“But look,” Lynn said, “the increase in the white count is with lymphocytes, not neutrophils. Doesn’t an increase in lymphocytes usually happen later in an infection as a hormonal immune response?”
“That’s the way it’s supposed to work.”
“And look, the lymphocyte count went up progressively with each passing day. What do you make of that?”
“I need to cheat,” Michael said. He pulled out his tablet and Googled meaning of increased lymphocytes. Thanks to the Internet, he had multiple results in a fraction of a second. He read the conditions out loud: “Leukemia, mono, HIV, CMV, other viruses, TB, multiple myeloma, vasculitis, and whooping cough.”
When Lynn didn’t respond to his list, Michael glanced at her. She was busy reading the results of the infectious disease consult. “No source of infection was found,” she said. “Chest was clear on X-ray, urine normal, no infection of the operative incisions, no nothing.”
“Did you hear the list of what causes an increase in lymphocytes?” Michael asked.
Lynn shook her head. “Sorry. Come again!”
Michael repeated the list. Lynn listened and thought for a moment. “Well, we can ignore most. I suppose ‘other viruses’ and ‘vasculitis’ are the most probable.”
“Yeah,” Michael agreed, “but doesn’t something jump out at you?”
“What do you mean?”
“Multiple myeloma causes an increase in lymphocytes. That caught my eye because of what I learned yesterday — that Ashanti has multiple myeloma. Maybe Morrison has it, too.”
“Now, that would be too much of a coincidence,” Lynn said. “I’ve never seen a case of multiple myeloma and don’t know much about it other than it involves too many plasma cells. Isn’t it rather rare?”
“If I remember correctly, it’s not that rare,” Michael said. “Of course everything is relative. I remember the one lecture in pathology that included multiple myeloma.”
“You remember the lecture we had in pathology about multiple myeloma?” Lynn questioned with a touch of dismay.
“I don’t remember a lot, and not much more than that it involves plasma cells, like you said. But I do remember that among the brothers it is one of the top ten causes of cancer death. Maybe that’s why I remember it. Anyway, of all the conditions that I just read that cause an increase in lymphocytes, I couldn’t help but notice it.”
“I wonder if it is because of the increase in lymphocytes that Dr. Erikson is seeing the patient,” Lynn questioned.
“Makes sense,” Michael agreed. “Do you think we should risk asking her?”
Lynn looked over at the attending, who was still bent over a chart, dictating a note most likely for the EMR. A few minutes earlier she had been writing a note. Until the hospital fully adopted the computerized record and gave up on the physical chart, consults had to do both and complained bitterly.
“I don’t think we dare,” Lynn said after a pause. “If we actually engage her in a conversation, she’s bound to ask us more details of why we are here. As you said, people are going to be sensitive about these cases.”
“Right on, girl!”
“Let’s see if she wrote a note in this chart. That could answer the question.”
Redirecting her attention to the chart in front of her, Lynn turned to the continuation notes, where progress reports were placed. The last note was from Dr. Erikson. The handwriting wasn’t good.
Thank you for asking me to see this patient again. As noted on my previous [illegible word], the patient has had a persistently elevated body temperature, although it has gradually subsided and is today at 100º F. Her blood count continues to show a moderate and [illegible word] lymphocytosis, currently at over 6,300 lymphocytes per mcl, representing 45 percent of the white count. I am pleased to see that no source of infection has been found. Total globulins are [illegible word] elevated. Protein electrophoresis shows a small and narrow gamma globulin spike, which suggests the [illegible word] of a developing monoclonal gammopathy (MGUS). However, I do not see this possibility or her persistent fever as contraindication for her scheduled transfer to the Shapiro Institute. I believe such a transfer will be in her best [illegible word], and I will continue to follow her. Dr. Siri [illegible word but presumably Erikson]
“What the fuck is a gammopathy or MGUS?” Michael asked with frustration. “I hate it when consults throw around these shit-ass esoteric words and acronyms to make you feel incompetent.”
“My turn to cheat,” Lynn said as she pulled out her tablet and Googled gammopathy. Although she didn’t know the exact meaning, she had a good idea. She selected the Wikipedia choice, and, placing her tablet on the desk, they both read the article titled “Monoclonal Gammopathy of Undetermined Significance.”
When Lynn was finished Michael asked: “What’s your take, besides knowing what MGUS stands for?”
“I’m so tired I’m having trouble thinking,” she confessed.
“It’s not surprising. You’re exhausted and you’re starving. Come on! Let’s go down and get you something to eat. You’re running on empty.”
“In a minute,” Lynn said, trying to rally herself. “At least I understood that MGUS involves a group of lymphocytes overproducing the same antibody. What surprises me is reading how prevalent it is, and I barely remember it even being mentioned in pathology.”
“But it is only prevalent in people over fifty. This patient is twenty-eight.”
“True,” Lynn said. “And I guess it’s not that serious.”
“It’s not serious unless it develops into multiple myeloma. It makes me wonder if Ashanti started out with this MGUS, which then led to the multiple myeloma.”
“I guess that is a possibility,” Lynn said. “Let’s look at the test Erikson mentions in her note: the protein electrophoresis. I know something about that from having used it to follow a patient with acute hepatitis last year in our medicine rotation.”
Lynn flipped back to the section of the chart for laboratory tests. It didn’t take her long to find the proper page with the results of the protein electrophoresis. The levels of the various plasma proteins were listed and also portrayed in a graphic schematic. She and Michael concentrated on the schematic. In the far right-hand portion where a smooth mound representing the gamma globulins was expected, there was a small, narrow peak at the mound’s crest.
“That’s easy to spot,” Michael said. “So the woman’s immune system is producing a specific antibody. What do you think is causing it?”
“Has to be an antigen of some kind. And maybe the antigen that stimulated the first lymphocyte to produce the specific immune globulin is still in Scarlett Morrison’s body, continuing to stimulate more and more antibodies. What do you think of that?”
“It’s definitely a possibility unless that first lymphocyte just went a little berserk, if you know what I am saying.”
“You mean, sorta like a cancer cell.”
“Something like that,” Michael said. “The cellular machinery to produce an antibody got turned on, and someone forgot to turn it off.”
“Going back to your question about whether the anesthesia could have caused the fever. Now the question is if the anesthesia could have turned on this monoclonal antibody?”
Michael stared at Lynn, understanding perfectly where she was coming from. She desperately needed an explanation for Carl’s sorry state and was willing to grasp at straws.