I met Mr. Archer on the 7th floor around 9 AM on a forgettable day in May. He was basking in the morning sun at the window near the end of the hall, staring out onto Mitchell Field below. He reminded me of my grandfather; an aged farmer with gruff hands and a warm smile like morning coffee. Mr. Archer turned as I approached. He smiled and shook my hand the same as he had done the past three mornings. However, I hadn't come this morning to ask more probing questions about contact with cats and cattle, travel to the Southwest, or to check on his fevers- I came to find out how much he knew.
"It's leukemia," he said, with a twinge of grief in his eye. Apparently he knew a lot. "They told me last night." He forced a meek don't-you-worry-bout-me smile. I gently returned the smile through a frown. I had been working Mr. Archer up for possible infectious endocarditis. He had fevers without a clear source and some recent heart surgery, two minor Duke criteria. But he also had a peculiar rash that didn't fit the bill. A skin biopsy of his rash returned the night before- leukemia cutis. Probably from acute myeloid leukemia. Blood cancer.
It was not my place to inform Mr. Archer of his cancer, but I don't deny that I wanted the task. I had liked him instantly. An old-timer with a solid heart, nothing more and nothing less. I had spent time with him. Asked him about his crops and kids. He deserved to hear about his leukemia from someone familiar.
This medical jungle inspires strange desires and peculiar prayers from its inhabitants. As a prime example, I have never wished so badly that a man had endocarditis.
Sunday, May 27, 2012
Saturday, May 19, 2012
Malaria Man
ID consults this month. The other day my fellow threw me a new patient- "middle aged HIV+ guy in the Obs unit with 5 days of fever and malaise: go check it out." Needless to say the differential diagnosis for this guy could stretch from here to the Indian subcontinent. I scouted out his records, checking his last CD4 counts and viral loads. Lingering in a healthy range and undetectable, respectively. I reviewed his admit and ED notes- some nausea (an equally nonspecific symptom), fever of 104, maybe a day of upset stomach. Nothing to grasp onto too tightly.
Then the story got strange. This guy was an academic, and as such he had traveled in recent years to Thailand, Myanmar (or Burma depending on your political persuasion) and remote regions of the aforementioned Indian subcontinent. He was a bit of an eccentric guy (I already told you he's an academic, right?) and had apparently eaten some pickled chinese mustard root and pork pot stickers earlier in the weak. What in the name of Buddha is pickled chinese mustard root, you ask? I have no idea, and apparently neither do the medical databases I searched in my over the top efforts to piece this dude together.
Then I stumbled on it: eosinophilia. The guy had two CBCs showing eosinophils in the 26-28% range, grossly elevated (should be around 3-5% or so). Eosinophilia occurs in a few different scenarios, specifically:
1. Helminth infections (worms for the lay folk out there- we're talking blood flukes, hookworms, roundworms, etc.)
2. Fungal infections (your basic aspergillosis, coccidiomycosis, histoplasmosis, etc.- these can get real nasty, especially in an immunocompromised HIV+ guy).
3. Allergic reactions- (nuff said).
4. Eosinophilia syndromes (these are some oddball conglomerations of symptoms that constitute things like the infamous Churgg-Strauss syndrome)
The fact that his eosinophils were so elevated gave me something to work with- it allowed me to narrow my differential and cater my interview to specific risk factors and exposures (like caves and bat guano for histoplasmosis, for example). But wait! What's that there? Another CBC? A CBC WITHOUT eosinophilia (2%)? Why are there two auto differentials showing elevations and one manual diff showing normal levels????
I phoned up the hematology lab, inquiring about the discrepancy. No explanation. The slides had been reviewed and the counts confirmed, but it made no sense. The nice lab tech on the phone offered to review the slides personally. Perfect. I marched off to the obs unit to interview the guy.
Halfway through the interview I get a call from the lab.
Lab: Is there anyway this guy could have malaria?
Me: Uhhhhh......yeah, actually, there is.
Lab: Good, because he has malaria.
Plasmodium vivax had been lying dormant in his liver for at least 9 months. He had no idea. The lab had missed it completely on three different CBCs that they allegedly reviewed. Had I not called about the eosinophilia discrepancy he would have likely remained undiagnosed for a long long time. As it is, he'll take some chloroquine for 3 days and primaquine for 2 weeks. That's it.
Malaria. Best day of med school yet.
Then the story got strange. This guy was an academic, and as such he had traveled in recent years to Thailand, Myanmar (or Burma depending on your political persuasion) and remote regions of the aforementioned Indian subcontinent. He was a bit of an eccentric guy (I already told you he's an academic, right?) and had apparently eaten some pickled chinese mustard root and pork pot stickers earlier in the weak. What in the name of Buddha is pickled chinese mustard root, you ask? I have no idea, and apparently neither do the medical databases I searched in my over the top efforts to piece this dude together.
Then I stumbled on it: eosinophilia. The guy had two CBCs showing eosinophils in the 26-28% range, grossly elevated (should be around 3-5% or so). Eosinophilia occurs in a few different scenarios, specifically:
1. Helminth infections (worms for the lay folk out there- we're talking blood flukes, hookworms, roundworms, etc.)
2. Fungal infections (your basic aspergillosis, coccidiomycosis, histoplasmosis, etc.- these can get real nasty, especially in an immunocompromised HIV+ guy).
3. Allergic reactions- (nuff said).
4. Eosinophilia syndromes (these are some oddball conglomerations of symptoms that constitute things like the infamous Churgg-Strauss syndrome)
The fact that his eosinophils were so elevated gave me something to work with- it allowed me to narrow my differential and cater my interview to specific risk factors and exposures (like caves and bat guano for histoplasmosis, for example). But wait! What's that there? Another CBC? A CBC WITHOUT eosinophilia (2%)? Why are there two auto differentials showing elevations and one manual diff showing normal levels????
I phoned up the hematology lab, inquiring about the discrepancy. No explanation. The slides had been reviewed and the counts confirmed, but it made no sense. The nice lab tech on the phone offered to review the slides personally. Perfect. I marched off to the obs unit to interview the guy.
Halfway through the interview I get a call from the lab.
Lab: Is there anyway this guy could have malaria?
Me: Uhhhhh......yeah, actually, there is.
Lab: Good, because he has malaria.
Plasmodium vivax had been lying dormant in his liver for at least 9 months. He had no idea. The lab had missed it completely on three different CBCs that they allegedly reviewed. Had I not called about the eosinophilia discrepancy he would have likely remained undiagnosed for a long long time. As it is, he'll take some chloroquine for 3 days and primaquine for 2 weeks. That's it.
Malaria. Best day of med school yet.
Detroit Delight Ride
O'leary, Mack, and I leisurely cruised Detroit one fine day. Here's a glimpse.
 |
| O'leary in the lead. |
Atwater Brewery for an IPA.
O'leary and Mack with a storm a brewin'
Waterfront ride.
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