Brain Worms
Charles Kaluza, DO
Copyright 2010 Charles Kaluza
Forward
My intention for writing "Brain Worms" was to explore the potential for using the cystic stage of the pork tape worm as a bioengineering tool. The basis of the story was a patient who had presented to my hospital some years back and the ensuing discussion amongst us physicians. It was remarkable how few symptoms he had from the multiple cysts in his brain. Apparently the human body tolerates the tapeworm cyst with very little inflammatory reaction, which would allow us to use it medically if we could genetically engineer the tapeworm to do our bidding.
All characters and scenes are entirely fictional and all religious references are meant to merely enhance the story. This work is not meant to be an affront to any ethnic or religious group but merely a story to explore the potential of bioengineering. Using bioengineering to allow for control of someone's mind has been an interesting experience which I hope you enjoy.
Chapter 1
Holding the syringe up to the light, Dr. Ahmad could see tiny moving crescents. These were his babies: the product of Arab science. Dr. Ahmad listened absently while the surgeon explained to the young Saudi about the mild burning he was about to feel in his ear. The surgeon touched the eardrum with a small pledget of phenol that produced enough burning to bring tears to the young man’s eyes. Almost immediately, numbness and blanching of the eardrum followed. Dr. Ahmad passed the syringe to the surgeon almost reverently. The surgeon removed the cover from the syringe and attached a long needle. Staring intently at the monitor, Dr. Ahmad watched the needle advance through the ear canal and penetrate the eardrum. The surgeon slowly pressed the plunger and the precious fluid was injected into the ear.
After the needle was removed, Dr. Ahmad could easily see his creations. One hundred of his genetically engineered worms were wiggling around the middle ear of God’s newest recruit, searching for an opening into his brain. Not all of them would make it, but enough would to give this warrior superhuman strength when the time came.
The surgeon asked the young warrior if he felt dizzy. Hearing a negative reply, the surgeon told him to sit up. Dr. Ahmad could see the twitching in the young man’s eyes and knew he had some dizziness. It would soon pass. The young man complained of a sensation of movement in his ear and the surgeon said, “It is from the medicine. That feeling will gradually diminish.”
Dr. Ahmad recited a short prayer of thanks and handed the warrior a modified cell phone. He reminded the young man, “This phone is now your most precious possession. It is what will activate the power of God now instilled in your ear. When the time comes, you will be given the code which you must enter into the phone and then inhale deeply with the antenna in your nose.”
Chapter 2
When Dr. Harry Williams arrived at the emergency room, the receptionist greeted him with a simple, “Room 13.” Harry walked to the far end of the emergency room and stood in the doorway watching the activity. The patient was anesthetized and connected to the respirator, but the EEG monitor still showed spikes of activity suggesting persistent seizure formation despite the general anesthetic. Harry spoke up saying, “I think you should deepen the anesthesia.”
Both the ER Doc and the anesthesiologist looked up to see the doorway filled with Harry. Harry asked, “What do we have?”
The ER Doc replied, “This young adult male of Middle Eastern descent was brought in because of status epilepticus. Seizures began almost two hours ago with no prior history. Patient had been complaining of a headache recently and became progressively more confused this afternoon. The grand mall seizures persisted despite IV Phenobarbital. We just now got him anesthetized. I was about to perform a spinal tap.”
Harry said, “I’m not sure I would do that. It sounds like he has developed hydrocephalus and if you relieve any pressure in the spinal column he may end up herniating his brainstem.”
“Oh. I hadn’t thought of that. How about I let you take over here and I see to the other patients. They’re stacking up.”
Harry replied, “Happy to help. Seems like the craziness has started early this evening.”
Harry spent less than a minute examining the patient. Not much to examine when the patient is anesthetized. The young man seemed to be in his mid-twenties and in good health. His tongue was grossly swollen and dark colored from being repeatedly bitten during the seizures. There was some bleeding from one of the ears but no obvious skull fracture. He did use an ophthalmic scope to look in the patient’s eyes and saw the papilledema, which is the hallmark of increased intracranial pressure.
