Photo courtesy of Rachel

Ariel, a previously healthy one-year-old, is getting celebrity level treatment. Everyone (doctors, residents, medical students) wants to take a peek at her. On the wards, this means only one thing: she has something really interesting and probably rare.

“I’ll just take a quick look to make sure she’s stable,” Robin, my senior resident, said when Ariel first arrived. We were on call, meaning it was our team’s job to admit patients to the hospital that night. Typically during call, Robin would first do a quick physical exam, then exit, leaving me to take my own history and physical. After collecting information and trying to formulate a plan, I’d then present my findings to her. It’s a wards-learning exercise. In fact, Robin already knew Ariel’s probable diagnosis but withholds it, so I can attempt to “diagnose” on my own.

I know Ariel has a rash, but that's about it.

After examining the baby, instead of leaving as usual, Robin fires off questions at Ariel’s parents: “How long has this been going on? Allergies? Bleeding problems?” I’m confused. Why is the resident doing my job?

Robin dashes from the room, pulling in Dr. Stevens, our attending, and Dr. Mundy, a pediatric surgeon, who both happen to be strolling by. “Dr. Stevens, take a look. She was sent in for Henoch-Scholein Purpura (HSP), but I’ve never seen it look like this!” Robin points out Ariel’s very shiny, purplish hand, so swollen it looks like it might burst, “Dr. Mundy, should we worry about compartment syndrome?” Robin’s behavior makes more sense now; she isn’t sure this is HSP.

Dr. Mundy squeezes Ariel’s fingertips, which turn white and pink up immediately. “Good capillary refill, so not compartment syndrome. Impressive swelling in the hands and feet though,” he remarks, leaving to see another patient. Dr. Stevens, who’s got a fondness for rashes, hangs out a bit longer, observing Ariel in the crib. “Not the classic HSP presentation, but she’s definitely got palpable purpura.” He thinks a bit. “There are cases that present with swelling, so most likely HSP.” Looking to Ariel’s parents he asks, “Would it be OK if we took some pictures?” Dr. Stevens loves his rashes.

Ariel’s parents agree to a photo shoot. For the most part, they seem amused by our antics. Other than the intensely red-purple rash covering the majority of her arms and legs, and the swelling of her hands and ankles, Ariel is acting like her normal happy self. No fussing, no crying.

The next morning, it’s determined that Ariel does not have HSP, but a very rare “cousin” of HSP called Acute Hemorrhagic Edema of Infancy.

The brilliant doctor who made the diagnosis? Not quite a doctor…not really that brilliant either…I still can’t believe it… but it was me.

Honestly, it still feels more like dumb luck than a diagnosis.

Generally, I knew HSP was a vasculitis, but couldn’t recall the details, so went to read up on it that morning, for reinforcement.

I noticed Ariel’s picture didn’t quite match HSP’s, but diseases don’t always present by the book. Scanning a section on other vasculitides with normal platelet levels, I clicked on the accompanying photo. Exactly like Ariel! The more I read about Acute Hemorrhagic Edema of Infancy, the more it matched the story Ariel’s parents had told.

Excited, I ran to grab Robin—and Dr. Stevens, who agreed with my findings, “Yes, it explains the swelling!”

I finally get why being "House" would be awesome. Solving the puzzle leaves you with a very gratifying high.

Later in the day, we give Ariel’s parents the new diagnosis. “Can it happen again?” they ask. “Hmm, I’m not sure,” answers Dr. Stevens. “Rachel, perhaps you know a bit more about this than me?”

Hilarious. No attending has ever said that to me. “Very, very small chance it could happen again,” I tell them. “See, you beat the doctors!” laughs Ariel’s mom.

Graduation gets closer every day, but I still can’t quite picture myself as a fully functional MD. I’m convinced the transformation from idiot medical student to attending doctor must involve a cocoon somewhere in between. This week, I took a small step towards becoming that doctor.

Guess it means I’ll really get there after all…?

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