Was This a Recurrence of Non-Hodgkin’s Lymphoma or One thing 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 clergymen. He gripped the handrail on both facet 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 capable of sleep in any respect. Now all he needed 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 crimson and glossy with sweat. The crimson continued down his chest and onto his stomach. His complete physique ached. He crawled gratefully beneath his covers. What he actually wanted was a great evening’s sleep, he advised himself. However as sleep continued to elude him, he immediately felt chilly. He shivered uncontrollably. The shaking chills confirmed what he already suspected: He was sick. And that anxious him.

Six years earlier he felt this dangerous after a flight. He went to the hospital and was identified with non-Hodgkin’s lymphoma. Therapy had been brutal. The seven months of chemotherapy killed the most cancers but additionally destroyed his physique’s capacity to make any blood for himself. He was rescued with stem cells — the cells that create the blood he wanted — harvested from his personal physique earlier than he began the therapy. He had been disease-free since then however knew that recurrence was doable. It was a low-level nervousness he confronted with each subsequent symptom. Earlier than 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 advantage the decision. “Go to the emergency room,” the physician advised him after listening to of his journey and fever, rash and whole-body weak spot. “You could be seen.”

Hassle Carrying His Suitcase

One in every of his housemates drove him to the emergency division at Beth Israel Deaconess Medical Heart. It was darkish exterior by the point he handed by way of the busy E.D. and right into a room within the hospital. He repeated his story a half-dozen instances to varied 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 capable of relaxation.

Dr. Martin Kaminski was the hospitalist on the evening shift. He launched himself and requested the affected person to inform his story, listening as the person described his journey, his weak spot, 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 just 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 town or go for hikes in wooded areas? Had he been in touch with any home or cattle? No, he was too busy to go away the resort the place the convention was held.

Kaminski requested if he had any physique aches. He did. And earlier, his proper hand felt achy and somewhat weak. He had hassle carrying his suitcase. On the trip residence, his neck felt unusually weak, as if his head had immediately gotten a lot heavier. His neck nonetheless felt sore and stiff. The physician requested him if he might put his chin on his chest. A stiff neck might recommend meningitis. However the affected person demonstrated that he might. He was anxious, the priest advised Kaminski. He had felt this sick solely as soon as in his life — and that point was identified with lymphoma. Might it have come again? Within the E.D., the hematology-oncology group 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. However they’d know extra after the CT scan.

A Chunk on His Ankle?

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 crimson 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 sort of irritation within the pores and skin fairly than blood leaking from the vessels under it. There was a young crimson nodule on his ankle — probably a chunk. In any other case, his examination was unremarkable. The lymph nodes in his neck and groin and people underneath his arms weren’t enlarged. If he had lymphoma, it wasn’t apparent. An infection was nonetheless the most probably reason behind his distress.

In line with the Facilities for Illness Management and Prevention, the physician advised the priest, there was an outbreak of chikungunya fever — a viral an infection unfold by mosquitoes — in Paraguay. And a lot 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 and even years after the an infection is gone.

In fact, there have been different potentialities, Kaminski added. It may very well be dengue, one other viral illness — unfold by the identical mosquito. Dengue could cause excessive fevers and physique aches so extreme the sickness is named breakbone fever. And it may be lethal. Whereas sufferers contaminated the primary time are sometimes simply depressing, these unfortunate sufficient to catch it a second time are liable to growing a hemorrhagic model of the an infection. Every an infection is widespread all through South America. Every 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. One other chance was that it was one thing he caught earlier than he left his residence within the Northeast. Possibly some tick-borne illness — like Lyme or anaplasmosis. They need to have the reply throughout the week.

Lingering Aches and Fatigue

The affected person felt higher by the following day and was wanting to go residence. The fever and weak spot had been gone, and the rash was fading. Solely the achiness remained. His medical doctors nonetheless weren’t certain what he had. The one factor identified at that time was that this was not a recurrence of his lymphoma. The CT scan confirmed a few enlarged lymph nodes in his chest, however the radiologist thought these had been most in step with an an infection. The scans of his stomach and pelvis, the place his unique most cancers had been positioned, appeared high quality.

Within the days after the priest’s discharge, Kaminski watched because the check outcomes got here again. The check for chikungunya was damaging. So was the check for dengue. It wasn’t any of the opposite ailments 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 physique aches held on. His head felt cloudy; even studying was exhausting. Over the next weeks he felt higher, however not nicely. He went to see Zuromskis and described his persistent malaise. What else might this be? Zuromskis smiled. He was assured this was chikungunya. However the check was damaging, the affected person reminded him. “That check was damaging then,” he replied. If he repeated the check now, the physician felt sure it will be optimistic.

These 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 primary an infection, it will take days for the physique to gear up and create the bespoke antibodies, tailor-made to this particular invader. It might need been damaging whereas he was within the hospital, however Zuromskis was certain it wouldn’t be damaging now. He despatched the exams for the suspected viruses. The outcomes got here again just a few days later. Just 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 capable of 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 wholesome man.

Lisa Sanders, M.D., is a contributing author for the journal. Her newest guide is “Analysis:Fixing the Most Baffling Medical Mysteries.” You probably have a solved case to share, write her atLisa.Sandersmdnyt@gmail.com.