Was This a Recurrence of Non-Hodgkin’s Lymphoma or Something Else?

The 57-year-old man appeared up the lengthy staircase that led to his rooms within the rectory, the residence he shared with three different monks. He gripped the handrail on both aspect of the steps and compelled his foot onto step one. Slowly he pulled himself up the 2 flights of stairs to his rooms. His journey residence to Boston from a convention in Asunción, Paraguay, had been tough. It was an in a single day journey, however he hadn’t been in a position to sleep in any respect. Now all he wished to do was take off his Roman collar and lie down.

When he lastly made it to his rooms, he appeared into his toilet mirror. His face was brilliant pink and glossy with sweat. The pink continued down his chest and onto his stomach. His complete body ached. He crawled gratefully beneath his covers. What he actually wanted was a good night time’s sleep, he advised himself. But as sleep continued to elude him, he out of the blue felt chilly. He shivered uncontrollably. The shaking chills confirmed what he already suspected: He was sick. And that nervous him.

Six years earlier he felt this unhealthy after a flight. He went to the hospital and was recognized with non-Hodgkin’s lymphoma. Treatment had been brutal. The seven months of chemotherapy killed the most cancers but in addition destroyed his body’s skill to make any blood for himself. He was rescued with stem cells — the cells that create the blood he wanted — harvested from his personal body earlier than he started the remedy. He had been disease-free since then however knew that recurrence was doable. It was a low-level anxiousness he confronted with each subsequent symptom. Before the most cancers, he might need simply toughed it out. Not now.

He referred to as Dr. Peter Zuromskis, his longtime major care doctor. He hated to hassle him on a Saturday, however he thought this was necessary sufficient to benefit the decision. “Go to the emergency room,” the physician advised him after listening to of his journey and fever, rash and whole-body weak point. “You need to be seen.”

One of his housemates drove him to the emergency division at Beth Israel Deaconess Medical Center. It was darkish exterior by the point he handed by the busy E.D. and into a room within the hospital. He repeated his story a half-dozen instances to numerous medical doctors, nurses and trainees as he was poked, prodded, caught and imaged for hours. The priest was grateful for the quiet of the small room the place he was lastly in a position to relaxation.

Dr. Martin Kaminski was the hospitalist on the night time shift. He launched himself and asked the affected person to inform his story, listening as the person described his journey, his weak point, his rash, his fever. His temperature was 102 when he arrived on the hospital however had come down with acetaminophen and IV fluids. When the affected person acquired to the tip, Kaminski had a few extra questions. Had he used insect repellent whereas in South America? No, the priest recalled. A fellow priest gave him a wristband that was supposed to maintain the mosquitoes away. He hadn’t felt any bites whereas there. He drank solely bottled water, he added. Did he depart the town or go for hikes in wooded areas? Had he been involved with any home or livestock? No, he was too busy to depart the lodge the place the convention was held.

Kaminski asked if he had any body aches. He did. And earlier, his proper hand felt achy and a little weak. He had hassle carrying his suitcase. On the trip residence, his neck felt surprisingly weak, as if his head had out of the blue gotten a lot heavier. His neck nonetheless felt sore and stiff. The physician asked him if he may put his chin on his chest. A stiff neck may counsel meningitis. But the affected person demonstrated that he may. He was nervous, the priest advised Kaminski. He had felt this sick solely as soon as in his life — and that point was recognized with lymphoma. Could it have come again? In the E.D., the hematology-oncology crew really useful a CT scan of his chest, stomach and pelvis, however he hadn’t had it but. Kaminski advised the anxious man that he thought an an infection was more likely than most cancers. But they’d know extra after the CT scan.

As he examined the priest, Kaminski famous that his rash was on his again and arms in addition to his chest. It appeared like a sunburn, and the pink pores and skin paled to near-white when Kaminski pressed his finger into the bright-colored pores and skin on his chest, indicating that it was some type of irritation within the pores and skin moderately than blood leaking from the vessels under it. There was a tender pink nodule on his ankle — presumably a chew. Otherwise, his examination was unremarkable. The lymph nodes in his neck and groin and people below his arms weren’t enlarged. If he had lymphoma, it wasn’t apparent. Infection was nonetheless the almost certainly trigger of his distress.

According to the Centers for Disease Control and Prevention, the physician advised the priest, there was an outbreak of chikungunya fever — a viral an infection unfold by mosquitoes — in Paraguay. And most of the circumstances had been reported the place he’d been, in Asunción. The illness often isn’t deadly however could cause an arthritis that may final months or even years after the an infection is gone.

Of course, there have been different potentialities, Kaminski added. It might be dengue, one other viral illness — unfold by the identical mosquito. Dengue could cause high fevers and body aches so extreme the sickness is named breakbone fever. And it may be lethal. While sufferers contaminated the primary time are sometimes simply depressing, these unfortunate sufficient to catch it a second time are in danger of growing a hemorrhagic model of the an infection. Each an infection is widespread all through South America. Each is a virus, unfold by the identical mosquito. Chikungunya is legendary for its abrupt onset and quick incubation interval, and in order that was first on his checklist. Another chance was that it was one thing he caught earlier than he left his residence within the Northeast. Maybe some tick-borne illness — like Lyme or anaplasmosis. They ought to have the reply throughout the week.

The affected person felt higher by the subsequent day and was desperate to go residence. The fever and weak point have been gone, and the rash was fading. Only the achiness remained. His medical doctors nonetheless weren’t certain what he had. The solely factor recognized at that time was that this was not a recurrence of his lymphoma. The CT scan confirmed a couple of enlarged lymph nodes in his chest, however the radiologist thought these have been most in line with an an infection. The scans of his stomach and pelvis, the place his unique most cancers had been positioned, appeared fantastic.

In the times after the priest’s discharge, Kaminski watched because the check outcomes got here again. The check for chikungunya was adverse. So was the check for dengue. It wasn’t any of the opposite illnesses that he and the infectious-disease medical doctors had appeared for.

As for the affected person, though the fever was gone by the point he left the hospital, the fatigue and body aches held on. His head felt cloudy; even studying was exhausting. Over the next weeks he felt higher, however not effectively. He went to see Zuromskis and described his persistent malaise. What else may this be? Zuromskis smiled. He was assured this was chikungunya. But the check was adverse, the affected person reminded him. “That test was negative then,” he replied. If he repeated the check now, the physician felt sure it will be optimistic.

Those first outcomes confirmed the priest’s immune response to every of the infections they appeared for. If he had ever been uncovered to that bug earlier than, the check in search of the antibody would learn optimistic instantly; the template to combat off that bug would have already been made by his immune system and saved away. If, as a substitute, this was a first an infection, it will take days for the body to gear up and create the bespoke antibodies, tailor-made to this particular invader. It might need been adverse whereas he was within the hospital, however Zuromskis was certain it wouldn’t be adverse now. He despatched the exams for the suspected viruses. The outcomes got here again a few days later. Only one was optimistic. Very optimistic. He had chikungunya fever.

The journey to Paraguay was eight months in the past. Full restoration was sluggish. The stiffness and joint pains lasted for months. It’s solely just lately that he has been in a position to tackle the steps along with his previous vigor and pace. And but, regardless of the an infection and his historical past of most cancers, he’s, he tells me, a healthy man.

Lisa Sanders, M.D., is a contributing author for the journal. Her newest ebook is “Diagnosis:Solving the Most Baffling Medical Mysteries.” If you have got a solved case to share, write her

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