Hello Steemians, I bring you the (I hope) longed-for second part of my series about the most interesting cases that I have received during my nights on-call, this time without any previous warning; with content suitable for all audiences and with information about a very common pathology. Hope you enjoy it!
Tales from a Night On-Call: "My Horse, My Horse!"
It was my third night on-call under the General Surgery service. I had arrived recently, and being a Wednesday, I imagined it would be a night without too many eventualities (the most interesting days are usually on Fridays and weekends, when the demons of alcohol and debauchery take over our innocent souls). Reading the morbidity record, where the data of all the patients that arrive at our service are recorded, I noticed that throughout the day the number of patients did not exceed the dozen, and I resigned myself to what I thought would be many long hours counting the old bloodstains on the floor, and listening to old songs from my huge playlist. While talking with my partner that night, 
It was a 16-year-old boy, whose real name I will omit, partly to preserve his identity, but mostly because I really do not remember it. Let's pretend that it was Ramón. He arrived on a stretcher, in the company of his mother and cousin, both distressed, and at first sight he looked diaphoretic (with excessive sweating), restless, and with a cast on his right leg. His mother and his cousin explained us the reason for consultation: the young man was under treatment with antibiotics for a small abscess in his broken leg, and upon receiving the first dose of a drug whose name they did not remembered, he began to present the symptoms described above, along with generalized weakness (asthenia), fever, nausea, vomiting, and an intense headache.
Along with the resident doctor who supervised us, we diagnosed a pharmacological hypersensitivity reaction caused by the antibiotic he had consumed. "This is a case for Internal Medicine," we told the mother, who asked us to speak with the doctors in that area to transfer him. I went to Trauma Shock (the name of the Internal Medicine emergency area, which fortunately is next to our minor surgery room), and noticed that the area was more populated than a metro station during peak hours. I told the resident doctor about the case, and he answered that they were well above their current capacity (there were 10 patients, the room had a capacity for 7) so he asked me that, since the case was not very complicated, we treated it ourselves.
on the left, me on the right. We had an exam that day, so we did not exactly have many hours of sleep.
on the left, me on the right. We had an exam that day, so we did not exactly have many hours of sleep.
The truth is that the patient´s management was, in theory, easy; despite the nervousness of the relatives (and his own), the young man was in good condition, and only had to be administered an antipyretic for the fever, and replenish the lost fluid by giving him intravenous saline solution, seeking also to dilute the blood concentration of the antibiotic causing the reaction and thus relieve the body of its symptoms. We called the nurse to insert him an IV line with 500 ml of 0.9% saline solution, and seeing that no other patient required our attention, we dedicated ourselves to calm him and his family. We had no idea then of the, let´s say, interesting variety of symptoms that he was going to present.
Doctor, I don´t have chances anymore, right?
“Chances of what?" I ask.
Of living ...
I admit that I did not expect that, and I had to contain a bit of laughter, at such levels of drama that I thought only happened in Mexican soap operas.
Calm down boy, you had a hypersensitivity reaction to the antibiotic you used, but it will pass in an hour at the most. Just lie down and do not worry.
My words seemed to have an effect, as both he and his relatives calmed down. I saw that his temperature was 38°C, lower than the 39°C that his mother told us he had before coming to the hospital, the doctor in charge of our service considered that the antipyretic was not going to be necessary, and I thought "great, case solved" (Mental note: I must stop believing that things are always so easy). I put away the thermometer, and just before returning to the desk to continue listening From Yesterday, Ramón speaks again, this time with a significantly better mood and tone of voice:
You're very cute ... Do you have a boyfriend?
He asks
She´s pretty, you like her, right? If you smile, it's because you like her. You should try something with her, tell her you like her
Laughing, I followed his game, "damn, you discovered me!" I said, as I looked at my partner and thought about how quickly young people get in confidence nowadays (and what my girlfriend would have said if she had been there). A few seconds later, however, his tone becomes more dismayed, and begins to repeat as if it were a mantra "my head hurts... my head hurts..."
We immediately noticed his mother´s concern, and we tried to calm them both by reiterating to them that they would just have to hold still for a few more moments while the effects of the reaction passed. Then, the young man´s cousin comes into the room, having gone out to make a call minutes before. Seeing him, Ramón shouted...
No, go away! Don´t look at me, don´t look at me!
His mother immediately embraced him and tried to calm him, before our look of confusion. "What happens? Why don´t you want him to see you? It’s your cousin, calm down," I said.
I don´t want to be seen! Then they´ll tell everyone that I was here!
