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Interesting Cases

Joi De Vivre

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I must admit, there have been many days in the past year when I resented work. Life often seems like a hamster wheel - the harder you run, the more tired you get, but you never get ahead. Fighting with insurance companies, dealing with difficult patients, worrying in the face of disease, sadness, death, I am both physically and emotionally drained at times. The buzz of my alarm in the morning is often a disheartening sound.

It's not that I don't love what I do. I feel very privileged to be able to make a real difference in people's lives - that is what keeps me coming back for more. Despite all of the battles, I do make a good income and get to use my talents in doing so. I really couldn't see myself doing much else. But there are times when it takes a lot to pull up the emotional strength to face another full schedule. I am sure this is a feeling echoed throughout the medical profession.

There is someone in our office, however, who sees life in a totally different manner. She comes at each day with joy and enthusiasm. It isn't an artificial smile that she wears because she feels she must; it is an honest joy to be where she is, doing what she does. Her job is to stock our exam rooms with the things we use during the normal course of a day, as well as to keep the kitchen and conference rooms clean. This is the best job she has ever had.

Last year I was approached by one of my longstanding patients to see if we would be interested in participating in a program to employ the mentally disabled. She had worked with this program for some time and felt that our office environment would be well-suited for this type of thing. Our initial reluctance was overcome by the fact that there would be a supervisor for the disabled person in the office to help them train and answer any questions that come up. We would be only responsible for part of the salary and would be able to address any problems to the supervisor. It seemed like the kind of thing we should be doing, and I was always frustrated that we ran out of ear tips and tongue depressors (it was the last thing on the list for our busy nurses), so we agreed to join the program.

It turned out that this patient had her daughter in mind as the one who would work in our office. Her daughter (who I will call Alice) had a brain tumor when she was seven, requiring high-dose chemotherapy and radiation. It left her with a non-functioning pituitary gland and a significant mental handicap. She is now in her upper 20's and still reads and functions mentally at a 3rd grade level. She wears a cap to cover her hairloss and scars, and has the typical appearance of someone who has been on steroid replacement for many years.

For her the job proved to be a challenge. Keeping track of all that needed to be done in each room, and finding time to stock the rooms while they were not being used proved to be difficult at times. We had to take away the job of keeping the printers filled with paper because she would over-fill them at times, causing them to jam up. Sometimes the drawers with the patient gowns were so over-filled that they were difficult to close. Yet she stuck with it, and with the kind guidance of her supervisor, she has now gotten very adept at sneaking in between patients or at lunch to stock the rooms.

Her mother is ecstatic. Alice is the happiest she has ever been, working at our office. She feels like she is needed and important, and looks forward to going to work each day. We notice when she has been gone - the nurses and doctors are all used to having well-stocked rooms, so when they are not stocked, we know she has been gone. I never have to look for ear tips when she is here. The kitchen is always clean at the end of the day, and the refrigerator is well organized.

But perhaps the best part of having Alice around is the air of joy she brings to the office. She is always wearing a smile under her pink cap. Our entire office staff enjoys having her here.

After lunch, it is my practice to go to the kitchen and make my afternoon pot of coffee. Alice is always there in the kitchen cleaning up after our lunch. I will often tease her, "Alice, how come you are just hanging out here in the kitchen? Did you drink my coffee?"

She gets a big smile and responds, "Dr. Lamberts, you know I don't drink coffee! You're teasing me, aren't you?"

"I'm teasing you, Alice. I just wish you wouldn't always drink all of the coffee!"

"I just can't help myself, Dr. Lamberts. I just drink all your coffee." She laughs back at me.

This afternoon ritual is a ray of sunshine in my day. I have a little sister to playfully tease, someone who carries no shard of anger or bitterness. She loves what she does and brings to it a determination to do her best and a big smile while she does it.

It says in the book of Matthew: Blessed are the meek, for they shall inherit the Earth. Alice is one of the meek. She does not have ambition to save lives, make lots of money, or rescue healthcare. She does not fret much about the future or complain about the present. She just wears her cap, does her job, and smiles.

Truthfully, it would be just fine with me if she inherited the Earth.

******

There are numerous resources for employers to participate in supported employment of the disabled. I highly recommend these programs to all employers.

