Sunday, January 14, 2007

Whoops. That'll take some 'splaining.

The latest issue of the Journal of Neuroscience Nursing reminded me of something.

There's an article in this issue about the possibility that Al Capone, who suffered from some interesting psychological pathologies (putting it gently), may have had neurosyphilis. The authors cite his bed-making habits and megalomania, among other things I don't recall because I haven't read the article carefully yet; only skimmed it.

Anyway, we had a little situation some time ago at the hospital.

A very nice couple had come in. They'd been married for donkey's years, had kids all in their forties, and had had a pretty good life...until the husband started manifesting some signs of dementia. His memory had gotten poor, his gait ataxic, and he was beginning to be incontinent. His primary care doc had sent him to us, thinking that there was a chance he had normal pressure hydrocephalus that could be controlled with a shunt.

So neurosurgery put in a lumbar drain (for the non-medical types, it's a drain that goes into the small of your back through which we can drain off cerebrospinal fluid and reduce the pressure in the brain) and drained it religiously for a few days, every four hours. Physical therapy and neuropsych came in and administered a battery of tests, both before and after, to see if there was any improvement after draining.

No go. As it is in the majority of cases we see, the dementia is due to something else. So neurology came in and started running a battery of tests to determine what, exactly that something else was.

It's basic practice to run a test for syphilis early on, just as it is to run tests for HIV and a number of other, less common things. We'd only had one syphilis serology come back positive before, so nobody was expecting that.

Especially not the patient or his wife.

Sammy the neurosurgery resident wandered into the nurses' station, looking for me. I'd had care of the patient for two weeks, off and on, and Sammy was wanting some moral support when he went into the room to tell the patient and his wife that the cause of his dementia was a bad decision he'd made probably twenty or thirty years prior.

Syphilis, you see, is a tricky little bug. It's a bacterium that can be easily cured with high doses of antibiotics administered in a certain way over a certain time frame, but if it's not cured, it tends to hide out in the body. Over time, it can cause things like weird lumps in joints, strange rashes that come and go, and eventually (if you're one of the roughly thirty percent of people who's unlucky) neurological complications. Or cardiac complications. Or bits of your face--though this is increasingly rare--can begin to fall off. Most people catch it and get treatment fairly early, though Oliver Sacks recorded a case of a woman who developed neurosyphilis seventy years after her infection.

Apparently our man had had a little fling, or had visited a prostitute, or had somehow otherwise put himself in a position to catch this particular spirochete. And he'd done it long enough ago that he'd probably thought he'd gotten away cold. His wife's reaction was such that it was unlikely he'd ever confessed to his indiscretion.

Poor resident Sammy had to break the news. I went in as multiple moral support person, and afterwards we had a cup of coffee. There are some things you just would rather not remember much of after the fact; that half-hour in the patient's room was one of them.

I don't remember what happened to that couple. I know he was treated, but there was no way we could reverse the damage that had been done. I know she was referred to the state health department for treatment. I know there was icy silence from that room from the time Sammy and I walked out until the time they were discharged. But after that? He probably had some 'splaining to do.


Sid Schwab said...

I saw some primary syphilis when I was serving in Southeast Asia. Saw a couple of cases of tertiary disease in med school, and as I recall, like your patient they were in people exposed many years earlier. A common thing a few decades ago; a rare thing to have seen now. Interesting.

woolywoman said...

The job I do now includes teaching patients how to go home with their PICC lines, and how to give themselves IV antibiotics. We have an entire pharmacy devoted to outpatient antibiotics. I have had, oh, maybe three neurosyphillis patients a year, and every one of them has been absoluely gobsmacked upon hearing the diagnosis. Dunno. Maybe a single exposure is less likely to become active, or something. But all of these guys were of the "I only did it once" types. Maybe people who cheat a lot just have a friendly doc they go to periodically. Icy silence doesn't begin to describe most of it. Even better are the relatives who are all excited that now there's a cure for Alzheimer's....uh, no, I can't tell you what he does have, but it's not Alzheimers.