CHAPTER 316: 316 TERATOMA?

(Thanks to friends Mangmangliu, Chensi, Nanrenxian, Empty Lonely Cold 671112, Yuanqi Yuanmie Yuanziyuan, and Yuze for their monthly ticket encouragement.)

After the patient’s parents arrived at the emergency center, Liu Banxia explained the situation to them again. Once they understood, he proceeded to induce the patient into a drug-induced coma.

Even though the patient was an adult and could make decisions for herself, without emergency circumstances, no direct actions could be taken. Otherwise, when her parents arrived and saw all those tubes inserted in their precious daughter’s mouth, they might have been terrified, caused a commotion, or both.

"Everyone, these are the current EEG, CT, blood, and urine test results. This is the first big challenge our emergency center has encountered, and we must tackle it head-on," Liu Banxia said once they were in the small conference room.

"Let me summarize the patient’s situation again: a 26-year-old female with a nearly three-year history of headaches. She experiences brief seizures, lasting 3-5 seconds, occurring frequently. The EEG shows brain damage, and she is currently in an induced coma."

"President Liu, I just looked at the blood and urine test reports. It looks like hemolytic anemia, doesn’t it? Increased red blood cell destruction, hematuria—it fits the bill, right?" asked Wang Huan.

"I discussed this with Brother Zhao and Brother Zhang earlier and thought along the same lines. However, after examining the patient again, I did not find symptoms of jaundice or an enlarged spleen," Liu Banxia nodded. "But we should note this down as a possible line of inquiry. We need to gather everyone’s ideas to diagnose the patient in the shortest time with the fewest tests possible."

"Actually, it is very likely," Wang Huan said. "The course of hemolytic anemia can be quite long, and presently it may not yet present symptoms such as jaundice, an enlarged spleen, chills, or fever."

"Considering the patient’s history of seizures, it’s possible she has an autoimmune disease. We should do a lumbar puncture; at the very least, it would rule out meningitis and encephalitis."

"We should also screen for systemic lupus erythematosus and systemic vasculitis. The former is more common in women, while the latter is more common in men, but we cannot rule it out."

"So, our next step is to perform the lumbar puncture first and evaluate the results, followed by screening for lupus and vasculitis?" Liu Banxia asked.

The three of them looked at each other and nodded in agreement.

They had no other choice but to proceed this way, one step at a time. They also understood why Liu Banxia was taking this case so seriously. As he had said, this was a difficult case. A successful diagnosis would be a big morale booster.

A lumbar puncture is a surgical procedure used to diagnose various inflammatory diseases of the central nervous system, vascular diseases, spinal cord lesions, and the like. However, hospitals do not often recommend this procedure and only perform it when the indications are clear. This is because a lumbar puncture can lead to various complications, such as intracranial hypotension syndrome, low back pain, bloody cerebrospinal fluid, and aseptic meningitis. After all, the puncture site is in the lumbar spine, so great care must be taken during the procedure.

After explaining carefully to the patient’s parents, Liu Banxia decided to perform it himself.

"Huang Bo, how do you determine the puncture point for a lumbar puncture?" Liu Banxia asked while preparing for the procedure.

"Choose the gap between the third and fourth lumbar vertebrae. The patient should be in the lateral decubitus position with neck flexed, hips flexed, and knees flexed, hands holding knees to arch the lumbar spine, ensuring the spine is straight and not bent," Huang Bo replied.

"Liu Yiqing, Xu Yino, help position the patient, sterilize the area, and mark the position," Liu Banxia further instructed.

Both hurriedly put on gloves and started working at the patient’s bedside.

"In fact, the technique for all puncture examinations is quite similar," Liu Banxia commented. "We can easily locate the puncture site because we can visually identify it."

"But for any type of puncture, one problem must be kept in mind: the depth of the needle. How do we judge it? We can only rely on feel."

"When we perform an abdominal paracentesis, if you feel a sudden loss of resistance in your hand, it means the peritoneum has been punctured, and the needle is in place. Lumbar puncture follows the same principle, though there’s a slight upward tilt towards the head as the needle advances."

"Once we feel that loss of resistance, it means the dura mater has been successfully punctured, and the needle has entered the subarachnoid space. Miao Rui, what should we pay attention to at this moment?"

"The speed of needle insertion; it should be kept slow," Miao Rui responded. "Otherwise, due to the reduced resistance, internal organs or the spinal cord can be easily injured."

"Very good. Li Hao, you’ll be my assistant and then handle sending the samples for testing," Liu Banxia nodded.

Miao Rui, who was initially excited, embarrassedly scratched his head. He hadn’t expected Liu Banxia to make a lighthearted comment at this time; he had thought the reward of being an assistant was for him.

"With time and more patients, you all will have the opportunity to perform these procedures," Liu Banxia said.

"The reason I asked him to be my assistant is that his practical skills are the weakest among you. My principle is simple: whoever is lacking gets the opportunity."

