Questions continue in meningococcal outbreak

Elizabeth Grant, like many other Penn students, went to several Greek parties the first weekend in February.

And like other students who had connections to the Greek system, Grant, a College sophomore, went to get a prophylactic dose of Ciprofloxacin on Feb. 14.

But unlike most of the over 3,000 other Penn students who took Cipro to protect themselves against an outbreak of meningococcal infection that had infected three students, Grant also had a bad headache and was running a fever - both early symptoms of the disease.

Though she was not too worried, her fever continued to climb even after taking medication, so she decided to err on the side of caution and go to the Emergency Room at the Hospital of the University of Pennsylvania.

Though Grant did not have a meningococcal infection, her four-day stay at HUP raises questions about the number of students who were hospitalized in connection with the outbreak. It also illustrates the difficulties hospitals face in administering spinal taps as they become a less common emergency room procedure.

As the third person who has come forward after being admitted to HUP to rule out a meningococcal infection in connection with the outbreak, Grant's story seems to call into question Penn officials' statements that two students had been hospitalized with suspected infections.

Both Max Greiner, a College senior, and Christopher Pynn, an Engineering junior, who were hospitalized in connection with the outbreak, have spoken in previous interviews about seeing other masked Penn students in the ER waiting room.

And Elizabeth Grant, her mother Stephanie Grant and her friend Lauren Mifflin, said nurses told them around six students had been admitted with suspected cases of the infection.

In an interview, Student Health Service director Evelyn Wiener denied there was any discrepancy in the numbers.

She said the two students who were reported hospitalized with flu-like symptoms were treated as if they had a meningococcal infection, even though it was never determined that they did.

"Many other students were evaluated in Student Health and in the ER," and some were admitted to HUP, she said.

She said that Penn did not include those people in its updates because they were not suspected of necessarily having a meningococcal infection.

However, Wiener did say that their evaluation at HUP "may have included testing" for that possibility, including some lumbar punctures, or spinal taps.

"Their admitting evaluation may have included testing to make sure that they did not have meningitis," she said.

Wiener refused to release the number of students who were seen at HUP in connection with the outbreak. She did say in a Feb. 26 guest column published in The Daily Pennsylvanian, that "numerous other students [were] evaluated in the Student Health Service and the Emergency Room, [and some were] admitted to the hospital for observation and empiric treatment pending test results."

Additionally, neither she nor HUP spokeswoman Holly Auer could comment specifically on Grant's case, citing privacy policies. Nor would Wiener confirm whether Grant or the two other students who came forward were counted among the two students at HUP for flu-like symptoms.

Grant's narrative has been substantially confirmed by both her mother and Mifflin, a College and Wharton sophomore, who spent a large amount of time with Grant. They were present for many of the medical procedures she underwent and for her conversations with HUP doctors and SHS director Evelyn Wiener.

When Grant arrived at HUP at about 5 p.m. on Saturday, Feb. 14, she was almost immediately given a mask to wear and placed in an isolated room. Three friends had accompanied her to the ER, and her mother had driven up from Wilmington, Del.

Doctors immediately suspected that she was suffering from a meningococcal infection. She was disoriented and was unable to recall her Social Security Number when asked for it.

To rule out a complication from an earlier head injury, doctors ordered a CT scan for her, which came back clear.

They also drew blood and decided to perform a spinal tap to collect cerebrospinal fluid needed to make an accurate diagnosis.

"This is when things got bad," she said.

A resident performed the procedure but was at first unable to draw spinal fluid because blood clots prevented it. He then tried lower down her back but faced the same problem.

After about 15 minutes, the doctor called in the chief resident, who tried a third time to get enough fluid without success.

On the fourth try, the chief resident was able to draw enough fluid for analysis. This puncture, however, was "incredibly painful," according to Grant.

"My entire body went rigid," she said, adding that it took about 5 minutes for the fluid to completely drip out. In total, the process took about 45 minutes, Mifflin said.

