Neurology

1. The Ancient Greeks thought of epilepsy as a sacred disease, and there has always been an aura of mysticism and superstition that surrounds it. Many great people through history are said to have suffered from epilepsy, and the cases of men such as Hercules and Aristotle inspired Hippocrates to call it the "great disease" (or grande mal). However, many of the famous and oft-cited cases may not fit our current definition. Would you diagnose the following people with epilepsy?

a. Alexander the Great - Collapsed once after taking an herbal medicine for a lung problem brought on by swimming in a cold river.

b. Edgar Allen Poe - Suffered from complex partial seizures in his later life, said to have been brought on by his bouts of alcoholism.

c. Napoleon - Had seizures resulting from kidney failure and exacerbated by stress.

d. Van Gogh - Most frequently cited "epileptic". Most of his documented seizures are linked to consumption of potent absinthe liquor, which in those days contained neurotoxins.

e. Tchaikovsky - Suffered from convulsions at the end of his life while dying of cholera.

f. Julius Caesar - Had four documented episodes that resembled complex partial seizures, and may have suffered further episodes in his youth. Historians argue about his health but in general it was fine until his later years.


Napoleon I on his Imperial Throne by Ingres


2. One famous person who likely suffered from epilepsy was Charles Dickens, and he was lauded by physicians for his accurate portrayal of the disease in his novels. For each character, name the type of seizure described:

a. (Oliver Twist) "The man shook his fists, and gnashed his teeth... He fell violently on the ground: writhing and foaming, in a fit." He was conscious during these events: "These fits come over me... thunder sometimes brings them on."

b. (Bleak House) "Guster falls into a staring and vacant state," appearing as "stunned admiration."

c. (Bleak House) "Guster fell into a fit of unusual duration: which she only came out of to go into another, and another, and so on through a chain of fits, with short intervals between..."


Great Book


3. Another Dickens case: Old Anthony Chuzzlewit had "fallen from his chair in a fit, and lay there battling for each gasp of breath, with every shriveled vein and sinew starting in its place." The next morning "He seemed to utter words, but they were such as man had never heard. And this was the most fearful circumstance of all, to see him standing there, gabbling in an unearthly tongue." What happened? Where? What would you call his deficit?


4. Let us revisit the case of Julius Caesar. Alternative theories have been proposed to explain his history of seizures. In the years leading up to his assassination in 44BC (shown nicely in the painting below), he exhibited increasingly erratic behavior, which included disturbances of consciousness, night terrors, and tremors. He also seemed to disregard his own wellbeing, reacting carelessly to assassination rumors and disbanding his personal bodyguard, which made his contemporaries think he "no longer wished to live". This was all in addition to his seizures and frequent headaches. The great Roman historian Plutarch called Caesar's ailment a "disease of the head," which specific diagnosis could explain all of these findings?

 
The Death of Caesar by Jean-Leon Gerome


ANSWERS (highlight to see):
1. None except Caesar. Need 2 or more unprovoked seizures.
2. Myoclonic seizures (may or may not lose consciousness, no consciousness in general tonic-clonic )
Absence Seizures
Status Epilepticus
3. Stroke, MCA, Wernicke's aphasia (Broca's would cause non-fluency and omission)
4. Meningioma near the temporal lobe

Rheumatology

1. One of the first well-documented cases of an autoimmune rheumatic disease was that of a famous 19th century French artist. In addition to the typical signs of the disease (shown in the picture below), he suffered from pleuritis, cachexia, and peculiar nodules on his back. As his conditioned worsened, he claimed the only thing that helped were his many visits to French thermal spas. Somehow he managed to continue his artistic achievements despite his debilitations. What disease was he suffering from? Can you name the artist?


Note the MCPs and PIPs...


He would tie a paintbrush between his knuckles to continue his work.

2. In 1776, Benjamin Franklin was appointed to the committee responsible for drafting the Declaration of Independence. Unfortunately, he failed to attend most of the meetings because of a joint illness, and Thomas Jefferson had to send him the drafts to look over at home so he could make corrections. At this point in history, his disease was well understood, and a Dutch man named Antonie van Leeuwenhoek had even described the structure of the causative agent. When he looked through his microscope, what did he see?


van Leeuwenhoek's microscope

3. Members of the famous Florentine Medici family were known to suffer from a peculiar series of rheumatic conditions. While renaissance doctors thought gout was responsible, their symptoms were so unique that historians coined the term "Medici Syndrome" to describe their disease. Each generation presented differently, but recent paleopathological studies of their exhumed skeletons showed that the most common findings were degenerative ankylosing of the spine, mutilating deformities of the small and large joints of the hand, slight subluxation of the fingers, demineralization of bony matrix, and an erythematous skin condition. There is no consensus on what the family suffered from, but which two diseases could these symptoms point to?


Spinal Column of Piero di Cosimo de' Medici (aka Cosimo the Gouty)

4. During his first voyage to the new world, Christopher Columbus had an episode of severe food poisoning that took him weeks to recover from. In the following years up until his death in 1506, he was known to complain of debilitating joint pain from "gout", despite the fact that he avoided alcohol and rich foods to help with his comorbid painful urination. In his later years he also had constant fevers, a fused spine, and difficulty seeing as a result of conjunctivitis. His illness wasn't described until over 400 years later when a nazi physician came across it. What is it called today?


Portrait of a man, said to be Christopher Columbus


ANSWERS (highlight to see):
1. Rheumatoid Arthritis, Auguste Renoir
2. Needle-shaped uric acid crystals
3. Psoriatic Arthritis, Ankylosing Spondylitis
4. Reactive Arthritis (previously Reiter's Syndrome)

Microbiology

1. In 323 BC, Alexander the Great died in Babylon at the age of 32 following two weeks of severe illness. While some speculate that he was poisoned, an event described by Plutarch points to an infectious cause. Alexander was said to have walked amongst a flock of ravens exhibiting unusual behavior in the days leading up to his illness. What disease (and what complication of the disease) did he possibly die of?

 
Alexander of Macedon

2. Many medical historians still think that Alexander probably died from malaria (plasmodium falciparum), though there were no accounts of his illness coming and going. However, there are accounts of him complaining of intense abdominal pain and urine discoloration, and it is known he passed through marshland in India. What specific parasite could have been responsible?


3. Charles Darwin had a mysterious illness that is still not fully understood. Though based on his numerous GI symptoms, the location of his travels, and one of his journal entries, what is a reasonable hypothesis?
"At night I experienced an attack of the Benchuca, the great black bug of the Pampas. It is most disgusting to feel soft wingless insects, about an inch long, crawling over ones body; before sucking they are quite thin, but afterwards round & bloated with blood, & in this state they are easily squashed."  *The "Benchuca" has a different name now... look it up if you need a hint.


Charles Darwin

4. Beethoven was frequently prescribed lead-based medications for a recurrent illness, and an autopsy report describing a cirrhotic liver points to lead infection as the main cause of death. However, a lead poisoning expert at Mount Sinai (Dr. Andrew Todd) tested a fragment of Beethoven's skull in 2005 and found no evidence of abnormal lead exposure. What is the most likely infectious cause of his death, given the presumed subclinical presentation?

ANSWERS:
1. west nile encephalitis
2. schistosoma haematobium
3. Chagas' disease (trypanosoma cruzi)
4. hepatits C