Chapter 112
Bzzzz-
As the automatic door opened, I strode toward Zone B, where Kim Jihoon was standing.
“Jihoon!”
Kim Jihoon had just set down the handset and turned his head.
“Uh, why? I just called the NP
(* Psychiatry)
on-call doctor... They said to give Ativan first, and once he calms down a bit, they'll come down to take a look.”
“Cancel the call. No, hold off for now.”
“What?”
Kim Jihoon looked flabbergasted.
“This might not be psychiatry. Could it be HSV encephalitis?”
“HSV? Herpes encephalitis?”
Kim Jihoon's eyes widened.
“Why encephalitis all of a sudden? The fever isn't even that high. If it's 37.8°C, it could just be from excitement.”
“No, I checked the EMR. She came to our ER three days ago for a cold—flu-like symptoms. Fever, sore throat, the works.”
I quickly ran through the textbook material in my head.
Herpes encephalitis.
A deadly disease that starts like a cold, with fever, headache, and sore throat, then a few days later suddenly causes personality changes, hallucinations, or seizures.
It has a high fatality rate and, if treatment is delayed, can leave permanent brain damage. It is a medical emergency.
“A cold three days ago. And acute confusion today. It fits the classic prodromal symptoms of viral encephalitis perfectly.”
At my words, Kim Jihoon's expression turned serious too.
“Hmm... now that you say it, you're right. If it's encephalitis and we send her to psychiatry, we're screwed.”
“Right. So let's run the full workup. First a brain CT to rule out bleeding or a tumor, and then straight to LP
(* Lumbar puncture, cerebrospinal fluid test)
I think we need to do that. We also need an MRI, but the wait right now is....”
I glanced sideways at the MRI wait list on the station monitor.
[7 waiting]
Even if we pushed it through as urgent, it would still take a while.
“For now, let's get the CT first, add more labs, and recheck the viral markers and inflammatory markers. Acyclovir
(* Antiviral)
might need to go on as empiric treatment....”
With that, we pulled back the curtain around the patient's bed.
We were going to do additional neurological exams.
Rustle.
But then.
“...Huh?”
Kim Jihoon froze.
“The patient's really quiet now?”
The bed was silent.
The person who had just moments ago been screaming about seeing ghosts and trying to bite through the restraints was now slumped over, sleeping with soft breaths.
Ativan 4 mg.
It was enough to knock out even an average adult man.
“Uh... yeah, I guess so....”
I muttered while checking the patient's pupils.
Her breathing was regular, and her pulse had stabilized from the 120s to the 90s.
The medication had taken effect.
“The benzo's working....”
Kim Jihoon let out a sigh of relief.
“If it were encephalitis, the brain tissue would be swelling and causing chaos. Would Ativan calm her down this much with just one shot? Usually, if it's an organic cause, sedatives don't even work that well, right?”
“If it's an acute seizure, benzos can work pretty well too.”
I was starting to get a little confused myself.
Even encephalitis patients will fall asleep if you give them a sedative.
Was it acute? Recurrent? Or....
No idea.
“Is it just acute psychosis? Temporary?”
Kim Jihoon watched my expression carefully.
Am I overdoing the workup?
But that chart note from three days ago kept nagging at me, and I couldn't let it go.
I looked down at the sleeping patient's face.
Hair damp with cold sweat.
Pale skin.
And eyelids that twitched faintly.
Was she simply crazy, or was her brain under attack?
“Still.”
I came to a conclusion.
“Let's get the CT. When she wakes up, get her to sign the consent form for the spinal tap too.”
“Yeah, we should.”
Kim Jihoon grumbled, but he brought up the order window.
As I covered the sleeping patient with a blanket, I thought to myself.
'Please let me have been overthinking this.'
***
I was looking at the monitor and studying the sleeping patient's face closely.
The patient's lips were moving on their own.
The way her lips were smacking and her tongue flicking out like she was chewing gum was too rhythmic and mechanical to be just a sleep habit.
'...Orofacial dyskinesia.'
A sinister medical term flashed through my mind.
It's usually a side effect seen when schizophrenia patients take antipsychotic drugs for a long time.
But according to the guardian, this patient had never taken any medication.
Acute dyskinesia appearing without any medication.
Does that make sense?
On top of that, the vitals were going haywire.
Her temperature, which had been 37.8°C, suddenly dropped to 36.5°C, then shot back up to 38.2°C.
The fever went up, then came back down.
Her blood pressure soared as if it would punch through the ceiling, then suddenly dropped to just short of shock. It was bizarre.
As if her autonomic nervous system had broken down.
“Damn, hmm....”
This feels off.
The clinical picture was too complex to be simple HSV encephalitis.
But to call it a psychotic disorder, the organic signs were too clear.
Just as my thoughts were tangling up, the ER automatic door opened and a man in a white coat came in.
“I'm the psychiatry on-call doctor. You called?”
It was Joo Jeonghyeon, a second-year resident in psychiatry.
Same year as me, but someone with a calm demeanor whom I didn't get to see often.
“Ah, yes, doctor. This patient's a woman in her twenties. She came in with acute confusion, visual hallucinations, auditory hallucinations, and persecutory delusions. We gave Ativan 4 mg, and she's calmed down for now.”
Joo Jeonghyeon alternated between the patient's lip movements and the monitor, his expression serious.
Joo Jeonghyeon's brow furrowed.
