Patients question their treatment at HUP during infection outbreak | Interactive timeline

Max Greiner and Christopher Pynn were two Penn students swept up in the extraordinary measures Penn took last month to halt the spread of meningococcal infection that sent shock waves through campus.

Between Feb. 12 and 13, three students were hospitalized with meningococcal infection, a bacterial infection within the bloodstream. An additional two students were hospitalized on the 15th with flu-like symptoms but were never confirmed to have meningitis. In the interlude, Student Health Service preventatively treated about 3,000 students with Ciprofloxacin.

Coming to SHS officials with flu-like symptoms during the preventative clinics, Greiner and Pynn were quickly transported to the Emergency Room of the Hospital of the University of Pennsylvania, where doctors attempted to rule out a meningococcal infection.

What followed was a medical odyssey. Both Greiner and Pynn fault SHS and Penn Health for poor communication, uncoordinated care and a confusing list of procedures done to them, though neither had the infection.

Their stories highlight the difficult conditions with which Penn officials were faced in their attempts to prevent a spread of the meningococcal outbreak. They attempted to balance the rights of patients and the risks of performing certain medical procedures with the danger that a student could die from an undiagnosed infection or spread the disease.

Both SHS and the Penn Health System declined to comment for this article, citing patient confidentiality. No doctor who was involved in either student's care returned a request for comment.

In a statement on behalf of SHS and Penn Health, SHS director Evelyn Wiener wrote that it was difficult "to diagnose the infection in the middle of the flu season." She added that, because of the outbreak, Penn worked to respond "with an abundance of caution."

It is unclear whether Greiner and Pynn were the two students who were hospitalized with flu-like symptoms as the University would not confirm those students' names in previous stories.

Max Greiner

Greiner, a College senior, went to SHS at about 4:30 p.m. on Feb. 13 with flu-like symptoms.

Though SHS said he had no reason to panic, he was referred to HUP to rule out a meningococcal infection.

By the time he was seen, at about 8:30 p.m., Greiner said his symptoms had subsided. Doctors checked the stiffness of his neck - a key indicator of an infection - and though he had good mobility, they recommended he get a lumbar puncture, or spinal tap, as a precaution.

Though doctors explained that the procedure would be simple, Greiner said it was anything but. He said the doctors who performed the procedure struggled with inserting the needle, poking around and hitting a nerve. He felt like he was being "electrocuted" and cried out in pain.

Doctors then put him on a drip of Vancomycin, a strong antibiotic that would treat an undetected streptococcal infection, and Ceftriaxone to treat a meningococcal infection.

Almost immediately, however, the Vancomycin caused a reaction known as red man syndrome: Greiner's upper body swelled and turned red, and he felt unbearably itchy.

Though red man syndrome is rare, a 2003 paper published in the journal Critical Care directs doctors to immediately discontinue administering the drug if it manifests. Then, when symptoms subside, the drug can be given at a slower rate with an antihistamine like Benadryl.

Greiner said, though doctors slowed his drip and gave him Benadryl, they never discontinued administering the medication or waited for his symptoms to subside. His symptoms continued until later that night.

He complained of slow nurse response times to his pages during the rest of his stay - it took an average of seven minutes for nurses to respond to them.

His stay at HUP ended in a confrontation with SHS director Wiener.

Wiener visited him in his hospital room on Feb. 15. Though two other doctors had earlier told him he could be discharged - they said his spinal tap and other test results came back clear - Wiener said he needed to stay another day for observation.

Greiner said Wiener also refused to discuss his test results with him and suggested that she would hold him at HUP against his will if he tried to leave. Greiner was discharged later that day by other doctors.

When asked about the exchange, in addition to other details about Greiner's stay, Wiener declined to comment.

But after being discharged, he began experiencing excruciating headaches and was almost too weak to walk. When he called HUP about the pain, he said, they told him that the symptoms would go away in a few days.

When they did not, his mother, who had flown in from Colorado, took Greiner to Presbyterian Hospital on Feb. 18.

Doctors there told him that the wound on his back left by the spinal tap had not sealed properly and that he was leaking cerebrospinal fluid, causing severe headaches as his brain rubbed against the surrounding membranes. After waiting four hours, Greiner was told the procedure to seal the hole, an epidural blood patch, was only performed at Penn Medicine at Rittenhouse. He had to trek to Center City, where doctors injected Greiner's own blood into his spine to cause clotting.

Complications from a spinal tap are rare, said Donald Forthal, chief of infectious diseases at the University of California, Irvine Medical Center.

When confronted with a known meningococcal outbreak, he said doctors are taught to err on the side of caution by going ahead with the procedure if they think it may be necessary. However, he added that doctors can perform a CT scan first to determine if there is any swelling around the brain, a sign of an infection.

Though Greiner is now OK, he said the experience made him lose a week of school. He is also frustrated at the lack of communication among his doctors and with him. When he asked whether he could be given an antibiotic instead of Vancomycin, for instance, he said no doctor gave him a straight answer.

Christopher Pynn

Pynn's complaints also stem from the lumbar puncture he received at HUP.

The Engineering junior went to the clinic SHS set up in Houston Hall on Feb. 15 with a 100-degree fever. As a brother in the Phi Kappa Psi fraternity, he had received Cipro the day before when the University recommended that members of the Greek community seek preventative treatment.

A nurse suggested he go to HUP to rule out a possible meningococcal infection, and while waiting to see a doctor, his symptoms worsened. He was placed in an isolated room.

He was given antibiotics under the care of Iris Reyes, an ER physician, and told that a lumbar puncture would not be needed.

The next morning, however, a new set of doctors recommended a spinal tap.

Pynn's sister, a doctor who had come to visit him, confronted the doctors, criticizing their decision to go ahead with the procedure.

She argued that, a day after being given strong antibiotics, a spinal tap would not be able to detect any bacteria in the spinal fluid. She said he should have immediately received a spinal tap if doctors hoped to gain a diagnosis from it.

Forthal, the infectious-disease doctor, said a diagnosis of a meningococcal infection is more "an art," especially in the midst of an outbreak. Though giving antibiotics beforehand can make a diagnosis more difficult, there will still be signs of an infection in the spinal fluid.

Though Pynn eventually consented to the procedure, he said it took him a week to recover and that he was so weak upon being released on Feb. 17 that he could not walk and decided to go home to Long Island.

Pynn said Joel Maslow, an infectious-disease doctor involved in his case, "very carefully admitted that [the] ER had made a mistake" by giving him antibiotics before administering the spinal tap.

Like the other doctors involved in both cases, Maslow did not respond to a request for comment.

Assessing the outbreak

Though neither Pynn nor Greiner suffered permanent harm, their treatment does raise questions about the full extent of Penn's response to last month's outbreak.

Both students say they saw other Penn students with suspected meningococcal infection in the ER waiting room with them, and it is not known how many students were sent to the hospital in connection with the outbreak.

Their stories also raise questions as to the steps Penn health care providers took to ensure that no students who went in with a suspected infection actually got sick, as well as the communication - or lack thereof - between health care providers and the two men.

No Penn students died as a result of the outbreak, but Pynn and Greiner wonder whether the University's caution ended up putting them at risk with the very procedures used to rule out an infection.

"It's difficult" to weigh these competing interests, Forthal said.

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