Was this a recurrence of non-Hodgkin’s lymphoma or something else?

The 57-year-old man looked up the long staircase that led to his rooms in the rectory, the home he shared with three other priests. He grabbed the railing on either side of the stairs and pushed his foot onto the first step. He slowly pulled himself up the two flights of stairs to his rooms. His journey to Boston from a conference in Asunción, Paraguay, had been arduous. It was an overnight journey, but he hadn’t been able to sleep at all. All he wanted to do now was take off his Roman collar and lie down.

When he finally reached his rooms, he looked in his bathroom mirror. His face was bright red and shiny with sweat. The red continued down his chest and into his stomach. His whole body ached. Gratefully he crawled under his covers. What he really needed was a good night’s sleep, he told himself. But as sleep continued to elude him, he suddenly felt cold. He shivered uncontrollably. The shaking confirmed what he already suspected: he was sick. And that worried him.

Six years earlier he felt so bad after a flight. He went to the hospital and was diagnosed with non-Hodgkin’s lymphoma. The treatment had been cruel. The seven months of chemotherapy killed the cancer, but also destroyed his body’s ability to produce blood. He was saved with stem cells – the cells that create the blood he needed – harvested from his own body before he started treatment. He had been disease-free since then, but he knew a recurrence was possible. It was a mild fear that he faced with each subsequent symptom. Before the cancer, he might have just survived. Not now.

He called Dr. Peter Zuromskis, his old GP. He hated to bother him on Saturday, but he felt this was important enough to deserve the call-up. “Go to the emergency room,” the doctor told him after hearing about his trip and fever, rash and weakness throughout his body. “You have to be seen.”

Problems carrying his suitcase

One of his roommates took him to the emergency department at Beth Israel Deaconess Medical Center. It was dark outside by the time he walked through the busy emergency room and into a room in the hospital. He repeated his story six times to various doctors, nurses and interns, while he was poked, prodded, pinned down and imaged for hours. The priest was grateful for the silence in the small room where he could finally rest.

Dr. Martin Kaminski was the hospital worker on the night shift. He introduced himself and asked the patient to tell his story, listening as the man described his journey, his weakness, his rash, and his fever. His temperature was 102 when he arrived at the hospital, but he had been given acetaminophen and IV fluids. When the patient came to the end, Kaminski had a few more questions. Had he used insect repellent during his time in South America? No, the priest remembered. A fellow priest gave him a wristband that was supposed to keep mosquitoes at bay. While he was there, he didn’t feel a single bite. He drank only bottled water, he added. Did he leave town or go for a walk in wooded areas? Had he been in contact with pets or farm animals? No, he was too busy to leave the hotel where the conference was being held.

Kaminski asked if he had body pain. He did. And earlier his right hand felt sore and a little weak. He had difficulty carrying his suitcase. On the ride home, his neck felt strangely weak, as if his head had suddenly become much heavier. His neck still felt sore and stiff. The doctor asked him if he could put his chin on his chest. A stiff neck can indicate meningitis. But the patient showed that he could do it. He was worried, the priest told Kaminski. He had only felt so ill once in his life – and then he was diagnosed with lymphoma. Could it come back? In the emergency room, the hematology-oncology team recommended a CT scan of his chest, abdomen and pelvis, but he had not yet had one. Kaminsky told the concerned man that he thought an infection was much more likely than cancer. But after the CT scan they would know more.

A bite on his ankle?

While examining the priest, Kaminski noticed that the rash was on his back, arms, and chest. It looked like a sunburn and the red skin turned pale to almost white when Kaminsky pressed his finger into the brightly colored skin on his chest, indicating that it was some kind of inflammation in the skin and not blood leaking from the blood vessels below. . There was a tender red lump on his ankle – possibly a bite. Otherwise, his exam was unremarkable. The lymph nodes in his neck and groin and those under his arms were not enlarged. If he had lymphoma, it wasn’t clear. An infection was still the most likely cause of his misery.

According to the Centers for Disease Control and Prevention, the doctor told the priest, there was an outbreak of chikungunya fever — a viral infection spread by mosquitoes — in Paraguay. And most of the cases were reported where he had been, in Asunción. The disease is usually not fatal, but can cause arthritis that can last for months or even years after the infection clears.

Of course, there were other possibilities, Kaminski added. It could be dengue, another viral disease spread by the same mosquito. Dengue can cause high fever and body aches so severe that the disease is called breakbone fever. And it can be fatal. Although patients infected the first time often simply feel miserable, those unlucky enough to contract the infection a second time are at risk of developing a hemorrhagic version of the infection. Each infection is common throughout South America. Every virus is a virus, spread by the same mosquito. Chikungunya is known for its abrupt onset and short incubation period, which is why it was first on his list. Another possibility was that it was something he caught before leaving his home in the Northeast. Maybe a tick-borne disease, like Lyme or anaplasmosis. They should have the answer within a week.

Persistent pain and fatigue

The patient felt better the next day and was eager to go home. The fever and weakness were gone and the rash faded. Only the pain remained. His doctors still weren’t sure what he had. All that was known at the time was that this was not a recurrence of his lymphoma. The CT scan showed a few enlarged lymph nodes in his chest, but the radiologist thought these most closely resembled an infection. The scans of his abdomen and pelvis, where his original cancer was located, looked good.

In the days after the priest’s resignation, Kaminski watched as the test results came back. The test for chikungunya was negative. This also applied to the test for dengue. It wasn’t any of the other diseases he and the infectious disease doctors had looked for.

As for the patient, although the fever had subsided by the time he left the hospital, the fatigue and body aches continued. His head felt cloudy; even reading was difficult. Over the next few weeks he felt better, but not well. He went to Zuromskis and described his persistent malaise. What else could this be? Zuromskis smiled. He was convinced this was chikungunya. But the test was negative, the patient reminded him. “That test was negative at the time,” he replied. If he were to repeat the test now, the doctor was sure it would be positive.

Those initial results showed the priest’s immune response to each of the infections they were looking for. If he had ever been exposed to that insect before, the test looking for the antibody would immediately be positive; the template to fight that insect would have already been created and stored by its immune system. If this were instead a first-time infection, it would take days for the body to prepare and produce the tailor-made antibodies tailored to this specific invader. It may have been negative when he was in the hospital, but Zuromskis was confident it wouldn’t be negative now. He sent the tests for the suspected viruses. The rash came back a few days later. Only one was positive. Very positive. He had chikungunya fever.

The trip to Paraguay was eight months ago. Full recovery was slow. The stiffness and joint pain lasted for months. Only recently has he been able to climb stairs with his old strength and speed. And yet, despite the infection and his history of cancer, he is a healthy man, he says.

Lisa Sanders, MD, is a contributing writer for the magazine. Her latest book is ‘Diagnosis: Solving the Most Baffling Medical Mysteries.’ If you would like to share a solved case, write to her at Lisa.Sandersmdnyt@gmail.com.