28. The Physical Findings
‘Maybe.’
Ben was a 35 year-old man of Middle Eastern descent. He was brought to Brooklyn’s Hospital for behavior changes in the last month. His mother, Jude, explained to me that her son wasn’t answering her calls so after a few days she decided to knock on his door. She found Ben mumbling unintelligible words. He seemed to be wearing the same clothes for some time, and hadn’t showered for a while.
‘How about before this episode? How was he?’
‘Well, a completely normal person.’ Jude would say. ‘He was kind, caring, very organized with his things. He was a high-school teacher, loved his job and his students loved him. But last month, all of a sudden, he just stopped going to work, I asked him about it and he couldn’t explain to me why. I think that’s probably when I first realized he wasn’t being himself.’
Ben had been admitted a week before I saw him for the first time. He didn’t speak to anyone, couldn’t bathe alone, and wasn’t even eating. As you can imagine, he got the full work-up, brain imaging, spinal tap, blood tests, the whole deal. His imaging showed some parenchymal changes in his brain, but nothing that pointed towards an etiology. The only thing remarkable was that his inflammatory markers like c-reactive protein and erythrocyte sedimentation rate were pretty high.
It was just sad to see such a young guy who was healthy before in that situation. Completely dependent on others and not making any sense. And to make it worse, we still had no idea what was going on with him or how to fix it.
It was the third day I was seeing him. I thought about what Peter said and decided to be more thorough that morning. So I started by talking to his mother.
‘Jude, is there anything else you remember? Anything that was bothering him about his health?’
‘I don’t know… I can’t remember.’ She seemed worried.
‘That’s okay, just tell me if you do remember. Anything at all: fever, pain, weight loss…’
‘Oh! He complained about pain in his joints a few months ago. He thought it could be the gym but said he would go to the doctor.’
‘I see. Thank you.’ That didn’t ring any bells at that time. But I kept it in mind and went to Ben’s physical exam.
Starting from the top, I could see his eyes were a little reddened, which I had noticed before but didn’t know why. Very subtle, but definitely there. But when I opened his mouth, I regretted so much not doing it sooner. There it was: several aphthous ulcers. I asked Jude about it, but she didn’t know he had them. I kept going. When examining his genitals, I could see some genital ulcers there too. At last, by the end of the exam, I thought his legs looked a little weird. It had some darker spots on the shin. It wasn’t the most characteristic I had seen, but I guessed it could be erythema nodosum. I thanked Jude and Ben, although he didn’t seem to fully understand me, and left.
Oral ulcers. Genital Ulcers. Maybe uveitis? Arthritis. And erythema nodosum. The first and only thing that came to mind was Behçet Syndrome. It made sense, a small and large vessel vasculitis that explained his findings and also his inflammatory markers. But I wasn’t sure it could explain his recent-onset dementia. Still, I brought it up during rounds.
‘That’s very interesting, Lisa.’ Dr. Collins said after my presentation that day. ‘And it can definitely explain all of his symptoms, including the behavioral change and dementia. When CNS is involved it’s called Neuro-Behçet. Discuss it with neurology to see what they think, but I’m pretty sure they will agree with you. If so, we start Ben on steroids and later on think of the best drug for his long term treatment.’
‘Okay.’ He was the last patient we discussed, so I was already getting up to find the Neurology resident on consults.
‘And Lisa.’ Lucy said before I left, ‘That was very good. Nice job.’
‘Thank you, Dr. Collins.’ I blushed and left.
‘Shit, that’s definitely it.’ The Neuro guy, Ryan, answered me as I told him what we had found out. ‘You can start him on corticosteroids today. There’s a good chance he will improve fast. And he will need long term immunosuppression, maybe with azathioprine.’
Ryan was right. After about a week of treatment, Ben was another person altogether. He was talking, eating and could even walk short distances with some assistance. His mother was the happiest woman on earth. I explained to him his diagnosis, that he would need help with his rehabilitation and the medication he would need to use for his condition.
‘Okay, doctor. Whatever you say.’ He smiled.
When I left his room, Peter was waiting for me in the hallway.
‘I know. You were right.’
He laughed. ‘No, Lisa. That was all you.’
…
Want to read more about Behçet’s Disease?
https://www.mayoclinic.org/diseases-conditions/behcets-disease/symptoms-causes/syc-20351326
Want to read a real case of Behçet’s Disease?
No comments: