Mr. Peace is a 40 year old alcoholic whose lives a “bed to couch” existence. His family said that he drinks up to a case of beer a day for the past 25 years and smokes 2-3 packs of cigarettes a day. When he rises from the couch to go to the bathroom, he has to steady himself against a wall, because otherwise, he staggers too much to walk straight. He drives if “he hasn’t had too much to drink, and it’s only a short distance,” according to his family.

He has had trouble breathing on and off for the past 15 years or so, and occasionally as a child, but has never been to a doctor for treatment. A few days ago, he developed so much trouble breathing that his family took him to the hospital in a small town about an hour from where I live. He had a chest x-ray as well as a CT scan of his chest that showed that both lungs were full of some sort of fluid…pus or possibly even blood. Remember the hantavirus spread by rodents in the desert southwest? That was a hemmorhagic (bloody) disease that might cause a similar x-ray to Mr. Peace’s. Perhaps he had tuberculosis, walking pneumonia, heart failure? Maybe he was immunocompromised (HIV, AIDS or chronic steroid treatment) and suffering from an opportunistic infection like cryptosporidium or pneumocystiscarinni (PCP).

The small rural hospital he was taken to by his family felt that he needed more sophisticated care and transferred him to our hospital. He was initially admitted to the “special care unit,” a unit for very, very sick patients not requiring mechanical ventilation or other invasive, advanced life support. But by 2pm the next day, his breathing deteriorated to the point where he was brought across the hall, to the intensive care unit, where I was on call. As the admitting intern, I had ‘first-shot’ at any and all procedures he might need. With the help of my upper-level resident, a 3rd year, the nursing staff and a staff physician sitting almost out of sight writing his admission note, I intubated Mr. Peace, and put in several invasive catheters into both arteries, veins and even one that goes all the way from his subclavian vein (the vein below the clavicle) into his heart, through the right atrium and the right ventricle and finally out into one of the arteries leading to his lungs. He required high levels of support from the mechanical ventilator, and the oxygenation of his blood was not reflective of the 100 percent oxygen being administered by the machine (normally we breath only 21% oxygen and our blood is fully ‘saturated’ with oxygen.)

It seemd as though we would easily uncover the cause for his sudden respiratory demise with so many invasive and advanced monitoring techiniques. We obtained live images of his heart function (an echocardiogram), that showed his heart was surprisingly strong, except for his right ventricle struggling to push blood against his lungs that had suddenly failed to work for him.

We did a bronchoscopy, performed by a pulmonologist (lung specialist) to look inside his lungs, expecting to see thick milky looking pus, or even blood. But disappointingly, we saw nothing. Just clean, relatively healthy looking airways. Sterile saline was injected into his lungs and suctioned back out to be sent off to the microbiology lab for cultures of bacteria, viruses, molds and yeast. In addition, we sent off blood samples to look for eveidence of specific types of infection…’walking pneumonia’, Legionaire’s disease?

Every culture and test came back negative.

Mr. Peace is our mystery patient, a medical enigma. It would be satisfying to discover the cause of his illness, treat it appropriately and watch him get better. But most likely, he’ll simply get better on his own, despite our most creative approaches to his diagnosis, and he’ll return to his previous “bed to couch” existence.