48. The Pentad


‘So, chips or salad?’ Jax asked me as we looked at a weird green mix labeled ‘Salad’ in the cafeteria.

'Definitely chips.’

Then we both chose fruit for dessert to even out. We grabbed our trays and sat on our regular table at the cafeteria. About 10 minutes later, Peter joined us for lunch.

‘So, how was the wards today?’ Jax asked Peter and me.

We looked at each other. ‘Intriguing.’ I answered first.

‘Yeah.’ Peter said smiling. ‘I agree with that.’

That morning we had a different attending covering for Dr. Collins. Dr. Morris was a middle-age man with meticulously tidy grey hair and a black button-up shirt. When we got to rounds, Dr. Morris was waiting for us with a cup of coffee in his hands. He introduced himself and asked us to start. We both presented our already known patients first then Peter finished with the admission for the day: Theresa Mayer. 

‘Mrs. Mayer is a 40-year-old woman, previously healthy, who was brought in this morning by her daughter for worsening confusion in the last couple of days.’

‘Sorry, Dr. Allen, which bed is she in?’ He asked looking through his list of patients written on a scrap paper.

‘B401. She actually wasn’t in our care until a few moments ago. A bed was cleared so they brought her up from the ER at the last minute. I just saw her.’

‘Oh, that makes sense. I didn’t know, I am sorry I haven't seen her yet. Do you mind if we switch to bedside rounds on this one?’

‘Not at all, Dr. Morris!’ 

We left to Mrs. Mayer’s room and found her a bit drowsy in her bed. 

'Good morning. Mrs. Mayer.’ Dr. Morris said in a loud clear voice as we walked in. ‘We are the physicians responsible for your care. I am Dr. Glenn Morris, I believe you met Dr. Allen, and this is Dr. Diaz.’

She mumbled something we didn’t understand.

‘You can go on, Dr. Allen.’

‘So, Mrs. Mayer is 40 years old. She was brought in today for worsening confusion for a couple of days. Her daughter states that Mrs. Mayer had no previous health conditions and lives alone. She doesn’t think her mother takes any medications and doesn’t recall any recent health complaint, except chronic fatigue.’

Peter made a pause looking for some incentive from Dr. Morris, who nodded for him to continue. 

‘The ER team confirmed she had altered mental status and couldn’t get much more history from her. On her physical exam, they reported paleness, fever, and tachycardia, but overall stable vital signs. She was prescribed Tylenol, which improved her fever. They ordered some initial blood and urine workup thinking of a possible underlying infection, and also a tox screen.’

‘I see.’ Dr. Morris said. ‘Do he have that workup?’

‘Not yet, Dr. Morris, let me check again.’ He opened the lab network on his cell to check if her results had been released. ‘Still nothing.’

‘Ok.’ He stood silently for a moment. ‘Do you have any thoughts for now?’

‘Hum, I am not sure, sir.’ Peter started hesitantly. ‘I think an infection is something we should investigate, but it bothers me that she doesn’t have any localizing signs and that an infection presenting with delirium is less likely in her age. Unless there’s something on her central nervous system, like encephalitis perhaps. And I agree we also must rule out toxic causes.’

‘True, Dr. Allen. It seems like a very broad differential so far, right?’

‘Exactly.’ Peter agreed.

‘Maybe we can get some more clues from her physical.’ Dr. Morris proceeded to the side of the bed and performed a thorough physical exam on Mrs. Mayer. ‘As you said, she is extremely pale. And even though her fever broke, she is still tachycardic.’ He said while pressing his fingers on her radial pulse. ‘Both these signs make me very confident we will see an important anemia in her labs.’

Peter and I nodded.

‘Her cardiac, pulmonary, and abdominal exams are unremarkable.’ He proceeded. ‘And there are no focal neurologic deficits or meningeal signs. There’s only one other thing I noticed.’ He pointed to the inner part of Mrs. Mayer’s left arm.

‘What? What was on her arm?!’ Jax asked us and we laughed.

‘Petechiae.’ Peter answered.

‘Which Dr. Allen had missed.’ I teased him.  

‘Interesting. Then what?’ Jax was intrigued.

‘Then we were dismissed.’

‘Oh, c’mon.’ Jax said. ‘I thought you were getting somewhere.’

‘We were. But we got stuck without the labs.’ Peter explained. ‘I already called them 3 times, and they still haven’t released her results.’ 

‘So Dr. Morris suggested we lunched and then came back later to finish her case.’ I completed.

‘Wait, it’s finally ready!’ Peter said looking at his phone. ‘Hemoglobin of 5, ouch. Nothing on her white blood cells, but hear this: 20.000 platelets.’

‘Damn.’ I said.

‘Is there anything on the blood smear?’ Jax asked with a puzzled look on his face.

‘Let me see. Actually, yeah.’ Peter said scrolling on his phone. ‘Schistocytes.’

‘It’s starting to sound like the pentad!’ Jax said and started counting his fingers excitedly. ‘Fever, neurological signs, anemia that could be microangiopathic with those schistocytes, and thrombocytopenia. The only thing missing is acute renal failure.’

Peter and I were shockingly taking in Jax’s incredible insight.

‘If she was a kid, I’d be telling you: Thrombotic Thrombocytopenic Purpura or Hemolytic Uremic Syndrome. Given she’s an adult, I am staying with TTP. ’ Jax finished and ate my last chip.

‘Hey!’ I complained.

‘I earned it.’ He winked.

‘Jax, you are a genius.’ Peter said getting up. ‘TTP it is. Come on, Lisa, let’s go.’ I got up in time to save my fruit from Jax and followed behind him. 

Dr. Morris listened carefully to Peter’s arguments supporting TTP and agreed it was a good shot. Theresa Mayer started treatment with plasma exchange transfusion with fresh frozen plasma and thankfully recovered with no sequelae.

I got home late that day with 2 bags of chips in my hands. Jax was watching the Nets when I threw them at him.

‘Did I get it right?’ He smiled while opening the fist bag.

‘Yes, nerd.’ I laughed.

‘You’re welcome.’ He raised his hands. ‘I don’t know what you would do without me.’ 

I sat beside him and we watched the Nets crush the Knicks once again.

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TTP: Thrombotic thrombocytopenic purpura; VWF: Von Willebrand Factor; MAHA: Microangiopathic hemolytic anemia; S/S: signs and symptoms; Tt: treatment.

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