King of Organs (1)
I was back at the hospital.
Leaving behind what had happened in New York. Still, Palo Alto at Stanford was far nicer weather-wise and more peaceful than bustling New York. Much better than some massive city that was a nightmare to navigate.
The Stanford Hospital ward was as lively as ever. Time to catch up on the backlog of patients. I plopped down at the station.
Quite a few patients had changed during the days I'd been away in New York. Some had worsened; a few had improved. The ulcerative colitis patient I'd seen last time had been cured and discharged... Good for him.
This one had multiple myeloma, leading to a hairline fracture in his leg. That one had developed heart issues and started on warfarin. I quickly skimmed the charts, checking for any prescription changes or dilemmas worth pondering.
Any new diseases? Or diagnoses that wouldn't have treatments known in the 1970s? Nothing jumped out immediately. I kept flipping through the internal medicine ward's charts as I sat there.
Alice walked by with her stethoscope and waved hello.
"Oh, you're back. How was the award ceremony?"
"Good."
"Let's grab lunch later."
Alice cut herself off mid-sentence, glanced at her watch, and hurried off somewhere in a rush.
About an hour passed like that. Just as I finished reviewing my ward's charts, I felt eyes on the back of my head. I turned around, and someone was staring at me from behind.
I nearly jumped.
"You're that resident, right?"
I turned fully. Probably.
"Hello, Professor."
This was Henry Kaplan, professor of hematology-oncology at Stanford. A pretty famous guy. The doctor who'd researched non-Hodgkin lymphoma and figured out its treatments. Even in the 1970s, he was relatively well-known in medical circles.
He eyed me.
"You're the resident who won the Lasker Award this time... I have a few patients with some unknown neurosis. Think you could take a look?"
"Yes, of course."
Kaplan let out a sigh of relief, like he'd finally reached safe harbor.
"The dean mentioned it. Said you can diagnose just by looking at a patient's face."
"You're too kind."
"No need to be so modest. Word is you spotted a Kawasaki disease case that the entire pediatrics department missed and even figured out the treatment."
All true. Kawasaki disease had already been researched by that point, but still.
I nodded.
"That's right."
Kaplan turned serious again, his face clouding over like he'd remembered a tragedy.
"Let's see if you can do the same for my patient. He's a father of three girls. We have to get him home safe, no matter what."
Doctors don't make promises they can't keep. Not to other doctors either.
"I'll do my best."
"No pressure."
No pressure? Impossible. The cost of failure was too steep. And there was no guarantee of a clean win.
Still, it was an intriguing puzzle.
Neurosis after cancer wasn't uncommon. Plenty of possible causes. Lots to mull over.
The most frequent culprit: side effects from chemo drugs. Cancer cells are human cells with human genes. Killing only them while sparing healthy ones isn't easy.
Platinum-based chemo like cisplatin was notorious for causing neuropathy. Could be that.
Examining the patient would tell. Was it drug-induced neuro symptoms? Brain mets from the cancer? Or something else causing it?
Kaplan strode quickly toward the cancer ward, and I followed. He seemed in a hurry.
"What kind of cancer?"
"Lung."
"What type?"
"Small cells."
Small cell lung cancer. That widened the differential.
Getting complicated.
Small cell lung cancer is a neuroendocrine tumor. Meaning it can produce hormones and neurotransmitters. A few more possibilities on the list...
"Small cell lung cancer."
"We biopsied, chemoed, and radiated. Tumor's shrinking as planned, but yesterday he lost speech. Like a stroke."
"Not a stroke, right?"
Kaplan nodded. Not exactly, but he'd invented the chemo and radiation protocols for this type of cancer himself.
I entered the patient's room.
"Hello there."
As the professor had said, he was a middle-aged man. Three kids crowded the bedside. The family must've rushed over after hearing he'd taken a turn for the worse.
A woman about his age—probably his wife—rushed forward.
"Do you know what's wrong? He can get better, right? It's been two days already..."
"I'll check."
"He can't even speak, just lying there."
I turned to the patient, who weakly gestured at me. Trying to communicate somehow... Aphasia?
I leaned in close.
"Can you understand me?"
"Y... yes..."
"Where does it hurt? How?"
"Legs... no strength..."
Good, not true aphasia. More like diffuse brain dysfunction slowing thoughts, or weak vocal cords. Not the focal language area lesion you see in stroke aphasia. Fluency and comprehension both intact.
I pulled a reflex hammer from my pocket, grabbed his knee, and tapped. Checking patellar reflex. It was suppressed. Sign of lower motor neuron issue.
Then I stroked his sole with the hammer handle. His toes fanned out like a bow. Babinski sign. Upper motor neuron lesion.
Odd. Both upper and lower motor neuron signs. I had a pretty good idea what it was.
I turned back to him.
"I'll see you again this evening."
He nodded weakly. The three kids stared holes through me.
We returned to the cancer ward station. The diagnosis had narrowed considerably. Enough to name it.
I looked at Kaplan.
"He's on mannitol now, right?"
Kaplan nodded.
"How... Does face-reading show that too?"
Diffuse brain dysfunction without focal lesion? Suspect cerebral edema first. And he'd ruled out stroke.
"No, well... Professor, you saw it too—this patient's got both upper and lower motor neuron involvement. Rules out stroke-like structural issues completely. And chemo side effects."
He frowned.
"Why not chemo?"
"Chemo drugs usually don't cross the blood-brain barrier. Chemo neuropathy is typically peripheral."
"Is that so...? Theory checks out."
He'd pioneered chemo and radiation for this cancer. But real-world side effects? Still a mystery even to the inventor.
Anyway, not chemo. The answer was clear: autoimmune encephalitis.
It could cause every symptom under the sun. Weakness, personality changes, depression, anxiety, confusion, seizures, ataxia, pain, you name it. The depression-anxiety link was fascinating, but later for that.
"He seized yesterday, right?"
That's probably why the family rushed in, thinking he was dying.
"Yeah, he did."
Might be before those receptors were even discovered.
I pondered how to phrase it.
"Autoimmune encephalitis. Explains the diffuse brain damage plus upper and lower motor neuron signs."
"What's that?"
"Autoimmune disease... Like lupus."
"Lupus encephalitis?"
"Means autoantibodies."
Kaplan squinted slightly. What nonsense is this? Fair enough. In the 1970s, autoimmune encephalitis wasn't a concept, and autoimmunity itself was poorly understood.
"So, unknown mechanism, unknown disease in this patient."
"Uh, yes."
"Not sure how that fancy hypothesis helps."
It does! Honestly, no need to pinpoint the exact type. Treatment's similar anyway.
"It's an immune reaction without pathogens, Professor. Means the encephalitis could be controllable—reversible even."
"Ah..."
"High-dose steroids. If that fails, inject into the CSF."
Kaplan's jaw dropped. He couldn't close his mouth.