Mystified by her head problems

One crisp morning during the fall of 2011, a 52-year-old operating-room nurse in Collegeville was walking her shih tzu when a neighbor's dog attacked them. The woman was pulled off her feet and slammed to the ground. She recalls hearing a kind of ringing sound but did not lose consciousness.

She texted her husband about the dustup, finished walking the dog, and went about the rest of her day, thinking that she had escaped injury.

In the coming weeks, however, she began having headaches, heard ringing in her ears and grew sensitive to light and noise. Her sense of smell was off, she had trouble focusing on tasks and felt dizzy, tired, disoriented, and moody.

After a month, when the symptoms persisted, she went to see her family doctor who ordered a CT scan of her head.

He told her that her sinuses were blocked and referred her to an ear, nose, and throat specialist, who prescribed antibiotics and nasal spray.

The medicines brought no relief. She felt sick to her stomach all the time, developed night sweats, became anxious, and felt her heart racing. Her blood pressure went up. In December, wondering if she might have a viral infection in her inner ear, the ENT doctor gave her a balance test.

She was diagnosed with left vestibular neuritis and treated with steroids.

Her condition only worsened. One night that winter, when she felt so ill she could not drive home from work, her father-in-law took her to the emergency room.

The doctors could not identify any physical source of the problem and told her she was probably having an anxiety attack.

She tried to return to work, but could not think clearly enough to take care of her patients. She had trouble finding words, she could not focus on any one task, her eyes moved of their own accord, and her head ached so ruthlessly, she said, "any noise felt like metal grinding in my brain."

One doctor told her she was merely sleep-deprived. Another suggested a complex drug cocktail that she declined to take.

Her family doctor ran through the list of possibilities. Could she have Lyme disease? Had she suffered a mild stroke? Was she showing early signs of multiple sclerosis?

He ordered more tests. MRIs. CT scans. Blood work. Neurological exams.

She was told that the results all appeared normal.

In January, at church, she ran into a woman who works as a physical therapist.

During their conversation, she mentioned her symptoms.

"Are you sure you didn't fall?" the woman asked, then suggested she go to see a neurologist.

Mijail Serruya, medical codirector of the Jefferson Comprehensive Concussion Center, told her she probably had a concussion, and asked, "Do you remember falling recently?"

She did not.

This made a definitive diagnosis difficult.

Her complaints were consistent with a concussion. Her diminished sense of smell, for example, suggested injury to the olfactory nerve, which stretches through a bone at the top of the nose and is prone to injury with head trauma.

Most people think you must pass out to have a concussion, but Serruya explained that one good thunk can be enough to cause one.

Usually, the neurologist said, patients notice changes in their mood, memory, balance, or sensory perceptions immediately. And usually, he said, if it was a mild concussion, the problems resolve on their own within a few weeks.

Sometimes however, there is a delayed onset, and even a minor brain injury can have long-lasting consequences.

Because there are no neat and clear biological markers and tests to identify a concussion, her neurologist told her, the most important diagnostic tool is the patient's history. But because concussions can cause memory loss, the patient may have no recollection of head trauma.

Serruya referred her for vestibular therapy, a kind of physical therapy designed for inner-ear problems.

Soon after, the patient recalled the dog attack. She looked back through the text messages on her cellphone.

There, she found the answer.

The morning of the dog incident, she had texted her husband, telling him she had fallen down.

While she continued with vestibular therapy, she was treated with an antidepressant and given melatonin to help her sleep.

Although she continues to have problems with balance, she has been able to return to work, although not in her full capacity in the operating room. Instead, she does triage intake.

"I'm still not 100 percent sure what happened," the doctor said. "There was some dog craziness and she was pulled off her feet, but without a witness no one can know."

And the shih tzu's not talking.