21. The Eyes
'Morning, Junior!'
I woke up the young boy who was my patient that week. He was just 20 years old, and I would see him every morning until the day of his surgery. I found out the nurses were calling him Junior since he was so young and he enjoyed it.
‘Morning, D.!’
It was just the second day I’d been with him. He was admitted for a colon resection. Yes, already in his 20s. He had familial adenomatous polyposis, his colon was filled with thousands of polyps. Most of his family had already done this surgery since it's an autosomal dominant condition, so he knew everything about it.
‘How are you feeling today?’
‘I’m great, no problems. I just want to finish this already and go home.’ He seems grumpy when I write like this, but he was actually a nice boy. He was just tired, and I couldn’t blame him.
‘I get it. But don’t sweat on it, your surgery is this afternoon so you’ll be home in no time.’
He smiled happily.
As I examined him, I noticed something I hadn’t seen before. His eyes were trembling.
I was doubtful though, had I seen it right? I decided to test his cranial nerves and nothing was wrong, except for the nystagmus. Puzzling. Junior noticed me staring at his eyes.
‘Is there something wrong, D.?’ The question no doctor wants to hear before they actually know what is going on.
‘Don’t worry about it now, I’ll let you know if there is, Junior. Go ace that surgery.’
He laughed.
‘Well, I’ll definitely ace the part of sleeping through it.’
I went looking for Peter and Lucy to discuss the cases of the day. It took me a while, but I found them at the cafeteria, which was odd since Lucy almost never ate there.
‘Morning, Dr. Collins! How are you?’
‘I’m great, thanks for asking. Let’s begin?’ She looked at me and Peter, and we nodded.
After a few of Peter’s cases, I could finally talk about Junior’s nystagmus.
‘Does he use any illicit drugs?’ Lucy asked. I had also thought about that, but he had denied it when I asked him at our first encounter.
‘He says he doesn’t.’
‘Do you believe him?’ Peter asked this time.
‘Honestly, I think I do. But who knows?’
Lucy thought about it for a moment.
‘Does he have any other symptoms?’
‘No, nothing. He’s only here for the surgery.’
‘Right.’ She sighed. ‘Well, if he doesn’t use drugs, we are going to have to come up with another differential. Do you think it’s peripheral or central nystagmus?’
‘I think it’s probably central. He doesn’t have any problem walking, no vertigo, and no sign of vestibular impairment.’
‘Then we’ll have to go for imaging.’ She looked worried. ‘Ask him again if he uses any drug, tell him it’s important. And check with surgery if you can postpone his procedure for tomorrow.’
I nodded. He was the last patient in our discussion so she got up to leave.
‘Dr. Collins?’ She turned to me. ‘What’s on your mind for him?’ I could see she hadn’t told me everything she was thinking.
She paused for a moment.
‘Turcot syndrome. Unfortunately.’
My heart raced as I worried about him. Lucy couldn’t hide her worry either. For the first time, I really hoped he was lying about the drugs, which was maybe a more solvable problem than a brain tumor.
I went to talk to him. He denied it again and I believed in him, especially now that Turcot didn’t leave my mind. I talked to the surgery team and they agreed with the postponing. We ordered an MRI.
‘Why do I need an MRI?’
‘Today I noticed something in your eyes. We call that nystagmus, when they tremble a little bit. That’s why I asked you again if you used any drug. We need to take a look at your brain to see if there’s anything there causing it.’
He seemed worried, but he didn’t want to talk about it. He stopped talking to me, just saying a few words now and then to the nurses. I wasn’t mad though, it is what it is. In the end, he agreed to get the exam. He was a nice kid.
Lucy was right. It looked like he had a chiasmal glioma. Thankfully, it didn’t seem like a glioblastoma, but still, it was no easy news to give, and he didn’t take it very well. He shut us out and we couldn’t figure out how he was feeling, just that he seemed mad. His mother was devastated, both by the diagnosis and by Junior’s behavior. I tried to calm her down by telling her that mad was good, mad is something. Mad meant that her son cared, and that was so much better than indifference.
We called neurosurgery to assess the MRI and discuss the next steps of his treatment, including bowel surgery. Hopefully, he could have a good prognosis. I didn’t really follow up on his case because he was upset and I believe his mother took him to another hospital after that. I wish we had got along better, but I guess I was just the person that gave him the really bad news. Either way, I found out years later he removed the tumor and was living a fine life in New Jersey.
To this day I think of him when I look at a patient’s eyes.
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Want to know more about Turcot Syndrome?
https://rarediseases.org/rare-diseases/turcot-syndrome/
Want to read a real case of Turcot Syndrome?
http://svimstpt.ap.nic.in/jcsr/Jul-Sep15_files/1cr15.pdf
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