Common sense is not so common: An illustration

We have a patient, a 40-something-year-old-guy who is kind of a drunk, kind of homeless, you get the picture. The story is, his family felt kind enough to make sure he was fed on Thanksgiving, and then his landlord (OK, I guess he's not actually homeless) felt sorry for him, gave him a $20, and dropped him off at the store.

He was found unconscious in a park over 24 hours later, surrounded by 24 beer cans, and hypothermic. Blah blah, etc, etc, now he's in the ICU. Spiking fevers every day and has altered mental status, which is why we (neurology) were consulted.

#1 on the differential is herpes encephalitis, and others include listeria, and lots of other fun stuff.

Infectious disease was also consulted for the fevers of unclear etiology and today we read their note, which included a nice tidbit about how the patient had a positive PPD test last week. And not just slightly positive, but 23 mm positive. The rest of the tuberculosis workup is now pending.

But today? The guy is still not in contact or respiratory isolation, his door is wide open to the rest of the ICU, and the respirators that prevent me from catching tuberculosis are nowhere to be found.

How likely is it that he has TB? Unclear, really, and probably low. But in a guy who can't give us his history, chronic alcoholic, found down in a park, and spiking fevers, I think his risk is a little higher than someone else's. But no isolation precautions in sight until a true cause is found.

Wonderful.

I go off service tomorrow and my next PPD isn't due until the spring. It had better be negative or we'll know why it isn't.

(This evening I've been doing a lot of coughing, just for the record.)