Brainwaves and pandemics

I thought I’d see my fair share of seizures, but my patient population is elderly, and have mostly stable blood pressure and good stroke prophylaxis. Maybe we misdiagnose seizures as mini-strokes, or miss them altogether. The first seizure I witnessed was impressive. I was a second-year resident in Winnipeg General, doing an ICU rotation. A healthy 15-year-old boy came down with meningitis. He had been admitted, hydrated, tested, cultured and LP'd. He had a couple of days of antibiotics before his cultures came back negative. Then his headache, stiff neck and conscious level got worse. He had a grand-mal seizure in front of me: the full tonic-clinic event—with incontinence—they talk about in textbooks. ABC, iv lorazepam, iv glucose and a gram of Dilantin didn’t do anything. He just kept on seizing. Read: The struggles of compliance The next thing I know my ICU staff and a consulting neurologist have him in a monitored bed in a barbiturate coma. He required volume, pressure and ventilator support for 11 days. I don’t remember his name or face, but the look on his parents’ eyes spoke volumes. It was very traumatic for them. Thursday I got a day off. On Friday, I showed up for work, and his bed was empty. This is often a bad sign. The head nurse said, “We woke him up yesterday morning, he came off life support in the afternoon, and now is on Ward B4. No deficits. Hearing is fine. Viral meningitis-encephalitis, there you go.” I ran down three flights from the ICU ward to see him. “How are you?” I enquired. “Who are you?” he replied. Of course, he had been in coma, and my efforts to optimize his internal milieu for 10 days meant diddly-squat to him. “Oh, just another of your doctors,” I said and I left. His parents took him home the next day. Read: The cases you never forget The commonest causes of viral encephalitis are Herpes Simplex 1 and 2, Varicella Zoster, and enteroviruses. Encephalitis strikes 10-15 people per 100,000 annually in the US, often younger people (30-40% are undiagnosed). There are a variety of outliers, like West Nile Virus, equine encephalitis, etc. It got me to thinking about how amazing the brain is. At birth, 86 billion neurons, 25 billion non-neurons. Although we do lose neurons after age 20, this loss is in part mitigated by regeneration and reorganisation.6. The brain functions at a high level for longer than my computer, my car, or cellphone. It resists infection pretty well, and poisons too. But when a short circuit happens, the presentation can be very dramatic. The passage of time may have allowed us to forget the consequence of viral pandemics. Smallpox killed a third of the world’s population. We have to thank Lady Mary Montague (smallpox variolation), Edward Jenner (cowpox inoculation) and little James Phipps (first smallpox vaccine recipient) for helping us understand and prevent this terror: it is now absent from the planet. The Spanish ‘Flu (proper name: The Great Influenza Epidemic of Influenza-A, H1N1) killed an estimated 21 million people worldwide (1918-20), including 55,000 Canadians and 675,000 Americans. Post-war malnutrition, overcrowding and poor-hygiene contributed to transmission; a bacterial superinfection, and together with cytokine storm, it put young adults at unusually high risk. Influenza outbreaks have recurred since then (Asian flu H2N2, 1957: Hong Kong flu H3N2, 1968: Russian flu H1N1, 1977 and Swine flu H1N1, 2009) but most of us are less fearful of the consequences. Polio, a human neurotropic enterovirus, usually affects children under five. To be honest, I just missed the 50’s epidemic, but certainly got prophylaxis. In times of vaccine hesitancy, we need to be reminded of the facts. Although many cases were asymptomatic, wee Johnnie might come back from the school playground with a fever, a sore throat and a headache. His mother, aware of the diseases going around, would take him to the family doctor, with considerable concern. “Yup, polio. Nothing I can do but treat the fever and recommend lots of rest. If he gets muscle spasms, we’ll put his legs in braces.” Johnnie would likely make an uneventful recovery, but he ran the risk of limb paralysis (0.5%). Two to 10% of paralysis patients would die as a consequence of respiratory muscle compromise. There is no cure for polio. It’s likely we’ve known someone with post-polio syndrome (although there aren’t many left now). There was a big epidemic in the early-50s, attributed to better-post war-hygiene (‘the immune system was less active’). Building on the generally unsuccessful work of Brodie et al, Jonas Salk and Albert Sabin saw success with both inactivated and live attenuated vaccines; the latter gaining favour in the early 1960s.1 Salk’s work gained him the 1954 Nobel prize. Polio cases have been reported in Pakistan, Afghanistan, Mozambique and Malawi. So, we are not done yet. Resistance to universal vaccination exists. In the middle East, there is mistrust of Western guided programs. Religious zealots have excluded any role for women in vaccination taskforces, a significant impediment when it comes to accessing children-in-the-home. Agencies in some countries expect financial incentives to allow the polio vaccination program to proceed. A new threat to humanity has come about from, ironically, the misinformation industry. Doubters of the scientific method (usually rogue political/scientific/medical non-believers) generate non-facts, active lies and fake videos to confuse the lay public. Q-Anon proselytes, square-Earth believers and ‘vaccines-make-you-magnetic’ nut-bars spread their views unchecked, like computer malware viruses.4 Those with uncertainty should visit the Third World, where Yellow Fever, Ebola, Marburg and other illnesses exist. They help remind us of mankind’s vulnerability to viral pathogens. I am writing this article in Costa Rica, a beautiful tropical country in Central America. Warm, lush, green and friendly, but home to mosquito vectors. Chikungunya (fever and joint pain, malaise), Dengue (fever, headache, muscle and joint pain), and Zika (mild symptoms but risk for pregnant women) are out there for the travellers amongst us.5 References http://dx.doi.org/10.1136/jnnp.2003.028530 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200696/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3758677/ https://www.hp.com/us-en/shop/tech-takes/top-ten-worst-computer-viruses-in-history https://mytanfeet.com/travel-tips/ways-to-protect-against-mosquitoes/ https://neurotray.com/how-many-brain-cells-do-you-lose-in-a-day/

Brainwaves and pandemics

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Hector Baillie

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