Fillers A memorable patient

A case of mistaken diagnosis

BMJ 2001; 322 doi: (Published 31 March 2001) Cite this as: BMJ 2001;322:775
  1. Barid B Bhattacharya, locum consultant psychiatrist
  1. Wonford House Hospital, Wonford, Exeter EX2 5AF

    It was around May or June 1977. I had started my house job in psychiatry in India a couple of months before. Psychiatry was a brand new subject for me.

    I was attending an outpatient clinic daily. The clinic was extremely busy. There were no set appointments (most of the patients did not have telephones at home), no distinct catchment area, and a referral letter from the general practitioner was not required. It was not surprising that a big crowd gathered in the clinic every morning seeking treatment. It was probably only the stigma of mental illness, which was more prevalent in those days, that prevented the clinic getting busier, and we were expected not to return anybody without providing treatment.

    It was a Monday morning, traditionally the busiest day of the week. A male patient was making too much noise in the waiting area, and his relatives made vain attempts to quieten him. My consultant called for the attendant, who told us that this man was an employee of the port trust. He had had problems with his supervisor in the past. He had been involved in a minor accident at work a few days ago and had been behaving strangely ever since. My consultant jokingly said that the patient probably had compensation neurosis. He asked me to see this man ahead of his turn so that peace could return to the waiting area.

    When I interviewed the patient in the company of his relatives I could not elicit any relevant stressors. The patient, and his relatives, played down the importance of work related problems. The patient was rather dramatic in his presentation. He complained of disturbed sleep and difficulty in swallowing which had coincided with the injury he sustained at work the previous week. Though he was incoherent and loud, at times my impression was that he was not psychotic or manic. My boss agreed with me. The patient was given the diagnosis of hysterical conversion, which was not uncommon among our patients. The patient and his family were reassured, a prescription for benzodiazepine was given, and the patient was advised to report back a week later.

    I did not take much notice when the patient failed to attend. Another fortnight passed, and a relative made a courtesy call to inform me that the patient had died four days after seeing me. He had become more incoherent and also refused to drink. He was taken to the infectious diseases hospital three days later. He was diagnosed with rabies and died soon after. His family recalled that he had mentioned being bitten on his leg by a stray dog a couple of months ago. He thought that the bite was superficial and did not bother to see a doctor.

    I opened Brain's Diseases of the Nervous System and read that rabies could have a long incubation period, up to 64 days. I felt guilty for this missed diagnosis and the ease with which we were fooled. The only consolation was that once the disease manifests itself death is almost certain, meaning that a correct diagnosis was not likely to have impacted on the final outcome at all.

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