There are some cases you see in the hospital that compel or affirm your interest in a specific field of medicine. I have always been interested in infectious disease (ID), and I am known as “the bug guy” in my class. It’s an odd choice, and I am one of the few that I have met in my class with a true passion for ID. I admit that it seems a bit alienating at times, but the cases I have seen with my ID mentors have been some of the most interesting I have experienced, and the following case is one of my favorites.
The patient was a 43-year-old man with a past medical history significant for hypertension and diabetes. He presented to the emergency department with a very simple complaint: “I blew out my eye.” Upon physical examination there was severe erythema of the right eye with periorbital swelling and marked proptosis. It was one of those cases where you look at the patient and you say, “I may not know much, but I know that is not good.” The patient’s extraocular muscle movements were not intact. My ID mentor, a wonderful fellow that may be my biggest influence to date, took one look and her face lit up with intrigue.
Based on the patient’s physical findings, the primary differential was orbital cellulitis. This is an ophthalmologic emergency, and the patient immediately underwent an MRI to gauge the status of his disease. The primary concern is that infection of the soft tissue behind the eye can extend into the brain and cause blindness or a brain abscess. The MRI revealed an extensive infection of his paranasal sinuses and a retro-orbital abscess. Basically, there was grey everywhere that should have been black with air on the MRI image, and when looking at the image, you are left with the feeling that “this is not good.” The patient was immediately sent to surgery, and the infected and inflamed tissue was removed.
Luckily, the patient got to keep the eye and his vision was intact! A medical victory, indeed. But the question remained: what was the actual source of the infection? The tissue was sent to the lab and cultured while the patient was being treated empirically with vancomycin and Zosyn.
The labs returned and showed cultures full of oral bacteria. The finding confirmed our suspicion. We found out that the patient had extensive tooth decay, which gave a better framework for the history of the patient’s infection. He had had a molar abscess which extended up into the sinuses, which then allowed the infection to spread to the tissue behind the eye. The end result was a nasty case of orbital cellulitis and one cool story for me to tell later!
This was one of the most interesting cases I have seen, but something I can not understate is how important it was to have a good mentor. My mentor was more than willing to guide me through the management of the patient step-by-step and explain why everything was being done.
In medicine, I have found that it is easy to feel that you are alone in a big and vast world of knowledge. It makes you feel small and useless. But having these kinds of mentors—whether they are interns, residents, fellows, or attendings—can make the world seem more manageable. In the end, we all want to learn, and the people that take the time to teach will have the biggest influence on our lives. Later on, we can pay them back by teaching others.