The 57-year-old looked up at the long staircase that led to his room in the parsonage, where he shared a room with three other priests. He gripped the railings on either side of the stairs and pushed his feet onto the first step. He slowly walked up the two flights of stairs to his room. The journey back to Boston from the conference in Asunción, Paraguay was difficult. It was an overnight trip, but I couldn’t sleep at all. All he wanted to do now was remove Roman’s collar and lie down.
When he finally got to his room, he looked in the bathroom mirror. His face was bright red and shiny with sweat. The red continued from his chest to his stomach. His whole body ached. He crawled into the futon with gratitude. What he really needed, he told himself, was a good night’s sleep. But as his sleep continued to get lighter, he suddenly felt cold. He trembled involuntarily. The shivers confirmed what he already suspected. I mean, he was sick. And that worried him.
Six years ago, he felt so sick after getting on a plane. He went to the hospital and he was diagnosed with non-Hodgkin’s lymphoma. His treatment was brutal. Seven months of chemotherapy killed the cancer, but also destroyed his body’s ability to make its own blood. He was rescued by stem cells (cells that make the necessary blood) taken from his own body before starting his treatment. Although he had not been ill since then, he knew there was a possibility of recurrence. It was a low level of anxiety that he faced with all subsequent symptoms. Before he got cancer, he might have just been patient. not now.
He called his longtime doctor, Dr. Peter Zlomskis. He didn’t want to bother Saturday, but he thought this was important enough to be worth a call. After hearing about his travels and his fever, rash, and general weakness, doctors told him to “go to the emergency room.” “You need to be seen.”
Difficult to carry suitcases
One of his housemates drove him to the emergency department at Beth Israel Deaconess Medical Center. By the time he made his way through the crowded emergency department and into a hospital room, it was dark outside. He repeated his story six times to various doctors, nurses, and residents while being poked, prodded, immobilized, and filmed for hours. The priest was grateful that the small room was now quiet, allowing him to finally rest.
Dr. Martin Kaminski was the hospital doctor on the night shift. He introduced himself, asked the patient to tell his story, and listened as the man described his travels, weakness, rash, and fever. He arrived at the hospital with a temperature of 102 degrees, which was brought down by acetaminophen and IV fluids. As the patient neared the end, Kaminski asked a few more questions. Did he use insect repellent while in South America? No, the priest recalled. His fellow priest gave him a wristband to keep mosquitoes away. He didn’t feel any bites while there. He was drinking only bottled water, he added. Did he leave the city or go hiking in the forest? Has he ever come into contact with livestock or farm animals? No, he was too busy to leave the hotel where the conference was held.
Kaminski asked if he was feeling any pain. He did it. And earlier, his right hand felt sore and a little weak. He had difficulty carrying his suitcase. On the car ride home, his neck felt strangely weak, as if his head had suddenly become heavier. His neck still felt sore and stiff. The doctor asked him if he could rest his chin on his chest. His shoulder stiffness may be due to meningitis. But the patient proved it can be done. He was worried, the priest told Kaminski. He has only felt like this once in his life, and that time he was diagnosed with lymphoma. Could he have come back? At the emergency department, the hematology-oncology team recommended a CT scan of his chest, abdomen, and pelvis, which he had not yet had. Kaminsky told the anxious man that he thought he was much more likely to have an infection than cancer. But we’ll know more after the CT scan.
Did you get bitten on the ankle?
When Kaminsky examined the priest, he noticed a rash not only on his chest but also on his back and arms. It looked like a sunburn, and when Kaminski pressed his fingers against the light-colored skin of his chest, the red skin turned pale to almost white, indicating that it was not blood leaking from blood vessels under the skin, but some kind of inflammation of the skin. It showed something. . There was a soft red nodule on his ankle, probably a bite. His exams were otherwise unremarkable. His lymph nodes in his neck, groin, and armpits were not swollen. If he had lymphoma, it wasn’t obvious. The cause of his misery remains most likely an infection.
According to the Centers for Disease Control and Prevention, a doctor told the priest that there was an outbreak of chikungunya fever, a viral infection spread by mosquitoes, in Paraguay. And most of the cases were reported in Asuncion, where he was. The disease is usually not fatal, but it can cause arthritis that persists for months or even years after the infection has subsided.
Of course, there were other possibilities, Kaminski added. It could be dengue fever, another viral disease spread by the same mosquito. Because dengue fever can cause high fever and body aches, the disease is called breakbone fever. And it can be deadly. Patients infected for the first time are often in dire straits, but those unlucky enough to become infected a second time are at risk of developing a hemorrhagic infection. Each infection is common throughout South America. Each is a virus spread by the same mosquito. Chikungunya is famous for its sudden onset and short incubation period, so it was first on his list. Another possibility was that it was the one he caught before leaving his home in the Northeast. It could be a tick-borne disease, such as Lyme disease or anaplasmosis. We should have an answer within a week.
Prolonged pain and fatigue
By the next day, the patient felt better and wanted to go home. The fever and weakness disappeared and the rash disappeared. Only pain remained. His doctors still didn’t know what he had. All we knew at that point was that this was not a recurrence of the lymphoma. A CT scan showed several enlarged lymph nodes in the chest, which the radiologist thought were most consistent with an infection. Scans of his abdomen and pelvis showed no problems where the cancer was originally located.
A few days after the priest was discharged from the hospital, Kaminski watched as the test results came back. Tests for chikungunya were negative. The same was true for dengue fever testing. What he and his infectious disease doctors were looking for was no other disease.
Although the patient’s fever had subsided by the time she was discharged, she continued to experience fatigue and body pain. His head felt cloudy. He was also difficult to read. Over the next few weeks he felt better, but his condition was not good. He went to see Zlomskis and explained his lingering malaise. What else could this be? Zlomskis smiled. He was convinced it was chikungunya. But the test result was negative, the patient reminded him. “The test at that time was negative,” he replied. The doctor felt that if he took the test again now, he would definitely get a positive result.
These initial results showed the priests’ immune responses to each of the infections they examined. If he had been exposed to the bug before, a test looking for antibodies would immediately come back positive. The template for fighting off that bug will have already been created and stored by his immune system. Conversely, if this is your first infection, your body will need several days to gear up and create antibodies tailored to this particular invader. He may have tested negative while in the hospital, but Zlomskis was sure he wasn’t negative now. He sent a test for a suspected virus. The results came back a few days later. Only one person tested positive. Very positive. He had chikungunya fever.
Our trip to Paraguay was 8 months ago. Full recovery was slow. The stiffness and joint pain lasted for months. Only recently has he been able to climb the stairs with his old momentum and speed. Yet, despite his history of infections and cancer, he tells me he is a healthy man.
Lisa Saunders, MD, is a contributor to this magazine. Her latest book is Diagnosis: Solving the Most Puzzling Medical Mysteries. If you would like to share your solved case, please email us at [email protected].
