zebras...

New York Times
January 24, 2006
The One-in-a-Thousand Illness You Can't Afford to Miss
By PERRI KLASS, M.D.
Evening session at the health center, three of us seeing patients in pediatrics. My colleague asked whether I would take a quick look at a boy with a fever and headache. In the exam room, the overhead light was off because it hurt his eyes. He was lying on the table, but he sat up and answered my questions, and he let me look in his throat, and he moved his head around when I asked him to.
We excused ourselves, my colleague and I, and went out of the room. We conferred. The boy didn't look good. Pronounced photophobia - avoidance of light - and severe headache and fever. And although his neck was not actually stiff, he did indicate some neck pain when we asked him to bend it.
He needs to go to the emergency room, we agreed.
What do you think, my colleague asked, would you send him by ambulance?
"Yes," I said. "I mean, if this is your meningitis, wouldn't you want him in an ambulance?"
She understood what I meant, of course. Sometimes it feels as if you spend your career in primary care pediatrics waiting for your meningitis, your leukemia, your dislocated hip.
The bad things, the things that cross your mind - automatically and usually fleetingly - day after day as you examine children, the diagnoses that statistically will come your way at least once or twice over the course of years and years of walking into one exam room after another.
Every time you examine a little baby's hips - and you always examine a little baby's hips - you are looking for congenital dysplasia of the hip, a hip that doesn't fit properly into its socket. Find it early, fix it early. Don't miss it.
Every time you find unexplained lymphadenopathy, enlarged lymph nodes, in a child, leukemia crosses your mind, at least fleetingly. Children have swollen lymph nodes all the time. But you had better not miss your leukemia.
Or meningitis. In winter especially, lots of children come in with high fevers. Most have flu or other viral illnesses or ear infections. Some look reasonably bright and bouncy, fever and all, and some look sick and miserable.
And as I go from room to room and examine those children and swab their throats for strep or dig the wax out of their ears, I think quickly about meningitis. O.K., the giggling 3-year-old eating crunchy junk food snacks while he runs busily around the exam room may have a temperature of 103, but he does not have meningitis.
But what about the hot-to-the-touch fretful 1-year-old who will not let her mother put her down? Or the feverish, headachy 12-year-old?
Fever, headache, stiff neck, photophobia - these are the clinical hallmarks of meningitis, an infection of the membranes that surround and protect the spine. It can be caused by a variety of viruses and bacteria, and the bacterial form, in particular, can be a virulent fast-moving infection, an infection that can devastate or even kill a child.
It needs to be treated promptly, and to treat it, you need to diagnose it, by doing a spinal tap, and to diagnose it, you need to think about it.
I have seen plenty of children with meningitis. I did my residency in the days before children were routinely vaccinated against Haemophilus influenzae Type b and Streptococcus pneumoniae, two bacteria with propensities for spinal infections, and I took care of plenty of hospitalized children with meningitis.
I worked in the emergency room and did my share of spinal taps, on the wards, where we took care of some children who ended up deaf or brain damaged, and in the intensive care unit, where the sickest children were on life support.
Nowadays, with children well protected against those two particular bugs, meningitis is less of a worry, but it has not gone away. I know my meningitis will walk in the door in primary care someday, one of those feverish hard-to-console babies or one of those flu-ish unhappy teenagers.
My colleague sent the boy to the emergency room by ambulance. By ambulance, because that way he got there as fast as possible. Because that way we knew he would receive attention immediately. Because that way, if by some chance he was her meningitis and his mental status began to deteriorate or he started to have a seizure - well, at least he would be in an ambulance.
So you worry about it with every sick child, week after week, winter after winter. Hundreds of cases of influenza and other viral illnesses, fevers and headaches and body aches and sore throats and general miseries will come and go.
But at some point, your meningitis will arrive, and it will all come down to whether you recognize it or not.
You stand in the exam room, worrying about this one particular very important child, mindful of the danger and trying to look the threat in the eye and recognize it - even with the lights off.