“I haven’t eaten anything since breakfast. The possibility of dinner has crossed my mind a few times.”
“I’ll tell you what. I’ll buy you all the pizza you can eat if afterward you get the team together for a meeting in the crisis center.”
“Now there’s a classy dinner invitation.”
“If I thought we had the luxury of a three-hour gourmet dinner, I would have suggested it.”
“How many toppings on the pizza?” she asked.
“No limit. It’s your heart attack.”
“I’ll accept your offer on one final condition.”
“Shoot.”
“During dinner, the topic of GNS and everything and everybody related to it is off limits.”
“Agreed.”
“Good. We have a deal,” she said reaching for her phone. “There’s a pretty decent pizza place a few blocks from the hospital. I’ll call Marc. We’ll have time to eat while he gets the team together.”
65
A little over an hour later, Jack and Madison met Marc in the crisis center. Seated around the conference table were two obstetric residents, a pharmacist, three medical students and one of the intensive care physicians. The room was cool and the table was covered with an assortment of coffee mugs, legal pads and at least a half dozen medical texts. In the middle, a mound of computer printouts stood on the verge of toppling over.
“I apologize for the hour,” Jack began. “But with the new evidence we’ve uncovered regarding the flu vaccine and the limited time we have, I wanted to see if there’s anything further we can pull from the National Patient Data Record to identify any other common factors amongst these patients.” He turned to Marc. “I know this is the last thing any of us wants to do, but let’s go back to the beginning and review our basic patient profile.”
“Our prototypic patient,” Marc began, “is a woman in her second or third trimester of pregnancy. As a result of what we learned from Isabella Rosas, an elevated inhibin level seems to be essential in order to contract the disease. We are all painfully familiar with the symptoms, so I won’t restate them. The final relevant factor is that the vast majority of these women have been pregnant before.”
“Which means that a prior pregnancy changed something in their metabolic or immunologic makeup that made them susceptible to GNS,” Jack stated.
“I agree,” Marc said. “The question is, how?”
“Have you considered chimerism?” came a partially muted voice from the far end of the table.
Every head turned at the same time.
“I beg your pardon,” Jack said, looking at the young lady with short blond hair, nervously tapping a pencil against her notepad. A yellow medical student identification badge was clipped to the pocket of her white coat. Jack had seen her a few times at the team meetings and on rounds, but this was the first time he’d heard her say anything, which was hardly unexpected for a third-year medical student. But what made Carolyn Olesanger unique was that prior to enrolling in the Southeastern State University medical school she had earned both a masters and Ph.D. from Rutgers University.
Dutch Richardson, a senior pharmacist weighed in, “For those of us who have absolutely no idea of what you’re talking about, perhaps you could explain.”
Carolyn looked at Madison for approval, which she received in the form of a single nod and a hand gesture to proceed with impunity.
“Ninety-plus percent of the population has one DNA cell line. Chimeras are individuals, largely women, who possess two distinct DNA cell lines. The term comes from Greek mythology. A chimera was a mythical creature that had the head of a lion and the tail of a goat. Pregnancy is by far the most common way women become chimeras.”
“How?” Richardson asked.
“Normally the fetus and the mother have two separate circulations, but sometimes a very small amount of the baby’s blood cells pass through the placenta to the mother. These blood cells can then become a permanent part of the mother’s DNA. They are most commonly found in the thyroid gland and lymph nodes.”
Jack and Madison swapped an intrigued glance.
“Your background is in . . .” Madison asked
“I have a Ph.D. in molecular genetics.”
“I’m not sure I understand the significance of all this,” Jack said. “Supposing our patients are chimeras. From what I recall, being a chimera is . . . is a medical oddity, not a disease.”
“That’s probably not entirely true,” Carolyn said in a voice increasing in confidence. “Over the past few years there’s been a firestorm of controversy over the relationship between chimerism and disease. There is a large group of medical researchers who believe chimerism predisposes individuals to certain diseases. The way this occurs hasn’t been totally worked out but it has been documented that chimeras have a higher incidence of autoimmune diseases such as lupus and rheumatoid arthritis.”
One of the residents spoke up. “You mentioned that being pregnant was one way a woman could be become a chimera. What are the others?”
“People who have received a blood transfusion for any reason can be converted to chimeras. Another way is to be a bone marrow or organ transplantation recipient. It’s also been shown that in vitro fertilization and artificial insemination can do it.” Carolyn paused and looked around the room before going on. “Twins can be chimeras if some of their red cells exchange during fetal life. There are only a few places in the country doing serious research on the subject. There’s still a lot of controversy, but if there’s one area of agreement, it is that the total number of women chimeras in the population has been grossly underestimated.”
Jack was intrigued by what he was hearing, but he was far from convinced the information on chimerism was the key that would unlock the mysteries of GNS. But with Sinclair breathing down his neck and Tess slipping further away with each passing hour, he was ready to grasp at any straw that might lead him to the cause of the most enigmatic disease he’d ever come across.
