17 July 2007

The Weirdest Damn Thing I've ever seen

I will preface this with the obligatory disclaimer: I shit you not.

The complaint was "Visual hallucinations," and the patient was not exactly the sort of individual you would expect to be hallucinating. He was a middle-aged, affluent corporate executive, a sharp and high-functioning individual with no history of either substance abuse or mental illness. He was, therefore, rather perturbed by the little red and green elves he kept seeing all over the place. He knew they weren't real, but they just wouldn't go away. (We attributed the fact that they were red & green to the fact that this case occurred shortly after Christmas.)


My partner, "Bill," was a superb physician, but I would never let him take care of me in a million years. Not because his skills aren't good: they're excellent. He's one of the best doctors I have ever had the honor of working with. But Bill is what is known in the business as a "black cloud," or, less politely, a "shit magnet." Somehow he always manages to get the most awful, obscure, or just plain bizarre cases, and when he works, the crazies always come out in force. In fact, it was Bill who signed out this gem to me. So when he came to me with this case, perplexed and looking for advice, I was not particularly surprised. It seemed par for the course for him. The work-up in these cases is pretty straightforward and almost always unsatisfying: rule out medical causes and consult psychiatry. So Bill orders a slew of labs and a CT scan of the brain.

This is where it gets weird. Um, weirder. For some reason, Bill ordered a Troponin, which is a blood test marker of heart damage. I wouldn't have ordered it -- there's no logical connection between the heart and odd psychiatric symptoms. I would have probably confined my lab tests to electrolytes, blood sugar, a drug screen, that sort of thing. But Bill, conditioned by the strange stuff he sees, casts his net a bit wider. And the troponin came back strongly positive.

Which was completely unexpected. We had not even done an ECG. But when he saw the troponin, Bill immediately ordered one, and saw something like this:

Which was even more unexpected. The following amusing conversation with a cardiologist ensued:

"So I have a guy here having a heart attack with a positive ECG and troponin."

"Great. I'll be right in. Is he still having chest pain?"

"Well, that's the funny thing. He's never had any pain."

"Interesting. What was his presenting symptom?"

"Visual hallucinations. Elves. Christmas elves, we think."

"Bullshit. You are kidding me, right?"

But we faxed him the ECG, which was really quite convincing, and the cardiologist came in reluctantly, and somewhat dubiously took the patient to the cath lab. Sure enough, the patient had a high-grade obstruction of his LAD, and upon opening it, that patient's ECG returned to normal. The next morning on rounds, the patient thanked the cardiologist for saving his life, and ventured that he didn't want to seem ungrateful, but the elves were still bothering him, and could he please do something about that? Psychiatry saw the patient and concluded that he wasn't crazy. So the neurologist was called in and noticed an odd motor tic every time the patient looked at the elves, who were always sitting to his left. The neurologist speculated that the hallucinations might be a form of a partial complex seizure, so he started the patient on an IV drip of dilantin, an anti-seizure medicine.

And the Elves went away.

So there you have it: Acute Anterior Myocardial Infarction presenting with Partial Complex Seizures manifested as hallucinations of Christmas Elves.

And that, ladies and gentlemen, is the weirdest damn thing I have ever seen.



(Apologies to Steven Colbert)

17 comments:

  1. Your partner may be a shit magnet, but if I ever start seeing elves and it's not Christmas, I think I'd like him to do the workup.

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  2. That. Is. Awesome.

    Problem solved. Merry friggin' Christmas.

    (Thanks for the full feed RSS by the way - you're fast)

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  3. Here I thought you were going to wax on about levodopa side effects. But this is waaaay better.

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  4. Slightly unrelated, but when I worked in neuro/epilepsy with the 24-hour EEG monitoring stuff, I had a guy who would "seize every time he heard Eminem on the radio." I figured it must be a pseudoseizure with that specific of a trigger.

    Doctor writes order to "play Eminem CD". I borrow from one of the other patients, pop it in, and, sure enough, 40 seconds later, excellent non-fake generalized seizure.

    You could play other rap and he'd not seize, but Eminem would do the trick every time.

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  5. Did you at least break the news to this guy that there is no Santa Claus?

    Nothing I hate more than breaking bad news to someone...

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  6. That sounds like a story right out of one of Oliver Sacks' books. The man who had a heart attack and thought it was Christmas Elves. Absolutely amazing. And to be honest, as an intern or resident would it be such a bad thing to be a shit magnet? Talk about education.

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  7. That was very weird, indeed.
    Monkeygirl sent me.

    Happy Tuesday to you. Without red or green elves.

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  8. And for this particular patient, you have a brand new descriptor for those T waves and elevated ST segments:

    Elf hats. ;)

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  9. That's great. Amusing story, happy outcome, life is good. I'm pretty sure almost every patient that walks in the door of our ER gets a troponin level. Just goes to show why.

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  10. Damn. I was thinking of an aortic dissection clipping a carotid and left main... but your story has a much happier ending...

    But the elves manifesting as seizures???... very cool. He wouldn't have an LV thrombus with that MI would he that might have sent a little "stimulus" to his brain, would he?

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  11. The thing that bothers me about how this story is told is the underlying assumption that the elves were a "hallucination".

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  12. That has got to be the highest art to work in an ER: unweaving psych symptoms from medical ones.

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  13. That makes a terriffic story, more so for the happy ending. Thank you for sharing. I followed a link from monkeygirl's blog which I also stumbled upon tonight.

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  14. OB...

    Um...seeing things that aren't there...that is a hallucination. Whether it's got a medical cause (seizure, MI, encephalitis), it's still a hallucination.

    I think your problem with the story would be better identified as "the assumption that Psychiatry needs to see him."

    I would not have ordered the enzymes or EKG. I would have ruled out electrolyte abnormalities, CVA, subarachnoid (maybe? no headache...), asked very carefully about drug use, considered an LP (not febrile, only symptom? better to do it, not wrong to not do it). When all that came back normal, yes, I would have called Psych...which would have been my plan from the start, with the known branch point of "unless some of this comes back abnormal..."

    Ya hear hoofbeats, you think horses...

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  15. Heh ... imagine if he hadn't seen the elves ... those little buggers saved his life. :-D

    Wacky!

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  16. WanderingMystic10/10/2007 2:54 PM

    I've experience "elves", under the influence of LSD.

    I talked to a woman, once, who described an experience of elves, while under the influence of 'magic mushrooms.'

    Terrence McKenna wrote extensively about the experience of 'machine elves', under the influence of DMT.

    I once read, in a 70s book about psychedelic plants, that one tribe in South America uses a hallucinogenic plant to "talk to the little people".

    What is this strange experience?

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  17. XD it would have been so funny if the doctor came back wearing an elf suite to screw with him

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