Jonathan Kellerman: Devil's Waltz

“How slow?”

“No retardation or anything like that. She just made very few sounds — in fact I didn’t hear anything from her at all, and mom said she was pretty quiet at home, too. I tried to do a Bailey test, but couldn’t because the baby wouldn’t cooperate. My guesstimate was about a two-month lag, but you know at that age it doesn’t take much to tip the scales, and given all the stress the poor thing’s been through, no big deal. But brilliant me. Bringing up language development got mom worried about that . So I sent them over to ENT and Speech and Hearing, who found her ears and laryngeal structure one hundred percent normal and concurred with my assessment: possible mild delay in reaction to medical trauma. I gave the mom suggestions about stimulating speech and didn’t hear from them for another two months.”

“Baby’s fourteen months old,” I said, writing.

“And back in the E.R., four days later. But not with breathing probs. This time she’s spiking a temp — a hundred and five. Flushed and dry, and breathing fast. To be honest, Alex, I was almost happy to see the fever — at least I had something organic to work with. Then the white count came back normal, nothing viral or bacterial. So I ran a toxicology. Clean. Still, lab tests aren’t perfect — even our error rates are running ten to twenty percent. And that spike was real — I took the temp myself. We bathed her and Tylenoled her down to a hundred and two, admitted her with a fever-of-unknown-origin diagnosis, pushed fluids, put her through some real hell: spinal tap to rule out meningitis, even though her ears were clear and her neck was supple, because for all we knew she had one heck of a headache she couldn’t tell us about. Plus twice-daily bloodwork — she went bananas, had to be held down. Even with that, she managed to dislodge the needle a couple of times.”

She exhaled and pushed the grapefruit farther away. Her forehead had moistened. Swabbing it with a napkin, she said, “First time I’ve told it like this from the beginning.”

“You haven’t had any case conferences?”

“No, we don’t do much of that anymore. Rita’s basically useless.”

I said, “How did the mother react to all the procedures?”

“Some tears, but basically she stayed composed. Able to comfort the baby, cuddling her when it was over. I made sure she never was involved in holding the baby down — integrity of the mother-child bond. See, your lectures stuck, Alex. Of course the rest of us felt like Nazis.”

She wiped her brow again. “Anyway, the blood tests kept coming back normal but I held off discharge until she’d had no fever for four days running.”

Sighing, she burrowed her fingers through her hair and flipped through her chart.

“Next fever spike: the kid’s fifteen months old, mother claims a hundred and six.”

“Dangerous.”

“You bet. E.R. doc records a hundred and four and a half, bathes and doses it down to a hundred and one and a half. And mom reports new symptoms: retching, projectile vomiting, diarrhea. And black stools. ”

“Internal bleeding?”

“Sounds like it. That made everyone sit up. The diaper she had on did show some evidence of diarrhea, but no blood. Mom said she threw the bloody one out, would try to retrieve it. On exam, the kid’s rectal area was a little red, some irritation at the external edges of the sphincter. But no bowel distension that I can palpate — her belly’s nice and soft, maybe a bit tender to the touch. But that’s hard to gauge ’cause she’s freaking out, nonstop, at being examined.”

“Raw rectum,” I said. “Any scarring?”

“No, no, nothing like that. Just mild irritation, consistent with diarrhea. Obstruction or appendicitis needed to be ruled out. I called in a surgeon, Joe Leibowitz — you know how thorough he is. He examined her, said there was nothing that justified cutting her open but we should admit her and watch her for a while. We put an I.V. in — great fun — did a complete panel, and this time there was a slightly elevated white count. But still within normal limits, nothing that would jibe with a hundred and four and a half. Next day she was down to one hundred. Day after that, ninety-nine point two, and her tummy didn’t seem to hurt. Joe said definitely no appendicitis, call in GI. I got a consult from Tony Franks and he evaluated her for early signs of irritable bowel syndrome, Crohn’s disease, liver problems. Negative. Another tox panel, a careful diet history. I called in Allergy and Immunology again, to test her for some weird hypersensitivity to something.”

“Was she on formula?”

“Nope, a breast-fed baby, though by that time she was totally on solids. After a week she was looking perfect. Thank God we didn’t cut her open.”

“Fifteen months old,” I said. “Just past the high-risk period for SIDS. So the respiratory system quiets and the gut starts acting up?”

Stephanie gave me a long, searching look. “Want to hazard a diagnosis?”

“Is that all of it?”

“Un-uh. There were two other GI crises. At sixteen months — four days after an appointment with Tony in Gastro clinic — and a month and a half later, following his final appointment with them.”

“Same symptoms?”

“Right. But both those times, mom actually brought in bloody diapers and we worked them over for every possible pathogen — I mean we’re talking typhoid, cholera, tropical maladies that have never been seen on this continent. Some sort of environmental toxin — lead, heavy metals, you name it. But all we found was a little healthy blood.”

“Are the parents in some sort of work that would expose the child to weird pollutants?”

“Hardly. She’s a full-time mom and he’s a college professor.”

“Biology?”

“Sociology. But before we get off on the family structure, there’s more. Another type of crisis. Six weeks ago. Bye-bye gut, hello new organ system. Want to take a guess which one?”

I thought for a moment. “Neurological?”

“Bingo.” She reached over and touched my arm. “I feel so vindicated calling you in.”

“Seizures?”

“Middle of the night. Grand mal, according to the parents, right down to the frothing at the mouth. The EEG showed no abnormal wave activity and the kid had all her reflexes, but we put her through a CAT scan, another spinal, and all the high-tech neuroradiology video games, on the chance she had some kind of brain tumor. That really scared me, Alex, because when I thought about it I realized a tumor could have caused everything that had been happening, right from the beginning. A growth impinging on different brain centers, causing different symptoms as it grew.”

She shook her head. “Wouldn’t that have been a happy situation? Me talking psychosomatic and there’s an astrocytoma or something growing inside her? Thank God all her scans were totally clean.”

“Did she look post-seizural when you saw her in the E.R.?”

“In terms of being drowsy and listless, she did. But that’s also consistent with a little kid being dragged to the hospital in the middle of the night and put through the wringer. Still, it scared me — that there could be something organic I was missing. I asked Neurology to follow up. They did for a month, found nothing, terminated. Two weeks later — two days ago — another seizure. And I really need your help, Alex. They’re up in Five West, right now. And that’s the whole kaboodle, history-wise. Ready to give me some wisdom now?”

I scanned my notes.

Recurrent, unexplained illnesses. Multiple hospitalizations.

Shifting organ systems.

Discrepancies between symptoms and lab tests.