Was it a recurrence of non-Hodgkin lymphoma or something else?

Was it a recurrence of non-Hodgkin lymphoma or something else?

The 57-year-old looked up the long staircase that led to his rooms at the rectory, the residence he shared with three other priests. He grabbed the banister on either side of the stairs and forced his foot up onto the first step. Slowly, he climbed the two flights of stairs to his rooms. His trip back to Boston from a conference in Asunción, Paraguay, had been difficult. It was an overnight trip, but he hadn’t managed to sleep at all. All he had to do was take off his Roman collar and lie down.

When he finally got to his room, he looked in his bathroom mirror. His face was bright red and shiny with sweat. The red continued on his chest and stomach. His whole body hurt. He gratefully crawled under his covers. What he really needed was a good night’s sleep, he told himself. But as sleep continued to elude him, he suddenly felt cold. He shivered uncontrollably. The trembling shivers confirmed what he already suspected: he was sick. And that worried him.

Six years ago, he felt so bad after a flight. He went to the hospital and was diagnosed with non-Hodgkin’s lymphoma. The treatment had been brutal. The seven months of chemotherapy killed the cancer but also destroyed his body’s ability to produce blood for itself. He was saved thanks to stem cells – the cells that create the blood he needed – taken from his own body before starting treatment. Since then, he had not had any more illnesses, but he knew that a recurrence was possible. It was low-level anxiety that he faced with each subsequent symptom. Before the cancer, he might have just toughened up. Not now.

He called Dr. Peter Zuromskis, his longtime primary care physician. He hated to bother him on a Saturday, but he thought it was important enough to merit the call. “Go to the emergency room,” the doctor told him after hearing about his trip and his fever, rash, and weakness throughout his body. “You must be seen.”

One of his roommates drove him to the emergency room at Beth Israel Deaconess Medical Center. It was dark outside by the time he walked through the busy emergency room and into a hospital room. He repeated his story half a dozen times to various doctors, nurses and interns while he was poked, prodded, squeezed and photographed for hours. The priest was grateful for the calm of the small room where he could finally rest.

Dr. Martin Kaminski was the hospitalist on the night shift. He introduces himself and asks the patient to tell his story, listening to the man describe his journey, his weakness, his rash, his fever. Her temperature was 102 when she arrived at the hospital, but she was brought down with acetaminophen and IV fluids. When the patient reached the end, Kaminski had a few more questions. Had he used insect repellent in South America? No, the priest remembers. A fellow priest gave him a bracelet said to ward off mosquitoes. He had not felt any bites during his stay. He only drank bottled water, he added. Did he leave town or hike in wooded areas? Had he been in contact with domestic or farm animals? No, he was too busy to leave the hotel where the conference was being held.

Kaminski asked if he had any aches. He did. And earlier, his right hand was sore and a little weak. He had difficulty carrying his suitcase. On the way back, his neck felt strangely weak, as if his head had suddenly become much heavier. His neck was still sore and stiff. The doctor asked him if he could rest his chin on his chest. A stiff neck could suggest meningitis. But the patient demonstrated that he was capable of it. He was worried, the priest told Kaminski. He had only felt this way once in his life – and that time, he had been diagnosed with lymphoma. Could it have come back? In the emergency room, the hematology-oncology team recommended a CT scan of his chest, abdomen and pelvis, but he hadn’t had one yet. Kaminsky told the anxious man that he thought an infection was much more likely than cancer. But they would know more after the scan.

While examining the priest, Kaminski noticed that his rashes were on his back, arms as well as his chest. It looked like a sunburn, and the red skin paled to almost white when Kaminsky pressed his finger to the brightly colored skin on his chest, indicating that it was some sort of inflammation of the skin rather than blood leaking from the vessels underneath. . There was a tender red nodule on his ankle – possibly a bite. Otherwise, his exam was unremarkable. The lymph nodes in his neck and groin, as well as those under his arms, were not enlarged. If he had lymphoma, it wasn’t obvious. Infection remained the most likely cause of his misfortune.

According to the Centers for Disease Control and Prevention, the doctor told the priest that there was an outbreak of chikungunya fever — a viral infection spread by mosquitoes — in Paraguay. And most of the cases had been reported where he was, in Asunción. The disease is not usually fatal but can cause arthritis that can last for months or even years after the infection has gone.

Of course, there are other possibilities, Kaminski added. It could be dengue, another viral disease transmitted by the same mosquito. Dengue fever can cause high fever and body aches so severe that the illness is called broken fever. And it can be deadly. While patients infected the first time are often just plain unhappy, those unlucky enough to catch it a second time risk developing a hemorrhagic version of the infection. Each infection is common throughout South America. Each is a virus spread by the same mosquito. Chikungunya is famous for its sudden onset and short incubation period, and so this was first on his list. Another possibility was that it was something he caught before leaving his home in the Northeast. Perhaps a tick-borne illness, like Lyme or anaplasmosis. They should have the answer within a week.

The patient felt better the next day and was eager to go home. The fever and weakness were gone and the rash was fading. Only pain remained. His doctors still didn’t know what was wrong with him. The only thing known at that time was that it was not a recurrence of his lymphoma. The scan showed some enlarged lymph nodes in his chest, but the radiologist thought these were more consistent with an infection. Scans of his abdomen and pelvis, where his original cancer was, looked good.

In the days after the priest’s release, Kaminski saw the test results come back. The chikungunya test was negative. The dengue test too. It wasn’t any of the other illnesses he and the infectious disease doctors had been looking for.

As for the patient, even though the fever had disappeared when he left the hospital, the fatigue and aches persisted. His head was cloudy; even reading was difficult. Over the next few weeks he felt better, but not well. He went to see Zuromskis and described his persistent discomfort. What else could it be? Zuromskis smiles. He was convinced it was chikungunya. But the test came back negative, the patient reminded him. “That test was negative then,” he replied. If he repeated the test now, the doctor was sure it would be positive.

These first results showed the priest’s immune response to each of the infections sought. If he had already been exposed to this virus before, the test for the antibody would immediately be positive; the blueprint for fighting this bug would have already been created by its immune system and stored. If it were instead a first infection, it would take days for the body to prepare and create tailor-made antibodies, adapted to this specific invader. It might have been negative while he was in the hospital, but Zuromskis was sure it wouldn’t be negative now. He sent the tests for suspected viruses. The results came back a few days later. Only one was positive. Very positive. He had chikungunya fever.

The trip to Paraguay was eight months ago. Full recovery was slow. The joint stiffness and pain lasted for months. It was only recently that he was able to climb the stairs with his former vigor and speed. And yet, despite the infection and his history of cancer, he is, he tells me, a healthy man.

Lisa Sanders, MD, is a contributing editor to the magazine. His latest book is “Diagnosis: Solving the Most Confusing Medical Mysteries.” If you have a solved case to share, email Lisa.Sandersmdnyt@gmail.com.

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Eric D. Eilerman

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