Think Like a Doctor: The Quarterback’s Headache

The Challenge: Can you figure out what is giving this 15-year-old boy the worst headache of his life?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to take on a difficult case and offer their solutions to a real-life medical mystery. This month the story revolves around a healthy 15-year-old quarterback who gets the worst headache of his life, and which never goes away. We will provide you with a single note summarizing the case and the imaging available to the doctors who figured out what was wrong.

The first reader to provide the diagnosis gets a signed copy of my book “Every Patient Tells a Story” and the satisfaction of solving a tough, tough case.

Pressure, Then Pain

The young man in the speeding ambulance lay with his eyes closed for most of the trip from his small town community hospital to the pediatric wing of the much larger Beaumont Hospital in Royal Oak, Mich. When the pounding in his head allowed him to open his eyes, he noticed that the paramedic traveling with him looked concerned. What’s she so worried about? he recalls wondering. Then, closing his eyes once more, he fell asleep and remembers nothing more until after his surgery.

His headache had started two weeks earlier, on Thanksgiving Day. He was playing Ping-Pong with his cousin and noticed that every time he leaned over to pick up the ball he felt a strange pressure at the top of his head. When he went to bed that night, the pressure was gone but he didn’t feel well.

The next day he woke up with a throbbing tightness in his head that was worse than anything he had ever felt before. A few years earlier he had been tackled at a football game and hit his head. He was totally knocked out for several minutes and when he woke up, wow, what a headache. But this one was much, much, worse. And unrelenting. He took some acetaminophen and went to church with his family. The light coming through the church windows felt like a knife in his eyes, and as soon as he got home he went to bed. And stayed there.

The next two weeks were a blur of sleeping and awaking to the pain in his head. He wasn’t hungry. He wasn’t thirsty. Nothing his mother gave him could stop the pain. After a couple of days he stopped going downstairs for meals. Opening his eyes made everything so much worse that it just became easier to stay in bed and keep them closed.

His parents brought him food and drink, but he took only a bite or two before retreating back into sleep.

Three Doctor Visits

His mother took him to his doctor. Any fever? he asked. Any nausea or vomiting? These are the symptoms of infection or increased pressure in the skull. Nothing but the pain and the terrible sensitivity to light, his mother reported. Migraine, the pediatrician told her, reassuringly. This is the age when they often start. They can last for days, so give it time.

Time didn’t help any more than the acetaminophen. So a couple of days later she took him to the emergency room. Migraine, they concurred, or maybe a viral meningitis. They suggested a spinal tap to rule out a bacterial infection and when the mother declined, prescribed the boy a stronger pain killer and sent them home.

After several more days the headache showed no signs of relenting. She went back to the doctor who asked the same questions. Still no fever; still no nausea or vomiting. This time he said that it was probably a viral meningitis. Also common at this age. Give it a few more days.

What about a head CT? the mother asked. Wouldn’t that show us what he had? Probably not, the pediatrician told her. Headache is one of the most common complaints seen in doctors’ offices and ERs and 99 times out of 100 it is caused by nothing that can be seen even with the best imaging.

Lying to the Doctors

But as the young man headed into his second week of pain, his mother was beside herself with worry. Her son had always been active and hard working. He was the quarterback of his high school football team and a top hitter on the baseball team. He had hardly been sick a day in his life. It scared her to see him spend entire days in lying in bed, hardly able to eat. One morning as she walked into her son’s room she was shocked by how much he had changed. He had lost so much weight. His face was thin; his skin had a grayish color. His eyes were sunken and his lips were dry. He couldn’t go on this way. She helped him get dressed and took him back to the emergency room. No matter what, she was going to make sure he got a head CT. Maybe it wouldn’t tell them anything, but just waiting for the boy to get better wasn’t working.

In the ER the doctors asked the same questions: any fever? Any nausea or vomiting? And this time she had a different answer for them. Yes, he had been having fever for days. He was so nauseated he could hardly keep anything down. It didn’t feel right lying to these doctors but the mother thought that symptoms that fit the doctors’ expectations would get action faster than her own motherly observation of his dramatically changed behavior and looks.

Perhaps they would have gotten a CT scan without her “fabrication” (as she called it) but she didn’t want to take a chance.

It seemed only minutes after the scan when the ER doctor approached her. The CT image showed something in his brain. He wasn’t sure what it was but it was big and ugly, and needed to be evaluated by a neurosurgeon. They were going to take him to the nearby pediatric hospital. Right now. She watched as they bundled her son into the ambulance and headed for Beaumont Hospital.

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A CT scan of the patient's brain.Credit

You can see the CT scan at right and report here:

Head CT

A Diagnosis at Last?

After that everything moved quickly. They arrived at Royal Oaks and the boy was taken for an M.R.I. The neurosurgeon broke the news. The boy had an abscess and he needed surgery to reduce the pressure in his brain caused by the walled off pocket of infection and the pus it was producing. And he needed it now.

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An M.R.I. of the patient's brain.Credit

You can see that M.R.I. and report here:

M.R.I. Report

A few hours later, in the early hours of the morning, her son was wheeled into the ICU, his head swathed in gauze. He was surrounded by bags of antibiotics dripping into IVs. As hard as it was to see her son this way, it was a relief to finally have some answers – even if the answer was terrifying.

The next day the patient and his parents met Dr. Bishara Freij, a specialist in pediatric infectious diseases. He listened as the father recounted the events of the past two week (including, eventually, the false story told in order to get the CT scan) and then he carefully examined the young man. Dr. Freij had already seen the CT scan done the day before and read the neurosurgeon’s notes. The young man had had a brain abscess — that much was clear. But why? Where did the infection come from? Most of the time an abscess is a complication of an infection of the ears or sinuses or teeth. Not in this case.

You can review Dr. Freij’s note here:

The Doctor’s Note

Advice From the Radiologist

After explaining his concerns Dr. Freij excused himself. He had to go down to talk with the radiologist who had seen something on the chest X-ray that was a little abnormal. He described it as a vague nodular density. Dr. Freij wasn’t sure what it was or if it was linked to the brain abscess but he wanted to discuss the finding with Dr. David Bloom, a pediatric radiologist he had known and admired for many years.

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The patient's chest X-ray.Credit

You can see the chest X-ray here.

Looking at the films Dr. Freij and Dr. Bloom figured out what the young man probably had – the diagnosis that underlies both the infection in his brain and the abnormality in his lungs. Can you put this puzzle together?

I’ll post the answer on Friday.

Rules and Regulations: Post your diagnosis and any questions you may have in the comments section. The correct answer will appear Friday on Well. The first person to answer correctly will receive a copy of my book and that warm, wonderful feeling you get from solving a mystery. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Updated, 3:50 p.m. | Thanks for all your responses! You can read about the correct diagnosis, and the winner, at “Think Like a Doctor: The Quarterback’s Headache Solved!”


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Correction: September 11, 2015
An earlier version of this post misstated the location of Beaumont Hospital. It is in Royal Oak, Mich., not Royal Oaks.