Harry asked when the MRI scan was going to be done. The nurse responded, “Radiology is backed up. It will be a couple hours.” Harry picked up the phone and called radiology himself. When the MRI tech tried to explain how busy they were, Harry barked, “I am declaring a neurosurgical emergency and I want the MRI done now!”
The tech replied, “It will take me a couple of minutes to get the patient out of the unit. Do you want anything special?”
Harry said, “I need the head down to the brainstem, with and without contrast, using the protocol for the surgical halo. And the patient is already anesthetized.”
“Yes, sir.”
The anesthesiologist grumbled about the hassle and risks of moving an anesthetized patient, but Harry said, “We have no choice. Let’s get going.”
The entourage proceeded in a somewhat orderly fashion to radiology, and despite the grumblings of the anesthesiologist, moved the patient onto the MRI unit. After the initial setup, Harry said, “I’ll go get something to eat while you’re getting your pictures.”
The anesthesiologist complained again, “If I have to sit up here while you eat, at least bring me something when you come back.”
“Anything in particular?”
“None of the greasy stuff. Something that looks reasonably fresh.”
Harry was so busy arguing with himself about the possible diagnosis that he forgot to pick up something for the anesthesiologist to eat. The cafeteria was closing down when Harry remembered. He asked one of the kitchen staff, “Do you have anything I can bring upstairs. I promised the anesthesiologist I would bring him something to eat.”
“Would a ham and cheese sandwich be OK?”
“Thank you. That would be great.”
Harry returned to radiology about the time the first MRI pictures were available. Not only were the dilated ventricles of hydrocephalus evident, but even without contrast the multiple cysts in the frontal lobes were obvious. It was not until the scan had progressed to the brainstem before Harry was sure of the diagnosis. A cyst was plugging the outlet to the fourth ventricle. Harry muttered, “Brain worms.”
The anesthesiologist asked, “What are you talking about, brain worms?”
Harry explained, “These cysts are caused by the larva of an intestinal worm, a tapeworm, I think. These images are just like the published reports. Never thought I would see a case myself. We have to remove the cyst from the fourth ventricle. I’ll go up and get the surgical crew set up. As soon as they are done here, let’s transfer up to surgery.”
Harry checked the position of the sensory halo one last time, making sure all the screws were firmly embedded in the patient’s skull. He centered his incision over the right eye, high on the forehead. With one stroke, the scalpel sliced through the shaved scalp and muscles down to the bone. He used the electrocautery to stop the bleeding. Using a sharp elevator, he lifted the pericranium off the skull, exposing the cream-colored bone. He carefully measured down from the coronal suture and marked the bone with a surgical pen. He said simply, “Drill.”
The nurse handed him the drill that
seemed to almost disappear in Harry’s huge hands. All the normal chatter in the operating room ceased when the whine of the drill began. Everyone’s teeth were clenched slightly as the high-speed drill ate into the patient’s skull, a sound reminiscent of a dentist office on steroids. As Harry began to expose the smooth white dura matter covering the brain, he had the nurse change the drill bit to a diamond burr. With a very light touch, Harry carefully sculpted the edges of the hole, removing all sharp edges. When the hole reached the size of a nickel, Harry was satisfied and stopped to stretch.
This break gave the anesthesiologist a chance to resume his complaining, “You know, I’m missing dinner just so we can help this rag head who doesn’t even have any insurance. He probably isn’t even a legal resident.”
Harry let him go on for a bit before saying, “At least it’s not the middle of the night. Besides, it doesn’t matter if he was bright green and from Mars, he still needs our help. You make sure he doesn’t move and let me relieve the pressure on his brain before permanent damage is done.”
The anesthesiologist then complained about excess radio interference with his instruments and asked if anyone had a cell phone on. Nobody admitted having a phone on, and Harry said, "Let's just get the job done."