We tried to reassure him by saying that no one was going to say he was in the hospital, that only his mother and cousin were present, and no one else was going to see him. We covered the stretcher where he was with a screen so that he could not be seen from the corridor, but because of the shouts, a nurse entered the room to see what was happening.
Go away, don´t look at me! I know how you all are, you´ll tell everybody that I was here!
Noticing that this was another symptom of his hypersensitivity reaction, we told the mother to talk to him and to try to reassure him; it should not be long before the effect was over. We stood at the door to keep out curious people, and after a few minutes Ramón had calmed down. When we tried to sit down again, however, he returned to his particular mantra...
My head hurts, my head hurts!
He said, with an increasingly exasperated tone of voice. Seeing this we decided to administer Dipyrone (Metamizole), an antipyretic and analgesic. After shouting at the nurse who was administering him the medication, he told us that the pain had spread to the arm where he had the IV line, and began what I like to call the second phase of his reaction. He continued to scream for a couple of minutes, and then he began to present what seemed like convulsions. Although, having seen many convulsions during my time at Internal Medicine, I noticed that they seemed somewhat forced, and that the young man was still conscious, and even screaming about his headache, in fact.
The resident doctor approached, worried, and noticing the same things as me, he told the mother (who by that point was crying a sea of tears) that they were not real convulsions by a neurological cause: his son was just moving uncontrollably in reaction to the intense pain he had, and in a few minutes he should calm down, when the Dipyrone made its effect. In the meantime we had to make sure that he did not disturb the IV line in his left arm, and his fractured leg. While we held him to keep him from moving too much, he arrived to what I classify as the third phase of its reaction: hallucinations.
My horse! My horse!
He shouted, while punching the stretcher. I remembered that just a couple of hours ago I thought it was going to be a boring night.
My horse, mom! My horse!
"What horse son?!" his mother asked between tears, hugging him. Seeing our faces and noticing that we had stopped understanding what was happening a while ago, she explained that she did not have the slightest idea of what was going on neither; her son had never owned a horse.
Our reaction, basically.
The doctor explained that on rare occasions, confusion can take place (we realized that) and even hallucinations as well due to drug hypersensitivity. Accepting his explanation, we continued to take care of the patient's arm and leg while he continued to move uncontrollably, while his mother sobbed and his cousin, who had some time watching us from a distance, held back tears of concern.
After a few minutes (which seemed like hours because of the back pain that I had. I'm too old for this), the "convulsions" diminished in intensity, and Ramón stopped calling for his nonexistent horse. He began to feel drowsy, and we told him that it was best to sleep; we were curious to see what other symptoms he could have, but we were somewhat exhausted, although more mentally than physically. We were lucky that his condition improved, because at that moment another emergency arrived, one far more important, about which I plan to tell you in the next chapter of this series (yes, this is a "to be continued").
About an hour later, while we were attending to our new patient, the mother approached us and told us that her son was already awake and feeling much better. We recommend another kind of antibiotic to replace the one that caused his reaction, and the young man said goodbye to us, apologizing for his previous behavior. When we had some free time, several hours later, we discussed the case with our doctor, who told us that although the symptomatology was that of a hypersensitive reaction, he was sure that the severity of the symptoms was, at least in part, an exaggeration by the young man. But, exactly what is this symptomatology that we are talking about?
Hypersensitivity to Drugs are immune reactions, generally similar to allergies, whose causes are not yet clear, although it is known that not every reaction is allergic; some may cause symptoms not mediated by immune mechanisms, and therefore allow future uses of the drug. They can cause a wide variety of symptoms, varying from patient to patient regardless of whether it is the same medication. They include skin rashes, anaphylaxis (severe allergic reaction including swelling of the face and constriction of the airways), uncontrollable itching, fever, joint pain, edema, anemia, digestive problems, kidney or lung pathologies, among others.
Facial swelling caused by anaphylaxis.
Its diagnosis is mainly based on the patient's clinical signs, which manifests themselves a few minutes after the ingestion of the drug, although skin tests can also be carried out to see if a hypersensitivity response to contact with the drug occurs. Finally, the treatment is basically waiting for the effect to pass, treating the symptoms if necessary (antihistamines for the itching, analgesics for pain, adrenaline for anaphylaxis, etc.).
This was our first patient with an adverse reaction to drugs, but surely not the last one. I only ask that the next one hallucinates something more interesting; come on, seeing nonexistent horses is boring, if you're having hallucinations you can surely imagine one with wings, at least.
Something like this, I´m not asking a lot.
References:
- Beers, Mark H., et al. The Merck Manuals of Diagnosis and Therapy, 11th ed., 2007.
If you enjoy medical-themed articles, or general curiosities, remember to follow me, there is much more on the way! And as always, I leave my thanks to 
