The viral fever that left 32-year-old Mumbai man in coma

The doctors performed decompressive craniectomy on Vaz, after a viral infection, in a bizarre development, lands him in comatose state

In December, when 32-year-old banker Keegan Vaz developed a fever along with a cough and cold, he did, what any of us would do. He went to a local chemist, got some over-the-counter medicines and popped the pills, maintaining the week-long course. He even recovered. Until late November, when he started getting headaches.

By December first week, his condition started deteriorating and Vaz started having a severe headache. A banker, he took a break from work and stayed at this Malad home with his uncle. But resting and more over-the-counter medicines didn't help. When he became increasingly weak, his friends then took to a primary health care centre.

Dr Vivek Agrawal, consultant brain, spine and interventional neurosurgeon at Sir HN Reliance Foundation Hospital, explains the procedure

The doctors there, on a quick check-up, asked his friends - by now Vaz had fainted - to take him to a multi-specialty hospital. At Girgaum's Sir HN Reliance Foundation Hospital, the doctors conducted an MRI on him - by now they had deduced that Vaz had slipped into coma - and diagnosed that he was suffering from Acute Disseminated Encephalomyelitis (ADEM) - an autoimmune disorder in which the body's immune system attacks its own brain tissue.

Dr Vivek Agrawal, consultant brain, spine and interventional neurosurgeon at the department of neurosurgery at the hospital, says, "While the immune system is meant to fight infections, in Vaz's case, the antibodies start working against him. This affects the nervous system and brain, which sends patients into coma."

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Keegan Vaz with his brother Kevin in May. Doctors say it took two months post the cutting of the skull for the brain to return to its normal size

The infection led to Vaz's brain swelling up compressing the skull from inside. A rare case in medicine. The doctors had to cut out sections of the skull to accommodate the brain. In fact, his doctors have now sent his case and the treatment as a study to an American journal. They are still awaiting a response from them.

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Line of treatment

Discharged in May, Vaz is now back to normal. But at the peak of his illness, his brain was functioning at a mere 5 percent of its total capacity say doctors. He now says, "I had a severe headache which turned more severe with every passing day. I just remember when I was taken to the hospital and the next thing I remembered was when I saw my brother sitting beside me, but I couldn't respond to him. Even though, I tried to talk, I couldn't, which scared me off and the feeling was indescribable."

While his parents, who live in Goa, rushed to Mumbai the same day, his brother Kevin had to fly in from Dubai. The sight at the hospital left him with little hope. "His body shutting down gradually. After the doctor saw the MRI, we felt there was no hope left. We were all in shock. We never thought he would come back home safely one day," says the brother.

In such cases, there are usually two options. Plasmapheresis is a process that filters the blood and removes harmful antibodies, much like dialysis. The other option would have been to introduce steroids in Vaz's system, which would compress the antibodies. But Vaz, say doctors, didn't respond to either of the procedures. This is when they decided to perform a decompressive craniotomy (see box) in which a piece of the skull bone is removed.

"His brain had swollen so much that it was causing the pressure inside the skull to increase. Thus, we decided to cut off two parts of the skull to help the brain expand. It was only after two months, that the swollen brain started shrinking," says Dr. Arun B Shah, a consultant neurologist and mentor at the department of neurosciences at the hospital.

By now, a one-centimeter layer of skin had formed in the area of the missing skull. Later, when Vaz's condition improved, in May, the doctors replaced the skull pieces with hocks and screws. A surgery that's done in cases of head injury or strokes, helped Vaz beat death. Yet, there are less than 10 case reports available in English medical literature across the world were this surgery was done in the case of ADEM, says Dr. Agrawal.

In April, the doctors won an award at the Emirates Critical Care Conference for the best 'Critical Care of Patients'. "People should be careful if suffering from weakness or dizziness during or after viral fever. They have a tendency to pop pills without consultation which can be life threatening," says Dr Darshana Rathod, consultant, critical care medicine from the hospital.

The surgery Vaz underwent

Decompressive cranie-ctomy is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke or other conditions associated with raised intracranial pressure. Studies show that the procedure lowers intracranial pressure (ICP), the pressure within the skull. Raised intracranial pressure is very often debilitating or fatal, as it causes compression of the brain and restricts cerebral blood flow.

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