Dr. Maller’s Blog

The scene was grim but familiar. A gurney arrived on the floor carrying a motionless young man. The attendant casually remarked, “Just another drug overdose; he’s DOA” (dead on arrival). I was in my infectious disease fellowship at Los Angeles County/USC Medical Center.

The patient was a 14-year-old black boy. He had been brought to the Emergency Department by police ambulance. He was admitted because the ED doesn’t like to handle deaths. We had no history. His mother came along soon afterward, and when the cause of death was suggested to her she became outraged. “My boy didn’t do drugs; he was a good boy!” He had stayed home from school with mild symptoms of a viral infection.

The intern on the floor then did something I can never forget. He examined the boy thoroughly. Although no rash could be seen on his mahogany skin, the young doctor retracted an eyelid and on the inside fleshy part he saw what he was looking for – a petechia, a broken capillary, purple and star-shaped. He ordered the stunned nurse to bring him a large syringe and needle, which he plunged into the still heart, drawing a post-mortem blood culture which did indeed yield the dreaded Neisseria meningiditis.

The intern’s diligence did two things. It removed doubt that his death was the result of drugs, giving the family some peace. It also alerted all the personnel who were in contact with the victim to obtain preventive antibiotics, thereby averting further tragedy.

Meningococcal disease is the stuff of medical drama. It is one of the three major causes of spinal meningitis, all of which are now preventable with vaccines. In my one year at County I saw about 350 cases. When the first vaccine arrived in 1985 (against “H. flu”) I had treated about ten cases in my own practice. Thousands of American children died yearly; now a case is so rare that most young doctors have never seen one.

You may have seen the TV ads for Menactra, the newest of the three vaccines and one targeted especially at adolescents. Young people in dormitories or military barracks are at somewhat greater risk, although actual numbers are quite small (about 3 per 100,000) and the victims are often smokers and party-animal types. Whereas the other two types of meningitis are essentially always fatal without treatment, some 40% of meningococcal patients recovered in the pre-antibiotic era, many with severe disfigurement from loss of extremities. At the other extreme are patients like the youngster described above who die so quickly that meningitis has no time to develop.
The only other infections I can think of that kill so quickly are plague in its pneumonic form and Ebola virus. Yet the bacterium is commonly found in healthy people. It is analogous to being struck by lightning.

I’ve seen exactly one case in my practice. My first Labor Day on call in 1967 an alarmed grandmother phoned me. Her daughter had taken her 8-month-old baby girl to an urgent care but was sent home with reassurance. Grandma wasn’t buying it. She called one of the pediatricians she knew (she was an LVN) and I was on call and in the office (our hospital did not have an Emergency Room yet). The baby was there in 20 minutes and had the classic petechial rash of meningococcal disease. Many children develop these little spots after vomiting or coughing, and they also appear on the soft palate in strep throat, but these were not benign little red spots. They were purple and star-shaped, caused by plugs of bacteria and dead cells clogging up small blood vessels. I gave Baby Paula a shot of penicillin and followed her with Grandma to an ED 5 miles away where she was admitted. My spinal tap was diagnostic of bacterial meningitis (she needed no anesthetic, so lethargic was she by that time) and she recovered fully.

This entry was posted on Sunday, February 10th, 2008 at 5:27 pm and is filed under Memorable Experiences. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.