Heart Murmur and Leg Edema (2)
A man in his forties. No history of heart disease or hypertension at all, and now he was showing a heart murmur and leg edema. It was a dangerous condition. He'd said he was too short of breath for a detailed conversation. So I'd stepped out for now. There were all sorts of infection signs too. I think I know what this is.
"Doxycycline!" I turned my head toward my senior.
Doxycycline is a type of antibiotic used for certain atypical bacterial infections. It's not one you'd use in ordinary situations.
"Why that?"
"Psittacosis."
He didn't catch on right away. Senior James stared at me like I'd said something insane. Psittacosis isn't something you see every day, after all. Research might've been limited in the seventies. The bacteria are hard to culture.
"What, does the patient keep parrots?"
"Not sure yet. He said he doesn't keep birds, but it still fits."
"Then why..."
"It's more about the nonspecific infectious disease pattern than psittacosis itself. Not many infections cause both pneumonia and endocarditis."
The classic example. Even Rocky Mountain spotted fever could be treated with doxycycline.
"The legs?"
"Edema. Seems like fluid from heart failure. Checked it out."
"So, you're saying we try empirical doxycycline right now?"
When infection is suspected but the pathogen isn't identified, you use the most likely antibiotic or combo based on experience. That's empirical therapy. Doxycycline would cover psittacosis and similar bacterial infections.
"Yes."
Senior James was pondering my words seriously. An internal medicine textbook lay open in front of him.
"Sounds right, maybe."
"I'd start the antibiotics ASAP. Regardless of the exact disease, the heart involvement makes it dangerous."
Senior James finally nodded in agreement.
"Got it. I'll call the professor."
It wasn't a minute-by-minute crisis, but we didn't have time to spare. Hurry up and get here, Professor. Time to prep the meds.
Professor Ellison had rushed over as soon as he heard the patient had come up from the ER. Edward Ellison, Stanford's internal medicine professor. I was loading meds onto the cart to take to the patient. The most important one, at least in my judgment, was doxycycline.
The professor walked toward me, breathing heavily.
"You the first-year resident? The famous young Asian doctor the dean brags about."
"Yes."
I stared straight at Professor Ellison. No time for chit-chat.
"So, how's the patient?"
"Critical. Suspecting atypical infection. X-ray shows pulmonary edema and atypical pneumonia pattern."
"What's your top suspicion?"
"Treating main symptoms as endocarditis and pneumonia, thinking psittacosis or similar. Empirical doxycycline would be good to start."
"Psittacosis. Isn't that rare?"
Same reaction as Senior James. But I hadn't changed my mind that atypical bacteria was most likely. Tick-borne disease at a stretch? I shook my head. Who knows. Couldn't ask in detail because he was so short of breath, but maybe he raised pigeons at home and ate them or something. Nah, low odds.
"Diseases hitting both lungs and heart at once are rare. Psittacosis is the poster child."
"Fair enough. Let's go see."
We headed back to the patient's room. Anyway, the key now was whether doxycycline would work. Edward glanced at the chart and sighed.
"James and I thought myocardial infarction, because of the murmur."
"That's possible too."
Myocardial infarction—heart attack in lay terms—could cause similar symptoms. It didn't fully explain the fever or pneumonia, though.
Back in Korea as a doctor, I'd seen it sometimes. One small misstep early on, and patient management goes off a cliff fast. Quick decisions matter, but being wrong is a problem.
We stood by the patient's bedside. He looked even more labored breathing than before. I prepped a furosemide syringe from the cart—diuretic to handle the edema. Gotta drain the fluid from his lungs.
Professor Edward started talking to the patient. The man winced.
"Hello, sir."
"Yes..."
"Do you keep parrots by any chance?"
He gave a what the hell look.
"Out of nowhere...? No."
Edward shrugged at me, but I shook my head. Psittacosis doesn't just come from parrots.
"Pigeons or other birds?"
The patient coughed for a good while.
"No? Don't keep wild birds at home, haven't seen any recently. Oh, but—"
"But?"
"Do chickens count as birds?"
Knew it. I smirked inwardly, but Professor Edward nodded slowly with the patience and gravitas of decades of experience.
"Chickens... easy to mix up. Hell, I don't think of chickens as birds either."
Now he's just saying anything. We administered the doxycycline, then wheeled the cart out of the room.
Edward looked at me.
"How'd you know?"
"Hmm. Unexplained fever pointing to bacterial infection—empirical doxycycline makes sense."
That's the modern protocol. Atypical bacterial infections might not have been well understood in the seventies. Maybe that's why even this professor didn't know.
"Sharp kid."
"Thank you."
"Doxycycline should fix it."
Bacterial infection, yeah, doxycycline would knock it right out. The issue was how much heart function would recover. We'd crossed the hump, but just barely.
I looked back at the professor.
"And we need to decide on heart failure treatment soon. If antibiotics don't resolve the cardiac issue, we'll need separate HF therapy."
Professor Ellison let out a small sigh.
"Dean Rich was right."
"About what?"
"Said he admitted a monster. No clue how you spotted doxycycline... It isn't in the books."
I thought about how to respond.
"I considered if one disease could explain all the symptoms."
"Yeah. Good work... Let's see if symptoms improve post-antibiotics. Go rest. I'll look up the textbook."
I returned the cart to the station and left the ward, leaving the professor behind.
Back in Stanford's internal medicine lounge, there was a letter waiting for me.
Nobel Prize? Nah, not Nobel season. Too bad.
Looking closer, it was from the Lasker Foundation. Addressed to me?
I opened the envelope.
Lasker Foundation
Dear Noah Parks,
The committee is honored to nominate Dr. Noah Parks of Stanford for the "Forward-Looking Research" category awardee.
Your research has provided a blueprint for studying gene-to-gene interactions alongside world-renowned scholars, empirically validated through the discovery of the human major histocompatibility complex. This spans seven years of work starting from your undergraduate days, including four Nature papers: the one with Professor Berg on gene editing methods, the proposal to utilize simple biological enzymes for gene editing, and the one with Professor McDevitt on research directions in immunology via immune system principles.
Your work proposes and proves that the language of life can be manipulated at levels previously unimaginable.
Thus, the committee seeks to shine a light on your research, publicizing this new horizon in medicine to researchers and the public alike.
We kindly request your presence in New York at year-end to receive the Lasker Award, along with a short acceptance speech.
Thank you.
I folded the letter. The rest was routine stuff.
Already getting the Lasker. At this rate, Nobel's totally within reach.
Then Senior James pushed open the lounge door.
"Psittacosis patient's awake."
I stuffed the Lasker letter into my coat pocket and stood.
"How's he doing?"
"Seemed fine. Let's go check."
Time to see if the treatment worked. Maybe the doxycycline knocked out the high fever.