Reaching Down the Rabbit Hole Read Online Free PDF Page A

cured him,” I said. “Apparently, that’s his baseline. I told his wife that if he started being nice to her again she should bring him back in immediately.”

    I was out on the ward at about 9:30 that morning when the call about Cindy Song arrived from the other hospital.
    “Is she salivating like she has rabies?” That was my first question, and would turn out to be my only one.
    “Yes, like a dog,” was the reply.
    “Holy cow!” I said. “It’s an ovarian teratoma. You’d better send her over.” It was a snap diagnosis, possibly wrong, but there was no harm in raising on a pair of aces. I had a pretty good idea what the other cards would be: memory deficits, gooseflesh, a high heart rate, and no family history of psychosis. The drooling alone was a tip-off.
    A teratoma is an unusual tumor that contains cells from the brain, teeth, hair, skin, and bone. Most teratomas are harmless, but they have the potential to wreak havoc by causing encephalitis. When you see it, the syndrome is unmistakable: an ovarian teratoma stimulates an antibody that will produce the very ensemble of symptoms that were described to me over the phone.
    Two hours later, when she was wheeled into the ICU, Cindy looked toxically ill, with a heart rate of 135 beats per minute and blood pressure of 160/90. She was sweating, salivating, and shivering wildly. Her eyes were wide open but she was by now entirely unresponsive. Her jittery limbs seemed as if they wanted to convulse. Joelle, the senior ICU resident, Hannah’s counterpart down on the ninth floor, immediately intubated her.
    The toxicology screen from the other hospital was negative, so I called the gynecology service to get an emergency ultrasound of Cindy’s pelvis. They thought I was crazy. Moreover, I insisted that theydo it transvaginally in order to get a good look at the ovaries. An ovarian teratoma can produce memory loss, seizures, and confusion—what neurologists call “limbic encephalitis,” or sometimes the “Ophelia syndrome” (not for Hamlet’s beloved, but for the daughter of the neurologist who described a similar condition). The psychotic symptoms are due to autoimmune antibodies that attach to a receptor in the brain, where they simulate the effects of PCP (aka “angel dust” or “wet”). When that receptor became blocked in Cindy’s brain—when the antibodies hit their target—all of her symptoms became manifest. She went nuts.
    “Remove her ovary?” the gynecologist said.
    “Right. Do you see that cyst on the ultrasound? It’s not so benign.”
    I had to insist that there was now no doubt about it: the ovary-brain connection. First—“Who would have thought?” Then—“What do you know? It’s a real thing.” Eventually, both the resident and the attending gynecologist were convinced, and they were comfortable knowing that Cindy could still have children with her remaining ovary.
    This was a rare, rare thing. No one fully understands it, but I know it clinically when I see it, or even hear it over the phone, because I collect arcana. If the problem is properly framed, there are very few other things it could be. It took a bit of cajoling, but in the end, they removed her ovary. The sweating, the salivating, and the wild swings in blood pressure were gone within hours. Her psychosis resolved within days.

    Back on ten, Arwen Cleary, our ice skater with the multiple strokes, had gone deeper into the rabbit hole than anyone else on the ward, and I wasn’t confident that we could pull her out of it. According to the notes in her chart, she had by now had three separate strokes, clearly visible on MRI scans, in addition to the vertebral dissection from her neck manipulation. An angiogram had been interpreted asshowing vasculitis, an inflammation of the blood vessels. She had a subplural lesion in her left lung, according to the pulmonary specialist. She had a low platelet count, according to the hematologist. “The patient uses humor to cope