Tests Indicated His Infection Was Getting Better. Why Did He Feel Worse?

“Something’s wrong,” the woman told the young doctor, her face lined with worry. “This is not my husband.” The 68-year-old man lay unmoving in the hospital bed, his eyes dull, his face expressionless. His wife stood by him, as she had for nearly four decades of marriage. You don’t know him, she said, but if you did, you’d know that something is not right.

George Goshua, a doctor in his first year of residency, looked at the distressed woman and then back at the man in the bed. He had spent nearly an hour reviewing the man’s hospital chart before coming to see him, and he knew the patient had been dangerously ill in the intensive-care unit for the last week.

Exhaustion Sets In

It all began about two weeks before, the wife explained. They were preparing for their son’s wedding, and her husband, normally a workhorse, was not feeling well. He was a tough guy — he worked as an estimator for a local builder and constructed his own house pretty much single-handedly. But now he said he was exhausted. At one point, just two days before the wedding, he said, “I think I might die.” At the time, she was irritated, because she thought he was just trying to get out of the work. Now she knew otherwise.

They made it through the wedding, but the next day he was a wreck. His neck was stiff, as if there were a crick on both sides. He went to the local urgent-care center. They thought it was probably just a sore muscle and gave him something for the pain.

The day after that, he had a fever. And the following day he was so weak he couldn’t walk. When his wife realized he was too sick to see his own doctor, she called an ambulance. As she struggled to get him out of his pajamas and into his clothes, he slid off the couch onto the floor. He just lay there, unable to even sit up. She couldn’t lift him. When the E.M.T.s arrived, they loaded him into an ambulance, and she followed them to Yale New Haven Hospital, in New Haven, Conn.

Raging Infection

Goshua had read the rest of the patient’s story in his medical chart. In the emergency department, the man’s temperature was 105. On exam he was found to be weak, particularly on the right side of his body. His speech was slurred and confused. His right ankle was red and swollen. His neck was rigid with pain. The E.R. doctors were concerned that he could have meningitis — an inflammation or infection of the tissue that surrounds the brain, beneath the skull. Or worse, encephalitis — an inflammation of the brain itself. A spinal tap did suggest an infection. But whether it was from a virus, like herpes, or from a bacterium, like streptococcus or the one that causes Lyme, was unclear. He was started on an antiviral medication and three broad-spectrum antibiotics and sent to the intensive-care unit.

His blood cultures quickly grew out Staphylococcus aureus, an aggressive bacterium usually found on the skin. The same bug grew out of his urine as well. And an M.R.I. showed lots of white dots in the usually dark matter at the back of his brain. These probably represented tiny bits of infection, most likely the same resilient agent found in the blood and urine. The swollen ankle was probably also infected. It looked as if a bug somewhere on his skin had gotten loose in his blood and the rest of his body.

Recovery or Recurrence

The antibiotics were narrowed to focus on this dangerous bug. And he started to get better. His fever came down. The bacteria disappeared from his blood and urine. His ankle and his mind cleared. He was thought to be stable enough to move from the I.C.U. to a regular floor of the hospital. He was very weak, it was noted, but he had had an awful case of sepsis for the last 7 days, and his strength was expected to come back as he improved.

But as far as the man’s wife could tell, he was getting weaker, not stronger. The patient told Goshua he couldn’t take care of even his most basic needs. He couldn’t change position; he couldn’t feed himself; he couldn’t even use the remote control to turn on the TV.

Goshua had always been fascinated with how the brain and the nervous system worked, and it seemed possible that this profound weakness was not a reaction to how ill he had been but evidence that he was still sick. He hoped that the physical exam, often discounted by doctors and patients alike in these days of high-tech testing, could help him figure out what was going on. Goshua had been taught to start his exam with the hands and then to work inward to the rest of the body. He picked up the man’s right hand; the arm hung limply against the bed. He held the man’s middle finger and flicked the nail down. As the fingertip snapped up, the right thumb jerked toward the index finger. He did it again, and again the thumb leapt toward the index finger, as if to make, paradoxically, an A-O.K. sign. The patient had a positive Hoffman’s sign.

A Simple Test

This reflex test, developed by the 19th-century neurologist Johann Hoffman, indicates a problem in the nerves that emerge from the brain to make up the spinal cord in the neck. It is a test that medical students still learn but rarely use, in part because the pathology it detects is rare, and in part because the test, like so much of the physical exam, is not terribly reliable on its own. When positive, as it was here, the problem is actually present only 60 percent of the time. Still, it was a clue. Was there any other evidence that a problem in the spinal cord was causing the weakness? Goshua tapped the right knee to elicit the usual kick reflex. If the patient was just weak from illness, his kick should have been normal or even reduced. Instead it was so brisk that the left leg jerked a little, too.

Emergency Surgery

Goshua knew that it was essential that the patient quickly get an M.R.I. of his neck that night. The scan indicated that the same infection that had already been carried to his brain, his kidneys and his swollen right foot was also raging in the bones of his neck right where it met the shoulders and inside the spine, impinging on and compressing the spinal cord.

The man’s wife was sitting at her husband’s bedside after the test when her mobile phone rang. Her husband needed to go to surgery right away, she was told. If they didn’t operate immediately, he would never regain his strength. Indeed, it might already be too late.

It was past 3 in the morning when the surgeon carefully cut away the infected bone and the abscess compressing the man’s spine, but it would be weeks or months before they would know if they had gotten there in time.

Looking for the Source

As the man recovered, he and his wife wondered where the initial infection came from. When the patient first arrived at the hospital, it was noted that he had a healing sore on his left hand next to his thumbnail. His wife remembered that it was filled with pus and looked awful. Her husband applied what he called “black salve” — a pine-tar-based ointment used in medicine since the time of the ancient Greeks. It reduces inflammation and pain. But it did not treat the infection, which spread from his thumb throughout his body to his brain, his ankle and his spine.

The patient needed six weeks of antibiotics to get the bug completely out of his system. It took much longer for the rest of him to recover. When he came home after five months of intensive rehab, he still couldn’t walk. But he never gave up. And slowly, slowly, he got better. Two years later he can walk without a cane. And he’s back at work — with his builder, and around the house.

As for Goshua, who cared for the patient just that one time, the amazing recovery felt like proof that the physical exam, even today, remains an essential tool.