I did wish she had meningoencephalitis. I really did. It was one of those young and beautiful girls you encounter sometimes. I’ll name her Andrea.

First in her class, smart, athletic, nice countenance, and had just finished school. She had just crossed the threshold to full adulthood and was in the beginning of her studies on engineering. In fact, she was attending the second week of class and making new friends at college. Then the issues appeared.

Her parents thought it was part of her well-acknowledged responsibility and accountability. “She always takes everything to its fullness,” they said. But some concerning sparks appeared. She started to be exceedingly “spiritual.” Although she was accustomed to prayer, going to church, helping the needy, and her parents reassured me that their daughter was very devout indeed, this time it was too much. So they started to worry. Her friends told me later that she had been “fine,” but sometimes said inexplicable things to them. “What kind of things?” I asked. “Well, sometimes she says… she says… she is God….” Wait a minute, things were getting darker, so apprehensions gave way to unconcealed concern and she was taken to see a psychiatrist. After 1 h he said to the parents that she had “an acute psychotic event, probably explained by the start of schizophrenia.”

They were devastated. They had another son with bipolar disease and now their princess was falling into the realm of those enigmatic diseases of the mind—diseases which make us stop and wonder whether they may be a psychiatrist’s invention, for many times symptoms are just a little step away from what is normal; but what is normality, by the way?

So she was admitted to the mental health facility of our hospital one Friday night. The psychiatrist found out something unsettling on Andrea’s medical history. She had suffered from herpetic lesions on her mouth 1 week before being admitted and had been taking acyclovir in high doses for 3 days and had a higher-than-normal white blood cell count. Smartly, she asked for non-psychiatric evaluation and admission to our intermediate unit. The hypothesis? She could be suffering from herpes simplex encephalitis.

Everything could be better than expected. There was some hope, but who is in need of hope? The patient? The family? The doctor?

Anyway, she could recover! And I took the unlikely prospect as mine. I acknowledge that the psychiatrist had primed me and I was very excited about this possibility. Perhaps we were facing a psychiatric-like disease. I could even publish it! Say, “Herpes simplex encephalitis as a differential diagnosis of schizophrenia: don’t forget the virus” or so. Therefore we performed cerebrospinal fluid (CSF) analyses, PCRs, and the like. As these events happened over the weekend, I met the patient on Monday morning with rather disappointing news: CSF was normal and HSV PCR was negative. All hope was lost and we had to face the unfairness of an overt psychiatric disease in a young lady.

As physicians, many times we want to turn around the inescapable course of the events. Somehow, someway, we get some hints that seem to endorse our innermost longings. Otherwise unintended happenings or smart and right colleagues’ opinions that, when thirsty for hope, we regard as providential.

Then, suddenly, I came up with an idea: Perhaps, the fact she was on acyclovir the week before of her admission could have caused the PCR results to appear negative and perhaps she had herpetic encephalitis, but our ability to diagnose it was reduced because of a previous use of an antiviral drug, and the clinical course of it was softened precisely because of a suboptimal treatment. Bingo! I talked immediately to the microbiology laboratory director and she informed me that effectively sometimes herpes PCR results are negative when previous and recent use of acyclovir is present. I did not pay attention to any warning she may have given me. That was what I needed to hear so I talked to Andrea’s parents and they agreed to give it a try: We would treat her with intravenous acyclovir and would expect her to recover from her psychotic burst and—perhaps—return no normal life and college in a couple of weeks.

She is not a schizophrenic girl, she just has encephalitis, and with the right treatment, at the right time….

Some days later she was transferred under acyclovir treatment to another hospital because of health insurance coverage issues. I submitted an epicrisis just stating that the patient had herpes meningoencephalitis with normal CSF due to a previous and recent use of acyclovir, and that we were pretty confident she would recover.

I was left with some sort of triumphant feeling; I told my colleagues that I had rescued a patient from the psychiatric ward; jokes went back and forth.

Four weeks later, reality abruptly returned. Our admission nurse, with a worried face, represented the executioner: “Did you hear about Andrea? She is back….” “Back? Where? In the ICU?” She softened her voice. “No… Andrea is back in the psychiatric ward.”

Time has passed and I am now pretty sure that I was totally wrong in many respects of my approach. Reality always stood in front of my eyes, but honestly I did and still wish that she had meningoencephalitis.

Ricardo Castro, MD MPH