"It’s both a reward and a punishment. His hand still lacks a bit of steadiness. He needs to practice more during his rest time. We’re considering giving you an opportunity to lead a surgery soon."

The group of interns, who had been listening calmly, suddenly showed an uplifted spirit, their eyes glowing with anticipation as they looked at Liu Banxia.

Not only Xu Yino and the others, but even Su Wenhao felt a sense of urgency.

"Don’t get too overexcited just yet," Liu Banxia continued. "It could be an appendectomy or a cholecystectomy, possibly a classic open surgery or potentially a laparoscopic procedure. Prepare well. If the first of you doesn’t do a good job, the opportunity for the next one to lead a surgery will be delayed by a month."

As he was speaking, the puncture needle had already penetrated. At this moment, he withdrew the stylet, and Li Hao quickly assisted him.

"Doctor, what exactly is Jingjing suffering from?" asked the patient’s father after the puncture was completed.

"We still can’t be sure at the moment," Liu Banxia replied. "The cerebrospinal fluid test will help us make a further judgment."

"For now, we have induced a drug-induced coma to stabilize her condition. We’re carrying out the necessary tests to get a clear diagnosis. So far, we have diagnosed her with hemolytic anemia and epilepsy. These are manifestations of her underlying condition."

"Doctor, you must find out what’s wrong. She’s our only daughter," said the patient’s father, wiping his tears.

"Rest assured, I have gathered the doctors from the emergency center for a consultation," Liu Banxia replied seriously.

He didn’t dare to make a sweeping promise that he could definitely figure it out; that would be nonsensical and deceitful. Although some clues were emerging, the exact disease had not yet been diagnosed. If you promise the patient’s family now but fail to diagnose it later, how would you explain it to them?

The wait for the results was agonizing. Once they were out, Liu Banxia called the team back into the small conference room for further discussion.

Systemic lupus erythematosus and systemic vasculitis were ruled out, and hemolytic anemia was confirmed. The cerebrospinal fluid test showed an increased white blood cell count.

"Does everyone share the same thought as me?" Liu Banxia asked. "Should we proceed with a thoracoabdominopelvic MRI scan?"

"Do you also think it’s a teratoma?" Wang Huan asked curiously.

"If it’s a teratoma, why is it causing such frequent epileptic seizures? Could there be brain tissue in the teratoma?" Zhao Bo asked with a furrowed brow.

"For now, it’s the only answer I can come up with," Liu Banxia said. "Only this really explains it, doesn’t it?"

"Only if there’s brain tissue in the teratoma would the white blood cells target normal brain tissue for elimination. This would explain the high number of white blood cells in the cerebrospinal fluid."

"Wave after wave of attacking white blood cells have caused the patient to experience frequent, transient seizures and have also damaged her cranial nerves. One or two such episodes might have been insignificant, but what about numerous occurrences?"

"Moreover, it’s possible that changes in the patient’s teratoma triggered the hemolytic anemia. The white blood cells are also attacking the red blood cells, shortening their lifespan."

"In recent years, there have been many similar cases. I suspect our patient’s situation is quite similar, and this explanation fits her current symptoms perfectly."

"Alright, this is much better than meningitis or encephalitis," Wang Huan said with a smile. "Let’s get the scan. If it shows up, we’ll remove it. Then she can return to her normal life and leave all this suffering behind."

With a plan for the next diagnostic step, Liu Banxia again took the interns out to explain the situation to the patient’s family.

As far as the patient’s family was concerned, they were ready to accept any test necessary; their daughter’s health was their top priority. They also sensed Liu Banxia’s deep concern for their daughter; otherwise, he wouldn’t have held a meeting to discuss the test results immediately upon receiving them.

"Teacher Liu, how many teratomas have you removed?" Xu Yino asked out of curiosity.

"To be precise, none," Liu Banxia replied. "I’ve never encountered one, only read about them in journals."

"Just because you call me ’Teacher’ doesn’t mean I’m old, okay? I’m only 29, not even 30 yet. My entire career spans just over five years, and the first four and a half were spent mostly on the sidelines."

This was quite a revelation for Xu Yino and the others. Yeah, Teacher Liu wasn’t that old after all. Doing the math, it seemed he was only a couple of years older than them.

"Don’t look at me like that. It’s just that I started school earlier than you all did; I just don’t have as high an academic qualification. So? Is anyone considering pursuing a Ph.D.?" Liu Banxia asked with a smile.

"Ah..." Xu Yino sighed. "I’ll think about pursuing a Ph.D. after working for a couple of years and recharging my batteries a bit."

The age difference felt significant now that they thought about it; they’d never really considered it before. They had just assumed Liu Banxia was at least seven or eight years older than them and simply looked young for his age.

After chatting casually with them for a while, the results of the MRI scan came out. After careful examination, Liu Banxia furrowed his brow. The thorax and abdomen were normal. In the pelvis, only the right ovary showed some signs of inflammation, but there was no sign of a teratoma.

It seemed like such a sure thing. Why didn’t it show up on the scan?