Part 1 is here.(Note: This post was written at the same time as the case presentation, so none of the comments are taken into account -- because they didn't exist as I write this.)
The patient's daughter had discovered a condition known as Herpes Zoster Oticus
-- also called Ramsay Hunt syndrome
. It is basically shingles of the geniculate ganglion
, and it explains every single one of the patient's symptoms!
Essentially zoster of the ear, Ramsay Hunt consists of a painful vesicular rash in the external ear canal associated with a facial nerve palsy, vertigo, oral vesicles and taste disturbance. Treatment is with antivirals directed against herpes zoster, which I had already initiated, and steroids. (Actually, I increased the dose of the Valtrex and extended the course another week at the higher dose.)
I still believe the right pinna had become secondarily infected with a bacterial pathogen, which also speaks to the question of steroids. By the time the diagnosis was clear, I didn't think we were still within the time window for steroid efficacy, so I elected to omit them. I did offer him narcotic pain relief. No wonder his ear didn't feel better even as the bacterial infection was clearly responding to treatment!
As I said, I never heard of Ramsay Hunt syndrome. I felt certain that all of the symptoms were somehow related, as they were anatomically related to his ear (vertigo from the labyrinth medially; facial nerve passing anteriorly) but I couldn't fit them together until the patient's family did my internet research for me, for which I was grateful. For me, it was a thrill to have a single entity to explain all the symptoms.
Now 'fess up: Who else has never heard of Ramsay Hunt Syndrome until now?Edited to address comments:
Ok, so apparently it wasn't all that obscure; oh, well. Then again, human nature being what it is, I suspect that there was a significant bias towards those who HAD heard of Ramsay Hunt saying so in the comments and those who hadn't just clicking on to something else.
As far as feeling bad about never having heard of such an "obvious" diagnosis: nope, ain't going there. I believe one of the things that differentiates me from other doctors, and especially other blogging doctors, is my ability to admit to my shortcomings; both to my patients and on my blog. Oh, plenty of people talk the talk about not knowing everything and not being perfect and such; I walk the walk. If I've never heard of something, I admit it, because that's how I learn. I'll thank my patients for finding me the information, and I'll come right out and blog about things that don't necessarily show me in the best light.
In private, dealing with patients, I firmly believe that this approach does a great deal to enhance my credibility when discussing material with which I am familiar. If they know I'll tell them when I don't know something, then when I tell them I am sure of something, they know they can trust me.
In public -- on the blog -- I've grown a thick-enough skin not to care (too much) when people berate or belittle me. Hell, I've had to! Otherwise I'd be cowering under the bed after those last two diabetes posts
Two feeble points in my defense, though: by the time I first saw his ear, it was already secondarily infected and swollen shut, so there was no way to appreciate any vesicles in the external ear canal. As for the very first symptom, the taste disturbance (dysguesia
) alone, drug reaction would be at the top of the differential. I dare anyone to even consider something as far-fetched as Ramsay Hunt when that's the only symptom. (Of course, *now* I will...)
As for sending my patient to a specialist, sure I could have called a neurologist; they would have been happy to see him in October or November. Fat lot of good it would have done him by then. And by the way, his cardiologist (with whom I remained in contact because of the recent stent and what I thought was the role of the Plavix) had never heard of it either.
Lynn: regarding your insertion of my evil twin in Chapter 17: I happen to know that book of yours has only 16 chapters.
Many thanks to all who commented.