An excerpt from Fifty Shades of Gray Matter.
He was Hitler. Not the evil Nazi dictator returned somehow from the Inferno to which he had been consigned. Apparently, as with the witches in Oz, there were both good and bad Hitlers. He informed me that he was, in fact, a good Hitler, having been unfortunately named for the infamous German monster. That a parent would name a child Hitler was both inexplicable and disturbing. However, it was not uncommon, so it appeared in his small village near Quito in Ecuador. Children there had been named not only Hitler but even Stalin and Mao. Clearly, name recognition took precedence over reputation.
His name never bothered him much. It mostly bothered other people wherever his ID was checked, at the airport, at the immigration office and even during his doctor visits. It was always greeted with stares and smirks and sardonic comments. But a name is a name, and not destiny. A Hitler is as likely to be good as an Angel, or Jesus is to be evil.
He was short, no more than five foot two with small, squinting eyes encircling a dark, wrinkled face and thin lips that smiled easily. He bore no resemblance to his namesake. He was, as well, a sweet soul who loved children and animals and had rescued several cats. The last one was a month ago, a skinny black kitten abandoned in a park on a small blanket.
It was early June of 2020, the year of the plague, and most primary doctors were only available on Zoom, a word not familiar to many patients. Hospitals were still overwhelmed with COVID admissions; everything else a secondary consideration.
His children did not want him to go to the ER for fear of contagion. My office had retained some sign of normalcy, but the COVID threat loomed over all. Hitler was sitting not so peacefully next to his wife Ninfa, a short woman with piercing black eyes, a dark complected face marked by deep lines, and an authoritative demeanor. But for the most part, she was showing fear and embarrassment. Both wore a black mask.
At 10 a.m., a few minutes after they had arrived, my office manager came running.
“There is a commotion. Mr. Hitler is making everybody uncomfortable. He’s flapping like a bird with a broken wing.”
“Yes, that is actually his name.”
“Put him in a room,” I replied.
When I finally saw him, his right arm was springing up and down in a fashion disturbingly like the Nazi salute. The motion was flailing and violent, seemingly uncontrollable, despite the efforts of his wife to physically restrain it with her two hands, at the risk of being struck. It was intermittent, unpredictable, and so dramatic that it almost looked hysterical.
Ninfa was frantic, her eyes teary.
“Hitler has been doing this for the last two weeks. Everybody, including his two sons, think he is suddenly going mad, maybe from the forced quarantine at home.”
I was skeptical.
“The COVID virus attacked his brain. He told me he can’t stop doing this, like a mysterious force is controlling him and moving his arm. He’s saluting like a Nazi, like bad Hitler took over his body. He’s only quiet at night in his sleep.”
I knew that they were unsuccessfully trying to contact a psychiatrist. Most mental health providers were barricaded in their homes, sometimes out of state, their phones disconnected or unanswered. Others were not accepting new patients.
The primary doctor on the phone told them that it was probably stress but had never heard of such a thing. He sent them to me since my office was open even though at a reduced capacity.
Hitler apparently had suffered a blood disorder when he was younger but was otherwise in good health, except for some mild fever, fatigue, and swollen lymph nodes for the last month. Those symptoms had been attributed to the COVID virus and treated with azithromycin empirically. It worked somewhat and he felt a little better. But this strange and embarrassing bodily motion was making his life a living Hell.
I was unconvinced of any COVID connection, and thought that it could be a rare movement disorder that I had seen only once during my training.
A movement so dramatic, violent, and unpredictable was impossible to miss. My suspected diagnosis was “hemiballism,” from the Greek “hemi,” meaning half, and “ballism,” meaning jumping. (I loved Greek and the array of medical words derived from its roots.)
I knew that in his age group the cause was usually a stroke, but I was in for a surprise.
“Ninfa,” I said, “we need a brain MRI as soon as possible. I think there is a reason for this odd behavior, and certainly he is not responsible for it.”
Her eyes fluttered and her lips formed a timid smile. I gave him an antipsychotic plus valium to sedate him and decrease the movements. Miraculously I was able to get a brain MRI the same day, despite the paucity of medical personnel created by the availability of unemployment and stimulus benefits. At 6 p.m. the radiologist called. Hitler was still on the table and needed a contrast injection. At 9 p.m. he called back.
“There is a lesion that looks like an infection, a mass lesion in the area of the left basal ganglia.”
A lesion? Suddenly, the light went on. I called Hitler and Ninfa. He needed immediate hospitalization. They wanted to wait until morning, and at 6 a.m. he promptly went to a major hospital with my referral and the radiologist report.
He was admitted the same day. The cause was acute toxoplasmosis, an unusual but not unheard-of cause of hemiballism. I remember Ninfa saying how Hitler rescued stray cats.
It appeared that the little black fur rescued a month ago was the cause of his misery.
A feral cat harboring the toxoplasma and shedding their cyst in the cat litter. The kitten had perhaps eaten infected rodents or birds while in the park. Hitler must have unwittingly ingested the parasites by touching his mouth with soiled hands after cleaning the cat litter.
He was immediately started on medications after his blood work showed a rising antibody titer.
Ninfa gave very precise instructions to his son. The little black kitten initially called “El Prince,” since rechristened “El Toxo,” was sent together with his littermates to an animal shelter.
Hitler was saddened but understood that there could be no more contact with cats regardless. He recovered completely and after one month the lesion was barely visible.
His flapping Nazi salute disappeared, but he decided to keep his name. After being named Hitler, and having his path crossed by a black cat, he was due for a change in his luck.
“The neurology of Hitler”
Toxoplasmosis is a parasitic infection caused by the Toxoplasma gondii. Cat feces and undercooked meat (particularly pork, lamb, and venison) as well as contaminated water can harbor the parasite. This infection can also cause severe birth defects when transmitted from the mother to the fetus (pregnant women should not clean cat litter). Most people are asymptomatic or show only mild symptoms, such as fever, swollen lymph nodes, or headache that resolve within one month.
Cerebral toxoplasmosis that can produce cerebral abscesses is more common in patients who are immunosuppressed, from HIV/AIDS, chemotherapy, or immunosuppressive agents.
It has predilection for the basal ganglia, an area of the brain that controls posture and movement. Lesions of the basal ganglia are the cause of movement disorders such as Parkinson’s disease, chorea, etc. In particular, lesion of subthalamic nucleus is responsible for contralateral hemiballismus, a sudden paroxysmal large amplitude throwing movement.