Jack said, “Let’s take another look at the patients who are pregnant for the first time.”
Marc tapped in the command and waited a few seconds for the information to appear on his screen. “There are only four at Southeastern State who are pregnant for the first time,” he said. “The first one is Grace O’Malley. She was admitted five days ago. The only thing of interest in her history is that she had her tonsils out at age six. She bled for several days and required an emergency operation to stop the bleeding.”
“Did she receive a blood transfusion?” Madison asked.
Marc looked up and with a surprised grin and said, “Yes. According to her mother, she did.”
“Who’s next?”
“Laura-Anne Elby. Let’s see . . . she was also admitted five days ago. She had leukemia as a teenager. She was treated in Atlanta at Scottish Rite Hospital. It took three years, but she fully recovered.”
“Does it mention whether she had a bone marrow transplant?” Carolyn asked.
“No, but it’s certainly possible,” Madison said. “It shouldn’t be too hard to find out. I’m sure her family must know.”
Marc looked over at Clayton Morton, the chief resident in obstetrics. “Clay, why don’t you give the ICU a call and see if any of Laura’s family is up there? I’m sure they’ll know if she had a transplant.”
“No problem,” he said, coming to his feet.
“Keisha Adams is next,” Marc said. “She was one of the first patients we admitted.” He scrolled down through her basic medical information. There was nothing of particular interest. When he reached the summary of her past medical history, his chin dropped. He projected the page onto the large screen. “In 2003, she underwent a kidney transplant.”
Jack’s eyes narrowed as his mind began to race. He could feel his stomach clench. “I know who the fourth patient is. Her name’s Sherry Rosenfelt.”
“The one who had the brain biopsy,” Madison stated.
“Yeah. I’ve gotten to know her father pretty well. I’ve been over her medical history so many times I could recite it by heart. She’s always been healthy.”
“Then how did she become a chimera?” Marc asked.
“I don’t have the first clue,” Jack responded, shifting his gaze to the other end of the table to address Carolyn directly. “How difficult is it to test someone for chimerism?”
“The testing has become fairly straightforward. There a several methods but the easiest is a DNA analysis of a blood or skin sample.”
“What’s the turnaround time?”
“I think most labs can give you an answer within forty-eight hours. There’s a pretty experienced one in Fort Lauderdale.”
Jack pushed his chair away from the table. “Let’s get Dr. Morales involved. With a little arm twisting, maybe we can get the lab to give us results in twenty-four hours.”
“How many of the women should we test?” Madison asked.
“To start, every one hospitalized at Southeastern State,” he answered flatly.
Marc’s cell phone rang. He nodded a few times and then slowly replaced the phone on his belt and cleared his throat.
“That was Clay. He just spoke to Laura-Anne Elby’s mother. She told him that after fourteen months of leukemia treatment in Atlanta, Laura was sent to Seattle for a bone marrow transplant.”
The meeting continued another half hour before Jack ended it by assigning everybody in the room a specific project to investigate the possible link between chimerism and GNS.
“That may have been the most productive meeting we’ve had so far,” Madison told Jack after everyone had left the room. He agreed with a quick nod, but his mind was only half there. He slipped his laptop back into the same scuffed black leather case his ex had given him for Christmas four years earlier.
“How hard would it be to get a copy of Sherry Rosenfelt’s slides from her brain biopsy?”
With a wary expression, Madison angled her head to one side. “I assume you have more than an academic interest for asking me that.”
“I was toying with the idea of getting another opinion.”
“The last time I checked, the slides had already been reviewed by two other pathologists who concurred with the findings.”
“Yeah, but all three of those pathologists are on staff at Southeastern State. Maybe it would be a good idea to speak with somebody who isn’t.”
“It shouldn’t be a big deal to get a copy of the slides, but tomorrow’s Sunday. Even if we overnight them to somebody on Monday, by the time he or she reviews them and gets back to us, it will be the middle of the week.” She shrugged. “I think we’ll be out of time.”
“I was thinking more of hand-delivering them . . . to expedite matters.”
“How come every time you and I have a conversation, I find myself lost?”
“How do you feel about driving up to Orlando tomorrow?”
“At the risk of repeating myself, I’ve never met a pathologist who worked on Sunday.”
“I know one who does,” Jack responded, not mentioning he had already made a phone call.
Madison shook her head and started toward the door. “I’ll tell you what. I’ll meet you in the pathology department at eight. I’ll arrange for the technician on call to be there and give us a copy of Sherry’s slides.”
“Great. Was that a yes or a no about coming with me?”
“I’ll come on one condition.”
“You’re just full of conditions tonight. Name it.”
“I drive.”
Unable to silence his groan, he said, “I wouldn’t have it any other way.”
66
DECEMBER NINETEENTH
NUMBER OF NEW CASES: 7,850
NUMBER OF DEATHS: 31
It was twenty minutes to ten when Madison and Jack pulled into the visitors’ parking lot of Orlando Memorial Hospital. They went directly to the patient welcome center, where an elderly woman wearing a pin recognizing her two thousand hours of volunteer service to the hospital directed them to the third-floor office of Dr. Lucien Androise, the chief of pathology. Before accepting the position, Androise had spent fifteen years at Case Western Reserve University. Over the years, Jack had worked with him on at least a dozen cases. They had an excellent professional relationship and there wasn’t a pathologist alive he respected more than Lucien.
