Chapter 2
Chapter 2
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Translator: crow
Chapter Title: VEXAS Syndrome (2)
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“……You son of a bitch.”
A curse slipped out unbidden.
Strength drained from my entire body.
This was reality.
I was just some hack who couldn’t even get the basics right while trying to write a novel.
“…Ha, fuck.”
A hollow laugh burst out.
Yeah, they say when something’s so absurd, you can’t help but laugh.
Crazy bastard who scavenges case reports? Novel-writing hack?
My mind suddenly cooled.
‘Wait a minute. What if that guy’s right?’
Everyone in the hospital knew Nam Seung-hyun was an asshole, but he was a third-year internal medicine resident.
He had way more clinical experience built up than a first-year ER drone like me.
In his eyes, I might’ve looked like a total idiot showing off with half-assed knowledge I’d scraped together.
What if this wasn’t VEXAS?
What if that “Ruined Doctors Gallery” was just a delusion my brain cooked up, and the coincidences were just that—coincidences?
Then I’d be the moron holding onto a patient with a nonexistent disease, getting publicly shredded by a third-year internal med resident.
“Bullshit….”
Okay, calm down first.
No cursing, think rationally.
I’m a doctor, damn it. Not some shaman diagnosing by gut feeling.
Evidence. Proof. Evidence!
That’s all that matters.
I grabbed the thick stack of records from the patient’s previous hospital, shoved in the corner of the on-call room.
They were poorly scanned PDFs of low resolution, barely linked to our hospital’s EMR (*Electronic Medical Record).
“Let’s see, you shitty records.”
Local clinic: Symptomatic treatment for cold and flu symptoms, no improvement.
Second visit: Hospital admission, 10 days of antibiotics and various tests, but fever persisted.
“Pumped full of antibiotics and the fever didn’t budge…. Low chance of infectious cause.”
I scrolled down. Labs crammed in densely.
Hmm.
Huh?
“…What?”
I narrowed my eyes.
Something I’d skimmed over as “mild anemia” on the first pass.
Hb (*Hemoglobin) 11.8. But next to it, the MCV (*Mean Corpuscular Volume) jumped out.
102.5.
Fuck. Normal range tops out at 100. This is clear macrocytic anemia. Not just any anemia.
Anemia from chronic disease in inflammatory states is usually normocytic.
But this was macrocytic.
“They missed this? No, they saw it but didn’t know what it meant.”
My heart started pounding again.
Like I was possessed, I pulled out my phone and opened UpToDate. This time, the diagnostic criteria for ‘VEXAS syndrome.’
Somatic UBA1 gene mutation in myeloid cells (*Somatic UBA1 gene mutation in bone marrow cells)
Yeah, that needs genetic testing.
Can’t check it right now, so skip.
‘Anemia is nearly universal. Progressive thrombocytopenia may also be observed’….
“…Near-universal finding.”
Found in almost every patient.
Fuck, the first piece fit perfectly.
Back to the chart. Radiology reads. Chest PA, Abdomen CT.
Chest PA & CT: No lung lesions, no lymphadenopathy.
Abdomen & Pelvis CT: No abdominal abscess or occult malignancy.
“Yeah, imaging’s clean, so everyone’s stumped. No cancer, no pus.”
Common FUO causes like abscesses, TB, cancer were ruled out.
Left with rheumatologic diseases or other rare inflammatory conditions.
Finally, I pored over the nursing notes.
Answers often hide in the messy doctor charts or the nurses’ meticulous records.
Day 2: Bilateral auricular swelling and tenderness reported. Erythema observed.
Day 5: Multiple erythematous papules on chest and back. Derm consult: Rule out drug rash, neutrophilic dermatosis. No biopsy.
Day 8: Patient reports swollen, painful nose. Physical exam: No clear lesions.
“Fuck yes, Eureka!!!”
I slammed my fist on the on-call room desk without thinking.
Relapsing polychondritis. Nasal chondritis. Skin rash suspicious for neutrophilic dermatosis. And macrocytic anemia.
The VEXAS text on UpToDate overlapped perfectly, letter for letter, with the patient’s records.
‘Retard? It’s VEXAS.’
That commenter spotted it in one second.
Just from a few lines of patient info.
And here I was, cheating off that answer sheet, still jumping through hoops to realize it was right.
Suspicion turned to certainty.
Nam Seung-hyun, you son of a bitch.
If I backed down now, I’d be a real idiot.
A doctor too scared of hierarchy and protocol to grab the right answer staring him in the face.
