Examples of case studies for historical clinical pathologic

Daily Record, The (Baltimore), Aug 9, 2003 by Nancy Kercheval

Below are examples of the case studies Dr. Philip A. Mackowiak has assigned for the historical clinical pathologic conference sponsored by the Veterans Affairs Maryland Health Care System and the University of Maryland School of Medicine.

The 39-year-old patient was discovered unconscious outside Ryan's Fourth Ward polls. Having been the day after an election, it was thought he was caught up in the act in which candidates' friends plied vagrants with liquor, provided them with changes of clothing and then escorted them from polling place to polling place to cast ballots.

His first day in the hospital, he talked to imaginary objects. Pale and covered in perspiration, it was difficult to subdue him.

As he appeared to regain his senses, he became so agitated that no one could understand his nonsensical answers. He napped and then woke in a delirium so violent it took two people to restrain him.

On the last day, obviously exhausted from the violent thrashings, he seemed to rest — opening his eyes only briefly to ask for God's forgiveness — and then he died. Then the diagnosis was "congestion of the brain."

Even his attending physician, Dr. J.J. Moran, in a letter to his mother-in-law, wrote: "Indeed we considered [him} an object of unusual regard."

Diagnosis: Rabies

Patient: Edgar Allan Poe

The 69-year-old male, who lived in Athens, suffered from fever, headache, sort throat and vomiting. He had been physically fit until a week before his illness when he was hit suddenly by headache, ocular erythema and halitosis.

As the illness progressed, he began to sneeze and cough, and then developed bilateral pleuritic chest pain, followed by projectile vomiting of dark bilious fluid.

His fever made him so hot, he refused all clothing, and his intense thirst could not be satiated, which worsened the vomiting. He eventually developed a rash. At day nine, he developed diarrhea, followed by cardiovascular collapse on the 11th day. The patient died.

The patient drank wine in moderation, did not smoke, was taking no medications and had no known allergies.

His sons, 30 and 25 years old, and his sister had died of illnesses similar to his own; his 10- year-old son by his mistress was well. His fellow Athenians were suffering from similar symptoms one year after neighboring troops marched into the city. The epidemic, known as the Great Plague of Athens, apparently came from Africa and spread from the Port of Piraeus.

Diagnosis: epidemic louse-borne typhus fever which touched off the Great Plague of Athens

Patient: Pericles

The 56-year-old man first showed signs of loss of appetite, diarrhea, weight loss, increased thirst and swelling of the feet and abdomen. Two weeks later, he realized the onset of chills, fever, scant hemoptysis and right-sided chest pain.

The patient already suffered from a loss of hearing, dating back to when he was in his mid-20s. First it was the high-pitched tones, then the low tones. By 44 years old, he was deaf, a state that pushed him into depression with increasing social isolation and personal neglect.

He also had smallpox as a child as well as an illness thought to be typhus or typhoid fever. In his late 40s, he started to notice chronic headaches and recurrent joint pains, and later he noted increasing lower extremity edema.

Unmarried, the patient did not smoke, but consumed moderate to large quantities of wine, as well as unknown medications, some apparently delivered by his pharmacist brother.

Treated for pneumonia, he started to rebound but then succumbed to jaundice, an enlarged liver and increased edema of the legs and feet. Paracentesis of 11 liters of fluid provided immediate relief, but three more were required and the puncture sites seeped.

Iced alcoholic punch gave him relief in future weeks, but then he went into a semi-coma. Wine consumption was decreased. Still his condition deteriorated. He eventually became comatose and died.

Diagnoses: pneumonia, possibly complicated by bacterial peritonitis; tertiary syphilis with gummatous cirrhosis, luetic otitis and luetic iridocyclitis; irritable bowel syndrome

Patient: Ludwig van Beethoven

High fever and abdominal pain struck after one of his drinking marathons. He bathed to soothe the heat, but it soon returned.

On the fourth day of his illness, one day after discussing the naval strategy for the Arabian campaign with his naval commander Nearchus, his strength began to ebb. By the seventh day, he had to be carried.

By the 11th day, racked with fever and unable to talk or raise his head, he died. He was only 33 years old.

His life was marked with tributes to his beauty, as well as to his endurance in battle. He was wounded at least 10 times, including an arrow that apparently pierced his lung. In addition, he contracted malaria.

He was bisexual with three wives and at least two male partners. Hephaestion was his oldest friend, lover and most trusted commander whose death by typhoid fever drove him to drink heavily and begin his carousing.

When the embalmers came to treat his body a week after he died, it is reported they were shocked at how life-like it appeared after lying in state in the Mesopotamian air for a seven days.