“No signs of cancer cells? Seriously?” I asked. “No cancer?”
He looked at me sullenly, stone-faced. “I’m a pathologist. Seriously, there is no cancer.”
Up on the floor, I cracked open Leon’s chart and dug in. He’d received his first dose of antibiotics in the ER after a liter and a half of cloudy pleural fluid was aspirated from his chest, the abdominal fluid sampled, and blood and urine cultures collected. But he wasn’t responding. The fever curve on the nursing graphs showed a hectic graph with temperature spikes over 103. Nothing was growing out on culture. It was a familiar story.
Last-Ditch Efforts
When I cracked open the door to Leon’s room, it was clear he was dying. Shrunken into his bed, belly distended, the fingers of both hands were puffy and red. He’ll carry his unknown inflammatory arthritis to the grave, I thought. The continuous shhhhhing of a nonrebreathing mask gently filled the room like drifting snow. I stood at the head of the bed, painfully aware that Leon was about to join my list of patients who died of an unknown disease. I reached over and patted his wrist. I felt like I should apologize for failing him. It felt awkward. I wasn’t sure how deeply he was comatose, so I leaned over and whispered in his ear, “Keep fighting, Leon. Don’t let go.”
But I was not optimistic. I checked the chart. Pasted on the inside cover was his NO CODE request. Makes sense, I thought. He’d had enough. His nurse entered the room to adjust the IV antibiotic infusion rate. I asked her if she could call lab and have them draw a red-top tube for me and to spin it down. I pulled my 3×5 notebook from my shirt pocket and wrote, “Don’t forget to pick up Leon Woodle’s red-top tube.” It will join a dozen or so red-topped tubes in my office freezer, awaiting the day when a new case report draws my attention and I draw off an aliquot of fluid to run a newly developed test. Someday, I may know what Leon died of.
Even as I accepted that I may not know the diagnosis, that I might never know Leon Woodle’s diagnosis, I continued to sift through the evidence. It’s not cancer. There is no clear evidence for infection. An atypical presentation of one of my diseases? Maybe. It’s nearly impossible to prove a negative. He’s dying; maybe I should order a pulse dose of steroids? Hey, at this point what harm will that do? I clicked my pen and wrote the order: 1,000 mg Solu-Medrol in 100 cc D5W. Infuse now. There is an old saying in rheumatology: No one goes to the grave with an undiagnosed disease without a wallop of steroids.
The Clues Come Together
Leon’s eyes flickered open and settled on me. He groaned as he shifted his head on the pillow. The faintest whiff of fresh manure flowed my way. Pig farmer. Polyarthritis. Weight loss. Fevers. I cocked my head and scratched behind my ear. Diabetes, hepatitis C, diarrhea, pleural effusions, pericardial effusions, ascites, lymph node enlargement. It’s not infection. Maybe it is infection, and he’s not on the right antibiotic? It’s not immunologic. Maybe it is immunologic, and he needs pulse steroids.