The figurative use of the word “airhead” originated in the late 1970’s and signified a simple-minded or stupid person. But what are the characteristics of the literal “airhead” (or in medical jargon, pneumocephalus)? Does this person also exhibit similar deficits in cognitive function?

The New England Journal of Medicine recently featured the case of an Argentinian patient who spontaneously developed the so-called pneumocephalus. She is a 54 year-old woman who experienced progressive visual, auditory, and speaking abnormalities. A head radiograph demonstrated an air pocket along her left temporal region (enlarged image). A computed tomography (CT) scan revealed similar findings, with the pocket measuring 4 cm x 3 cm x 5 cm. There was no evidence of fracture or trauma.

The cause of the woman’s sensory and speech deficits can be explained by the air compressing against her brain, with indirect compromise of her brainstem. Her symptoms resolved soon after undergoing neurologic surgery to decompress the air and to repair a defect in an adjacent bone (mastoid). No tumor or infection was noted. Although most cases of pneumocephalus occur secondary to head trauma, it is possible the mastoid bone defect discovered during surgery may have been the source for air to enter the skull.

On a lighter note, the next time someone accuses you of being an airhead, you could refute him figuratively and literally with the following response: “I do not manifest the typical characteristics of pneumocephalus”.

• Sources
• Villa RA, Capdevila A. Spontaneous otogenic pneumocephalus. NEJM 2008;358:e13.
• Image Copyright: New England Journal of Medicine

We typically characterize hives as an allergic skin reaction manifested with diffuse swelling, itching, and redness. In an unusual case (with accompanying image) recently reported in the New England Journal of Medicine, a woman developed a reaction of blue hives.

The cause is not as much an enigma as it is atypical. The patient was a 77 year-old woman who underwent surgical resection of a carcinoma of her right breast. In such cases, it is standard procedure to inject a colored dye (in this case, isosulfan blue) into the lymphatic system to delineate its drainage pathway. This allows the surgeon to roughly identify which sentinel lymph nodes to excise and biopsy. The patient, unfortunately, was one of the 1.5% of patients who are allergic to the dye. She subsequently developed hives intraoperatively. Although technically the hives is not blue, the presence of dye created this visual impression.

• Source
• O’Sullivan MJ, Morrow M. Images in clinical medicine. N Engl J Med 2008;358:e6.

The latest issue of The New England Journal of Medicine features an unusual case of trichobezoar (tricho- for “hair”; bezoar for “indigestible mass in stomach or intestine”), otherwise known as a stomach hairball. The patient is an 18 year-old lady who presented to the Rush University Medical Center (Chicago, IL) with a 5-month history of abdominal pain and vomiting with meals. Computed tomography (CT) demonstrates a large mass in the stomach (see Figure A), which likely contributed to the reported symptoms. Esophagogastroduodenoscopy (EGD)–the insertion of a camera via the oral cavity and advanced to the upper segments of the digestive tract–was able to visualize the impressive bezoar (see Figure B), measuring 37.5 x 17.5 x 17.5 cm. It was later discovered the patient had a habit of eating her own hair (trichophagia). The only option for removal was open surgery. The extracted bezoar weighed 4.5 kg and can be seen in Figure C. Not surprisingly, the patient stopped eating her hair, experienced an improvement in symptoms, and eventually regained her weight.

• Source
• Levy RM, Komanduri S. Images in clinical medicine. Trichobezoar. N Engl J Med 2007;357:e23.

My first–and hopefully, only–experience as a hospital patient occurred several years ago when I needed a minor surgical procedure performed. Although I would not want to repeat this experience, it was interesting to observe the delivery of medical care from the patient’s standpoint. It was pleasant to receive the attention and respect of the medical staff following my case. I also felt pampered by the ancillary services who did the cooking and cleaning. Regardless of how tempting it may have been to just move in, I was much more eager to leave.

The hospital can be a fairly inhospitable place. The most drug-resistant pathogens wander the halls. Noisy neighbors and their noisier visitors inevitably occupy every other room. Let us not forget the infiltrated IV lines that trigger endless alarms or the monotonous beeps of the telemetry monitors. There are the mass-production renal-cardiac-diabetic diets and bareback paper-thin cloths called “gowns”. As for the hospital odors that permeate throughout the premises? Unique. Then, there is the constant interruption by the army of medicine: phlebotomists, patient care assistants, nurses, nursing students, social workers, medical students, residents, fellows, and attending physicians.

Please don’t get me wrong. The goal of this post is not to lambaste the hospital system. As a cog in the American health care machine, I am endlessly devoted to the promotion and improvement of hospitals. I just continue to be amazed how some truly ill patients can endure their pain, discomfort, and the often unfriendly environment, yet exhibit enormous patience when I awaken them at some odd hour before dawn to do my pre-rounds. My hat goes off to them.

Note: I realize the image shows a building of the University of Michigan Health System. I have no affiliation with the institution and did not target them in this post. Any similarities between this post and a patient’s experience there may be more reflective of hospitals in general and not of the University of Michigan. I have no intention to denigrate any institution or anyone.