“Tentative diagnosis?” she asked. I admitted I wasn’t sure. She pushed a stray hair up and over her ear and did that odd up-and-out gaze to the right I’d noticed before. She was turning over the possibilities. “Blood cultures?” she finally asked. “It’s funny how a case sticks with you. The guy had horrible teeth. Maybe one of the more indolent bacteria, say Strep viridans, got into his circulation, and that heart murmur we heard was due to an infection of the valve. Endocarditis; that would explain a lot.”
“I agree,” I answered, “but the blood cultures I drew last week are sterile. It’s possible he has a fastidious organism, like Coxiella burnetii.”
“Q fever!” She almost shouted out.
The diagnosis didn’t sit well with me, like I was trying to cram the diagnosis of RA into a pair of shoes two sizes too small.
“Right. It’s spread by contact with an infected animal, so by working on a pig farm, Mr. Woodle is at risk for the disease. Only Coxiella doesn’t usually grow on blood cultures. I’m setting him up with infectious disease. If it’s Coxiella, I’m sure they can prove it’s the culprit. If it’s not endocarditis, maybe they can come up with another chronic infection to explain why he’s wasting away.”
Back to the Drawing Board
Only they didn’t. Although the consult note I received from ID two weeks later was thoughtful and thorough, nothing panned out. Thank goodness the malaria smear was negative, I smiled to myself as I reviewed the reams of normal lab ID had ordered. For a homebody who hadn’t traveled outside of Maine for the past five years, the only way Leon could have developed malaria would have been if a mosquito had snuck into a plane in Africa, been flushed alive down the plane’s toilet, and the toilet contents released as the plane passed overhead, misting Leon as he came out of the barn.
At our follow-up visit, Leon was down another 10 lbs. His hands were slightly more limber, but his elbows and ankles were now tender and swollen. For the previous seven nights, he’d suffered drenching sweats and fevers. He groaned as he eased himself into the exam chair. “Think I got cancer, doc?” he asked.
I met his eyes. “I don’t know,” I answered. “How are your blood sugars?”
“Whatever has dug in, it’s nearly cured my diabetes. I’m wasting away, and my primary has cut down my insulin and cut down my insulin to the point I stopped it altogether last week. I’m just about useless. I stopped that new medication you added, the plaquenil. Diarrhea got bad. Maybe it’s a little better off. I don’t know. Had to let my driveway pavement business go this summer.”