“There's nothing unusual in the history besides cold symptoms from three days ago?”
“Yes. Past history, family history, and medication history are all clear.”
“Hmm....”
Joo Jeonghyeon took out a penlight and checked the patient's pupils.
Then he stared at the patient's lip movements for a long time.
“There's some movement around the lips, isn't there? You said she hasn't taken any medication?”
“Both the guardian's statement and our hospital records are clear.”
Joo Jeonghyeon scratched his head with a troubled expression.
“We could suspect first-episode schizophrenia or a brief psychotic disorder... but the spiking vitals and that abnormal movement are concerning. So is the cold history.”
I looked at Joo Jeonghyeon and asked cautiously.
“Should we request a neurology consult?”
“Hmm, not sure....”
Joo Jeonghyeon rubbed his chin.
I explained the plan first.
“First, get a brain CT, and when the patient wakes up, get consent for CSF
(* Cerebrospinal fluid)
testing in the ER before sending her upstairs. We need to rule out encephalitis and meningitis.”
“That sounds best. If the imaging and cerebrospinal fluid results are clear, we'll admit her and take over then. For now, we'd appreciate it if you could keep the possibility of an organic mental disorder open.”
A reasonable judgment.
First, get the brain scan, and then do an LP to draw CSF.
'Encephalitis, huh....'
Was it really HSV encephalitis?
HSV usually affects the temporal lobe and causes memory loss or seizures, but those bizarre mouth movements and the wildly fluctuating blood pressure are a bit atypical, aren't they?
It was frustrating.
It felt like one puzzle piece was missing.
What on earth had driven this young woman insane?
While Joo Jeonghyeon went to speak with the guardian, I turned to my one and only outlet in frustration.
[Dead Medic Gallery]
========================
Suspected encephalitis in a woman in her twenties, but the symptoms are kind of strange
Author: HellJoseonSlave1
Woman in her twenties. Cold three days ago. Came in today with acute confusion and hallucinations.
After giving Ativan, she's asleep but keeps smacking her lips.
The fever goes up and down, and the blood pressure does whatever it wants.
Working her up for suspected HSV encephalitis, but something feels off.
========================
As soon as I posted my question, the bored ghosts started popping out one by one.
[Comments]
ㅇㅇ (210.94): She's possessed by a ghost. Looks like you'll need to do an exorcism, lol.
ㄴ HellJoseonSlave1: You're the ghosts, you damned ghost doctors. Get serious for once.
ㄴ ㅇㅇ (210.94): I'm kidding, you idiot.
Descendant of Hippocrates: Hmm. Strange. Could it be a drug side effect?
ㄴ HellJoseonSlave1: I said she hasn't taken any medication.
Back in My Day: Does HSV usually cause autonomic symptoms that severe? Usually seizures or decreased consciousness are the main thing. The mouth-smacking is a bit unusual.
NRNRNR: Isn't it limbic encephalitis? The autoimmune kind. If she's a young woman, you should also rule out lupus encephalitis. Did you send ANA and dsDNA?
ㄴ HellJoseonSlave1: Not yet. I'll add the labs.
All sorts of guesses were flying around.
Viral, autoimmune, metabolic...
But there was no clear answer that made me go, This is it!
Amid the flood of opinions, one comment caught my eye.
ㅇㅇ (118.235): Get an abdominal CT.
“...Abdomen?”
I frowned.
Her head's gone crazy, and you want me to scan her belly?
What kind of nonsense is that?
ㄴ HellJoseonSlave1: What are you talking about? I said her head's the problem. I don't want HIRA cutting the reimbursement.
Then that anonymous user immediately replied.
ㄴ ㅇㅇ (118.235): Do you know what an ovarian teratoma is?
“....”
Ovarian teratoma?
Teratoma?
Why would that come up here?
ㄴ HellJoseonSlave1: I know that, but what does it have to do with anything? This isn't OB-GYN.
ㄴ ㅇㅇ (118.235): Anti-NMDA receptor encephalitis. Know what that is?
ㄴ ㅇㅇ (118.235): It's usually caused by antibodies from an ovarian teratoma in young women. The symptoms fit perfectly: cold-like prodrome, psychosis, dyskinesia, autonomic dysfunction.
“Ah...!”
It felt like I'd been hit in the back of the head with a hammer.
Anti-NMDA receptor encephalitis.
A type of autoimmune encephalitis.
A disease caused by our immune system attacking the brain's NMDA receptors.
And the culprit that produces those antibodies is often an ovarian tumor, a teratoma.
A disease where a perfectly normal person suddenly goes berserk, shows bizarre movements, gasps for breath, and dies.
The very disease that, in the past, led to people dying after exorcisms because everyone thought they were possessed by demons.
Every puzzle piece fit together perfectly, in a way that gave me goosebumps.
I sprang up from my seat.
Just then, I saw Joo Jeonghyeon returning after finishing his talk with the guardian.
“Psych doc!”
“Yes. The guardian agreed too, so we've decided to proceed with the tests for now....”
“Let's get a brain CT, and a pelvic
(* Pelvis)
CT as well.”
Joo Jeonghyeon's eyes widened.
“What? The abdomen? Why the belly all of a sudden...?”
An abdominal CT out of nowhere for a psychiatry patient, or even a neurology patient.
It was bound to sound like insane talk.
But I looked at Joo Jeonghyeon with confident eyes and said,
“We need to check whether it's a teratoma.”