s why.
In medical training, the only bit of wisdom that’s more prevalent than “try to take a sip from that firehose” is “When you hear hoofbeats, think about horses instead of zebras.” Basically, if something walks like pneumonia, quacks like pneumonia, sings like pneumonia and tries on hats like pneumonia, it’s probably pneumonia. You can and should think about alternative diagnoses, but at the end of the day, it’s probably going to be what it looks like. Not histoplasmosis or something like that. (Also phrased as: “Common things are common. Uncommon things are uncommon.)
House, though? House is a zebra-huntin’ safari. Common presentations are just red herrings for bizarre diseases, and bizarre presentations are just red herrings for a common disease that has some weird thing going on that makes it present weirdly.
Plus, PLUS!
I have never, EVER seen a show twist itself into SUCH a pretzel to avoid doing BASIC LABS on these patients. Why? Because you’d get your first clue from the basic labs that would be drawn by the ER before an Internal Medicine doc ever laid eyes on them. And then that takes all the drama out of the show. Picture this:
Person on House: Geez, what a weird case.
House: Well, let me apply my amazing brain of amazingness….
Person on House: Oh, well look at that. The basic metabolic panel clearly states he’s got hypokalemia. Let’s just replete his potassium, and maybe he won’t die of a heart arrhythmia.
House: ::repletes potassium::
END.
Okay, so you have to have at least SOME suspense. But here’s how they do it.
Person on House: Geez, what a weird case.
House: He has been in the hospital five minutes and he is crashing and burning! No time to wait for the lab to tell us the most basic information about his physiological status! We need a brain biopsy, STAT! Without anaesthesia!!!!!
FLASH! BANG! BLOOD! MEDICAL DERRING-DO! SEIZURE! SNARKINESS! SHOCKING OF FLATLINES! MORE SNARKINESS!
House: Elementary, my dear Watson.
END.
Much more exciting.
Anyway. I’m getting away from myself.
One of the other things about House is that House’s peons do everything. They do the doctoring, they are the CT techs, they are the pathologists, they are the surgeons, they are the cytologists, they are EVERYONE. It’s practical; who wants to pay an extra when one of your main cast members can stare in disbelief at a computer screen just as well as she can?
Why are you talking about House? I wanted to hear about your fever dude.
Hey, you haven’t been here for a while.
I was on vacation. In Hawaii.
Self-referential blog-flashback humor, thank you very much. So, what’s the relevance to House?
My fever-dude case. Looking back, I basically just lived an episode of House.
Not only did I end up being my own lab tech and doing a number of other non-physician jobs that one finds oneself doing when one does internal medicine in a broken hospital dealing with an underserved population, I ended up with a diagnosis-twist worthy of the most diagnosis-twisty episodes.
You see, I’m happy to report that I misread the peripheral smear after all. My patient did not have leukemia. (Although I maintain that at least two of the cells I saw looked exactly like blasts.) (There’s a reason we have pathologists.)
It turns out that my patient had……………
…….babesiosis.
Babesiosis?
BABESIOSIS?!?!?!?!?!?!?!?!?!?!?!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Holy red herring, Batman!
Okay, here’s the story. A 42-year-old man with a past medical history of hypertension presented to the ER complaining of a cyclical fever. His temperature spiked to 103 on a daily basis, around 6-7 pm. That is a weird pattern; only a few diseases present that way. On further history, he noted that he had just gotten back from a short trip to Puerto Rico.
At this point, my differential is leaning heavily toward malaria. But malaria’s incubation period is a lot longer than my patient’s trip, so it would have been really weird for him to start spiking fevers in that amount of time. But patients will always surprise you, and that’s why I did the smear; I was looking for the plasmodium parasites in the red blood cells.
But malaria isn’t the only disease that causes cyclical fevers. Besides hematological malignancies like leukemia, another, less common disease that presents this way is babesiosis, a tick-borne protozoal disease that has a distribution in the northern and midwestern parts of the US. You can also see babesia on a peripheral smear, and about four smears later, they were able to visualize the parasites.
So: A person travels to a region where you’d expect a tropical disease like malaria or dengue. He develops a cyclical fever typical of a tropical disease like malaria or dengue. Then it turns out he actually contracted a similarly-presenting, rarely-diagnosed NON-tropical disease BEFORE HE LEFT, incubated it while on his trip, then came back and plunked a red-herring-filled presentation at the doorstep of a new doctor.
Gregory House, eat your heart out.
Interestingly, my intern says that there were at least two times during that night that I had muttered the word “babesiosis?”, quickly followed by “no, no, that would be absurd.”
And I was right. It was absurd.
But there you have it.
Patients will always surprise you. Always.
Anyway, have you decided on what it is that’s green with red wheels?
It’s grass.
I lied about the wheels to throw you off.
😀
Throne of the Crescent Moon
No, I didn’t post on schedule this week.
No, I haven’t actually written anything to post.
Luckily, Saladin Ahmed just published his first novel, and it launched yesterday!
So why don’t you stop by his website and check out Throne of the Crescent Moon!
(What? Fantasy ISN’T exclusively about white European-esque farm-boys who are destined to be king?!)
How To Kill Your Imaginary Friends 