Mysterious Symptoms: Intense Heartache and a Sore Behind
Patient: Marvin, a 55-year-old chemical engineer
Doctor: Dr. Brian Goldman, a Toronto ER physician, CBC host and author of The Secret Language of Doctors
One recent winter afternoon, a middle-aged man walked into the emergency room at a hospital in downtown Toronto, holding his head. Marvin had experienced headaches, but nothing like this. The pain came on gradually, then grew more intense over several hours until it throbbed across his forehead. He also felt fluish and kept rubbing his left buttock. “Aches and pains,” he told Dr. Brian Goldman, who was on call that day. “Must be getting old.” Marvin had no fever, and no one around him was sick.
“I’m an emergency physician, so I always think worst-case scenario,” Goldman says. “This was not a headache guy, so that factor made his case unusual.” Because of the intensity and atypical nature of the pain in his patient, the doctor immediately wondered whether he had a tumour or subarachnoid hemorrhage (a brain bleed often caused by an aneurysm). The other possibility was meningitis.
Goldman started with a physical exam. Marvin’s heart rate was a little elevated. His ears, nose and throat showed no signs of flu or viral infection. “I checked his neck for stiffness, which is a sign of meningitis, but it was normal,” Goldman says.
The only definitive test for meningitis is a lumbar puncture to look for white blood cells in the spinal fluid. But in a patient with intracranial pressure due to bleed or a tumour, the procedure would direct that pressure downward, squeezing the brain toward the base of the skull. “He would lose consciousness, go into a coma and eventually stop breathing,” Goldman says. The doctor ordered an emergency CT scan, which showed that all was well in Marvin’s brain, making it safe to proceed with a lumbar puncture.
Goldman carefully inserted a long needle in the middle of Marvin’s back, between the fourth and fifth vertebrae. The fluid went to the lab, which confirmed the absence of red blood cells, helping the doctor rule out a hemorrhage. However, there were white blood cells-a clear sign of infection. The test showed 95 white blood cells pure cubic millimeter-not a lot, but enough to reveal that Marvin did have meningitis.
The illness, an inflammation of the membranes around the brain and spinal cord, comes in several forms, including bacterial and viral. “Bacterial meningitis is rapidly progressive and often kills young adults,” says Goldman. The viral form has subtler symptoms and is also less likely to be fatal-but it’s most common in kids under five. “I had no idea why he had viral meningitis,” Goldman says. “Then I remembered his bottom.” The doctor asked to take a look.
There, on Marvin’s left buttock, was a red rash with groups of blisters. “The medical mind looks for the connection,” Goldman says. “It doesn’t assume there are two different illnesses.” Suddenly the viral meningitis made sense. In addition to a horrible headache, Marvin had shingles.
The illness is caused by the varicella zoster virus, one in a group of enteroviruses that tend to circulate in summer and early fall. Others include mums and West Nile-and all of them can cause meningitis. Goldman says it’s not uncommon for varicella zoster to lead to shingles, but he’d never seen shingles and viral meningitis occurring simultaneously.
Marvin was admitted and put on acyclovir-the only intravenous antiviral drug that treats meningitis. Two days later, the headache was gone and he made a full recovery. The moral of the story, Goldman says, is to look for a connection. “You never know what you’re going to find.”