On the web, go to:

Interesting Case #5 - Solution

First let me say that technically there are two correct answers, although I added an adjective to the choices that made it a little easier to separate the two.  The answer is:

MRSA.

Up to approximately two years ago, MRSA was limited to hospitalized patients.  In general, it was not an invasive organism, but its presence did mean that the patient had a higher mortality and it was treated with great care.  Two years ago, however, MRSA started showing up in the office.  It would generally show as skin abscesses with accompanying cellulitis (infection of the skin).  This transition from a non-invasive to invasive organism has been well-documented, the two known strains being described as community-associated MRSA (CA-MRSA) and hospital-associated MRSA (HA-MRSA).  From the CDC website:

Recently recognized outbreaks of MRSA in community settings have been associated with strains that have some unique microbiologic and genetic properties compared with the traditional hospital-based MRSA strains, suggesting some biologic properties (e.g., virulence factors) may allow the community strains to spread more easily or cause more skin disease. Additional studies are underway to characterize and compare the biologic properties of HA-MRSA and CA-MRSA strains.

A local ER physician told me that they get patients coming in regularly with a complaint of "spider bite."  Invariably, they have CA-MRSA infections.

In this case, the child had what appears to be CA-MRSA, due to the presence of skin lesions.  How exactly this was transmitted to the child is not clear, although daedalus2u astutely pointed out in his comment that since the child had been born via c/section, his skin was not colonized with the typical commensal organisms that would be transmitted via vaginal delivery.  This may have set him up for a more invasive organism to take advantage and cause this infection.

Why did it occur in the groin area?  Two possibilities come to mind: the first is that the child was circumcised and so transmission to this area from physician or caretaker may be more likely, with the healing "wound" from the procedure.  The second thing that probably set this up is the fact that the diaper area is wet and dark, so the skin is prone to becoming irritation, compromising the integrity of the barrier and allowing infection to ensue.

Technically, this is a case of impetigo, as staph and strep can both be the causative organisms for this type of infection.  My addition of the word typical tried to allay that problem.  Certainly it could have been bullous impetigo.

Herpes simplex is potentially transmitted to a child during the birth process as they pass through the birth canal.  Since this child did not do so, it is less likely the problem.  Herpetic bullae (blisters) are usually clear, not cloudy.  Herpes is, however, a great fear of pediatricians in this circumstance (so viral cultures were sent as well).  An infant with a herpes simplex infection is at higher risk of developing herpes encephalitis, a potentially fatal condition.  During my residency I saw a case where herpetic lesions were left untreated in an infant and the child ended up with encephalitis.  This caused massive destruction of the cerebral cortex.  The result was devastating.  I have had a great fear of herpes in children ever since.

Candida is a common "infection" in the diaper area of children.  The most common presentation is a red, raised bumpy rash with discreet "satellite lesions" around the periphery.  Since this child had blistering lesions, it was not the diagnosis.

In this case, Bactroban was applied and the child was treated with Trimethoprim/Sulfa - the first-line oral agent for this type of infection.  We also recommend that the child and family members are washed in Hibiclense (a strong surgical scrub) to decrease the chance of re-infection.  A recent article in the Annals of Internal Medicine suggests that if there is no cellulitic component to this type of infection, it can be treated with just drainage and topical antibiotics.  In a child this young, however, extra caution is warranted.

The shocking thing to us was the age at which this presented.

Thanks for your comments.  This one was easier than the others.  I have had some very interesting cases recently, so tougher ones are on the way.

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Interesting Case #5

OK - back to pediatrics. This one is quick.

8-day old male presents to the office with rash in diaper area. Mother noted it 4 days prior to the visit and had since gotten progressively worse.

He was born full-term via c-section after an uncomplicated pregnancy. No significant problems prior to developing the rash.

On exam, the child appeared normal. He was circumcised and that was healing appropriately. He had areas of redness on inner L thigh, on the shaft of the penis, and on the buttock. Each area had some accompanying blistering lesions with cloudy fluid.

A culture was obtained from one of the bullous lesions.

What is the diagnosis?

  1. Herpes Simplex
  2. Typical Bullous Impetigo
  3. Candida
  4. Methicillin-resistant Staph Aureus (MRSA)
  5. Thimerosal anticipatory stress syndrome (TASS)
  6. Physician Bullous Hallucination Syndrome (PBHS)

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