Doctors told her that she had suffered a "traumatic spinal tap," a common complication.

Though she felt sore, Grant said the pain was bearable. Doctors started her on an antibiotic.

At about 1 a.m., a nurse came in to admit her because her results, while not positive for a meningococcal infection, were still irregular. A doctor later told her she would be kept under observation for a day because, as he explained it, "we're finding new cases," Grant said.

On Sunday, because her test results showed an elevated white blood cell count and elevated protein levels, doctors started her on Vancomycin, which is used to treat certain bacteria that could cause meningitis.

This immediately caused an allergic reaction. Nurses immediately discontinued the drip and started her on Benadryl, which caused the symptoms to subside.

Doctors also started her on a seven-day course of Ceftriaxone, an antibiotic that would treat a case of strain B Neisseria meningitidis, the bacteria that infected the three students at HUP.

Her spinal fluid had tested neither positive nor negative for meningococcal bacteria.

On Tuesday, Grant was surprised when SHS director Wiener, who had visited her in the hospital both Sunday and Monday, abruptly suggested that she go home to Wilmington where a nurse could help administer her medication.

As Grant, her mother and Mifflin described it, Wiener was convinced that she did not actually have a meningococcal infection.

Wiener's idea came as news to some of Grant's infectious disease doctors, who had not heard about the suggestion beforehand.

Though Grant's doctors said they could look into it if it was what she wanted, the option was "completely up to me." By contrast, Wiener saw it "as my course of treatment," Grant said.

This difference of opinion frustrated Grant and her family, though her test results came back later that day from the Centers for Disease Control saying she did not have the infection.

She was discharged at 6:20 p.m. with a principal diagnosis of "viral syndrome," according to a discharge document Grant made available to the DP.

When Grant returned to her dorm, she began feeling a significant amount of pain running down her hip and right leg.

It was painful for her to remain sitting through her classes, her leg felt numb and reaching for things caused "excruciating" pain, she said.

Grant scheduled a Feb. 25 appointment with her neurologist. He determined that the HUP doctors had attempted two punctures on the wrong vertebrae and hit the sciatic nerve, she said.

Peter Axelrod, a professor of infectious disease at Temple University who was not involved in Grant's treatment, said that in order to hit the sciatic nerve during a spinal tap, the doctor would have to "be really off target." However, it is "relatively easy" to have difficulty locating the spinal cord in some patients, he said, especially if doctors are inexperienced and patients agitated.

According to Stephanie Grant, Elizabeth's mother, the neurologist also said that it looked like it had been performed by someone inexperienced.

The neurologist wrote Grant a prescription for physical therapy three times a week "for [right] sciatica after lumbar puncture," according to the prescription, which Grant made available.

Though the neurologist was concerned the pain could be permanent, it has gradually lessened in intensity, Grant said, and she elected not to use the prescription. Her limp has disappeared, though she cannot exert herself too much. She also said she expects to return to her club squash team.

Grant is the third student to speak of a negative experience from a spinal tap done in connection with the outbreak.

Greiner, the College senior, was leaking spinal fluid after receiving a spinal tap, and underwent an epidural blood patch. Doctors injected his own blood into his spine to cause it to clot.

And Pynn, the Engineering junior took a week to recover from his spinal tap.

Annette Reboli, chief of infectious diseases at Cooper University Hospital, said the risks of a serious infection like meningitis usually outweigh the "rare" complications that could arise from a spinal tap. Reboli is unconnected with the case.

At the same time, Axelrod said doctors receive less training today than they did when meningitis was more common and doctors had more practice.

He also said spinal taps are generally performed better at non-teaching hospitals because board-certified physicians perform the procedure.

Axelrod said, though, that teaching hospitals like HUP probably give better overall care because of the broader expertise of their doctors.

And though Grant can no longer receive certain types of anesthesia as a result of the procedure, she said she was satisfied with the rest of her time at HUP. She praised the hospital nursing staff and the dedication of her infectious disease doctors.

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