‘Fuck ’em.’
I picked up my phone again.
If the front door’s blocked, climb the damn wall.
‘What department handles this? Autoinflammatory disease… Rheumatology territory.’
Got chewed out by an internal med resident? Only one play left.
Go straight to the rheumatology professor.
Suicide mission.
A first-year calling past chief, resident, and fellow straight to the professor? Direct challenge to the hospital pecking order.
But I didn’t care. Patient in front of me needed saving, and I had the way in my head.
Found the rheumatology on-call professor.
[Rheumatology Clinical Assistant Professor Choi Young-jun]
Suck it up. Here goes.
Thought about the chief but they seemed busy, so no.
Pressed call with trembling fingers. Heart about to leap out.
“…Hello.”
Voice thick with fatigue.
I opened my mouth as calmly as possible.
“Professor, hello. Sorry to call so late. I’m Han Hyun-jae, first-year emergency medicine resident.”
“Emergency medicine? What’s up?”
Bemusement and a hint of irritation from the receiver.
“Well…. We have a fever of unknown origin patient in the ER right now. Transferred from another hospital after multiple tests, no cause found… And I think….”
Deep breath. No turning back.
“I suspect VEXAS syndrome, so I’m contacting you.”
Silence.
Heavier than with Nam Seung-hyun. Crushing.
“…What? VEXAS? You called the internal med on-call?”
His voice shook.
“Yes…. Nam Seung-hyun told me to rule out basics first, but the symptoms fit too well. Might need you to come down in person…. Any orders I should put in first?”
“I’ll come to the ER. Wait there, Han.”
‘Crazy bastard. Total lunatic.’
What the hell did I just do?
A lowly first-year ER peon bypassed a third-year god and called the professor direct.
Moment Choi Young-jun dismisses me as bullshit, I’m branded the clueless psycho and done for.
Glanced around. Nurses stealing looks.
Eyes mixed with emotions.
That guy’s got balls.
Gonna get skinned alive, this’ll be fun.
Yeah, those looks.
Five minutes passed. Ten.
Felt like ten years.
I fiddled with the patient’s chart, anxiously staring down the hall.
Cold sweat down my back.
He blew me off as first-year fantasy?
Worst-case scenarios swirling when—
ER automatic doors slid open. A man walked in.
Late 30s, early 40s. Aura screaming, “I’m not one of you slaves.”
Rheumatology Clinical Assistant Professor Choi Young-jun.
He scanned the room, locked on me, strode over. Heart dropped.
“Han Hyun-jae?”
“Yes! Professor! I’m Han Hyun-jae!”
Jumped up, bowed 90 degrees.
Choi barely acknowledged, snatched the chart from my hand.
From previous hospital records to my scribbles.
“Patient?”
“Over there.”
Choi headed to the patient silently.
Gloved up, started examining personally.
Flipped eyelids for conjunctiva, palpated auricles carefully for chondritis swelling and tenderness.
Is my diagnosis right?
It’s not even mine.
Just some anonymous ruined doctor’s comment.
What if it’s all wrong?
After long exam, Choi stood.
“Hmm….”
“Han. VEXAS was only properly defined a few years ago. You into the latest research?”
My mind went blank.
Interest? Fuck no.
Latest knowledge my ass, can’t even remember what I ate yesterday.
But how to say it’s all thanks to this insane gallery in my head?
One year of training had socialized my mouth perfectly. It spat the right answer instinctively.
“Yes! Absolutely, Professor! I’ve always been interested in rheumatologic diseases, so I read related papers whenever I have time! I believe we must constantly acquire new knowledge!”
Even I got chills at the smooth flattery and lies pouring out.
Choi chuckled shortly at my answer.
Mockery at the fool, or praise for the eager one?
“Good attitude.”
The looks from others shifted. Somehow, Choi had already ordered admission and tests.
A first-year resident—ER at that—nailing a rare rheum diagnosis, summoning the prof, securing admission.
ER legend material.
Finishing orders, Choi adjusted his coat, turned back.
“Han Hyun-jae, right.”
“Yes, Professor.”
“You did well. Hard to confirm on clinical symptoms alone… but it fits. Without you, this patient would’ve bounced between hospitals, worsening, cause unknown. Clinically, it matches VEXAS. Admit him.”
With that, Choi vanished as coolly as he came.
I stared blankly down the hall. Tension drained, legs wobbling.
Hot something filling my empty chest.
[Ruined Doctors Gallery]
Now, time to figure out how to properly milk these lunatics.