“Easy for you to say. But the radio interference is screwing up my electronics and I’m having a hard time adjusting the anesthesia depth. We need to get those electronic guys back and do another evaluation. I thought they had fixed the problem. How can you expect me to work in a situation like this?”
In response, Harry asked, “How did you get by before you had all of this electronic monitoring stuff?”
“Same way you did before your fancy computer guidance stuff was available. I doubt you would want to go back to the old days of guessing where you were in the brain.”
The conversation ended when Harry held out his hand and the nurse placed the pencil-like brain trocar in it. Indenting the dura matter with the point of the trocar, Harry looked up at the monitor. He adjusted his angle slightly to correspond with the guideline displayed on the monitor, which displayed a three-dimensional adaptation of the patient’s brain. With slightly more force, Harry pushed the trocar through the brain’s covering and into the brain substance of the right frontal lobe. Everyone in the operating room but Harry shivered a little as the trocar penetrated into the brain. Harry advanced the trocar about three inches before the computer monitor indicated he had entered the lateral ventricle. The collar of the trocar sheath was secured to the surgical halo and Harry removed the center shaft. The clear brain fluid began to flow out of the hollow tube. Harry controlled the fluid by simply putting his thumb over the open port. He said simply, “Scope.”
Harry passed the flexible scope into the lateral ventricle. The video monitor shared his view with everyone in the room. The ventricle wall was smooth and shiny with the blood vessels obvious along the surface. Harry operated the controls like a fancy video game, advancing the scope into a short tunnel, the interventricular foramen. Once into the third ventricle, Harry continued his dissent into a much longer interconnection, the cerebral aqueduct. The scope was able to descend to the base of the brain through this passage only because it was dilated from the increased pressure. When Harry’s view changed from the narrow aqueduct to the more open space of the fourth ventricle, the large cyst was evident. Advancing the tip of the scope slowly, several smaller cysts could be seen floating freely. Inside each cyst was a small structure, the cysticercus. When Harry advanced the scope next to one of the small cysts, he was sure the larva was still wiggling. He captured as many of the small cysts as he could using a small suction catheter.
The large cyst was much too large to simply aspirate up the catheter. Harry had to puncture the cyst and drain it before it could be removed. He passed the small grasping forceps through the narrow suction port of the scope and grabbed the cyst wall. He gradually withdrew the scope, dragging the cyst behind it. The brain fluid immediately began draining and the pressure on the brain began to recede.
Harry removed the scope with the large cyst dangling from the tip and held it up like a hunting trophy for everyone to see before placing the cyst in a specimen jar for the pathologist. Harry reinserted the scope and saw the dilated intraventricular foramen was already narrowing. He again maneuvered the scope down this passage to the floor of the third ventricle. He used a small catheter to make several punctures through the wall to create another drainage port to prevent a cyst from again blocking the natural drainage.
The hard part was now done. Harry removed the trocar sheath and began repairing the bone with a titanium mesh and dura patch. The anesthesiologist asked, “How often do you see these brain worms?”
Harry continued his work as he replied, “Once.”
“But, it looked like you knew what you were doing.”
“I read an article about it.”
“Geez, sure glad the patient didn’t know you hadn’t ever done this before.”
Harry laughed his big laugh and said, “Surgery is surgery. These brain worms are pretty interesting though. We had better start this guy on steroids. His brain is going to swell some.”
Harry finished sewing the deep layers together and then stapled the scalp closed before applying the head bandage. The circulating nurse asked him what she should do with the small cysts Harry had removed. Harry said, “Put a couple of them into a specimen tube for me so I can show them to the patient when he wakes up. The rest can go to pathology.”
The nurse very gingerly placed a couple of the cysts in a tube, checking several times to make sure the cap was sealed. They made her so squeamish, she could not help shuddering. She asked, “Are these things actually eating his brain?”
Harry answered, “I don’t think so.”
As Harry was about to leave the OR she said, “Here, don’t forget your friends,” and handed him the tube.
He laughed again before saying, “Thanks for your help. I’ll start writing orders and meet you in the ICU.”