Jack and Madison followed the main corridor to its end outside Lucien’s office. The door was ajar, and Jack saw his old colleague, a squat man with fatty ears and stubby fingers hunched over a microscope. Jack rapped on the door of couple of times. Lucien looked up, smiled broadly and waved them in.
After exchanging a warm greeting, Jack introduced Madison.
“My pleasure to meet you,” he said, shaking her hand. He redirected his attention back to Jack. “Let’s see what you two have.”
Jack handed him the leather case containing the slides. Lucien invited them to have a seat at the Formica-topped counter. Spaced equally apart were four state-of-the-art microscopes. They were of the teaching variety, manufactured with two eyepieces; one for the pathologist and one for the student.
“I can’t thank you enough for agreeing to review the case,” Jack said.
“It’s my pleasure. We’re taking care of a lot of women with GNS, but we haven’t performed any biopsies as yet.”
“To my knowledge, Southeastern State’s the only hospital that has,” Jack said.
Lucien ran his finger down the slides until he reached the one he wanted to look at first.
“So, did you pluck anybody’s tail feathers at Southeastern State by sneaking away with these slides and coming up here?”
“We may have ruffled a few,” Jack answered. “Officially, the request for your opinion comes from Arnold Kazminski, the father of the young lady whose brain tissue you’re about to look at. So, from a medical ethics standpoint, we’re on solid ground. I can’t say the same is true regarding the wisdom of the decision from a political standpoint. But, even if we come under fire when we get back, it shouldn’t amount to much more than a flesh wound.”
“You’ve always been the consummate diplomat, Jack.”
After arranging the two dozen slides in his preferred order, Lucien slid the first one on the viewing platform. He removed his five-dollar flea market reading glasses and looked in the eyepiece of the microscope.
“As I mentioned on the phone, I’m interested to know if you see anything at all that’s definitely diagnostic of a viral infection,” Jack said.
Lucien took several minutes studying a large sampling of the slides before he invited Jack and Madison to have a look.
“There’s a component of inflammation here that could possibly be the result of a viral infection,” he said.
Jack lifted his eyes from the microscope. “You’re saying possibly. The pathologists at Southeastern State were more on the definitely side.”
Androise interlaced his fingers behind his neck. “In my opinion, the findings on these slides are not specific. I can’t exclude a viral infection but it’s by no means the only possibility.” He raised his hands and turned his palms toward the ceiling. “You asked for another opinion. All I can say is I don’t feel nearly as strongly as the Southeastern State pathologists do that this young lady’s brain tissue is infected with a virus.” With an easy shrug of his shoulders, he reached for one of the few slides he hadn’t as yet looked at and positioned it on the microscope.
Jack glanced over at Madison. Her face was painted with a stony expression.
“I certainly appreciate you coming in on Sunday to have a look at—”
“Wait a sec,” Lucien said abruptly. He rotated the lenses to a higher magnification. “This is interesting. On this slide, there are
some very subtle features of . . .” Lucien said nothing for the next minute or so, but then glanced up from the microscope with a puzzled look on his face. “Let me have a closer look at these and I’ll give you a call.”
“What are you . . .”
“I’d rather not say anything right now.”
With narrowed eyes Jack asked, “I don’t mean to sound pushy but we’re on a pretty tight schedule, Lucien—do you have any idea when we might hear from you?”
“I understand. I’m only talking about a day or two. I don’t suppose you brought any of the original biopsy material. I might want to do some different stains on them.”
“I thought you might ask for that,” Jack said, removing a small container of formaldehyde and handing it to Lucien.
“Great,” he said, sliding his glasses back in place and coming to his feet.
With a knowing smile, Jack extended his hand. “Thanks again for having a look at the slides.”
“I’m happy to help . . . but I’m not sure I’ve done anything more than further muddy the waters.”
“I doubt that’s the case,” Jack assured him. “I look forward to your call. One last favor: Would you mind keeping our little visit here today confidential?”
“What visit?” he asked Jack before turning to Madison and extending his hand. “It was such a pleasure meeting you.”
Jack followed Madison out of Lucien’s office and down the main corridor. He was more than familiar with Lucien’s coy and cautious manner. Jack had a feeling his old friend was onto something.
“Do you feel like making a stop on the way back?” Jack asked Madison as they waited for the elevator.
“What kind of a stop?”
“My mother lives on Hutchinson Island. I owe her a visit.”
“Jack, I hate to sound like a jerk but do you really think with the time constraints we’re under this is the best time for a family—”
“You might find her interesting to talk to. She recently retired from the University of Georgia as the chief of pediatric cardiology. She spent her entire career doing research. Her department became pretty renowned for their work on congenital heart disease.”
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