Letter| Volume 119, ISSUE 3, e19, March 2006

The Answer You Get Depends on the Question You Ask

      To the Editor:
      I read with great interest the editorial, “The Answer You Get Depends on the Question You Ask.”
      • Alpert J.S.
      The answer you get depends on the question you ask.
      A 60-year-old man from nearby hilly area presented to the emergency department with complaints of anorexia, headache, and back stiffness for two days. As the patient was on anti-tuberculosis treatment for pulmonary tuberculosis for the last one month, a provisional diagnosis of tubercular meningitis was made, and the patient was managed accordingly. Routine investigations and CSF examination were normal. One day later, he was noted to be irritable, hostile, paranoid, and hallucinating. He was reevaluated independently by a psychiatrist and a neurologist and received multiple doses of sedative-hypnotic drugs for treatment of agitation. His condition deteriorated further with development of fever of 38.6°C (101.5°F) and tremors.
      During clinical rounds the patient was asked about the history of animal bites, his wife revealed that the patient had been bitten by a mongoose on the face about 6 weeks ago. The patient developed aerophobia and hydrophobia. Saliva and a nuchal biopsy containing hair follicles were sent for investigation, which confirmed the diagnosis of rabies encephalitis. Direct fluorescent antibody staining of the nuchal biopsy was suggestive of rabies infection. Contact and droplet precautions were initiated. Several hospital staff also reported potential exposure to the patient’s body fluids before isolation precautions were initiated. The patient died on the fourth day of admission.
      As the patient was suffering from tuberculosis, his neurological symptoms were presumed to be due to meningial involvement of tuberculosis, and a possibility of rabies encephalitis was not considered even though it is still prevalent in this part of world.
      Initially we failed to elicit the history of animal bite, and the clinical diagnosis of rabies was missed. Only when the relevant question was asked, did we get the information that led to the correct diagnosis.


        • Alpert J.S.
        The answer you get depends on the question you ask.
        Am J Med. 2005; 118: 693