Error in Diagnosis (14 page)

Jack walked slowly around the hospital gift shop, browsing for another Christmas present for his daughter. Being apart from her, especially during the holidays, was becoming increasingly difficult. He had even contacted the American Hospital in Paris to see if a consulting position could be arranged for a few months, but the amount of bureaucratic hurdles to leap over made the prospect near impossible.

After a few more minutes of perusing the store's inventory, he decided on a rainbow unicorn stuffed toy. He was just about to sign the credit card receipt when he noticed Madison walk into the store.

“How did your meeting with Isabella's grandmother go?”

“No revelations,” he answered, handing the pen back
to the volunteer. “She did mention Isabella was having some lower abdominal and pelvic pain for the past few weeks. She spoke to her family physician about it, but he wasn't concerned.”

“Did he order an ultrasound or a CT scan?”

“No. He didn't think any tests were necessary.” Jack grinned.

“What?” she asked.

“It was nothing. I asked her if she had noticed anything at all out of the ordinary and she told me Isabella had been experiencing very rapid breast development of late.” He added, “I assured her that wasn't what was making Isabella sick.”

Staring steadily at Jack, Madison eased the container of coffee away from her lips.

“You're sure about the pelvic pain?” she asked.

“Yeah.”

“And the rapid breast development?”

“Of course I'm sure. I may be getting a little senile, but I still remember how to take a medical history.” A little taken back, he asked. “What's going on?”

Madison handed her coffee cup to Jack, grabbed her cell phone and dialed Marc.

While she waited for him to answer, she paced back and forth.

“C'mon, Marc, pick up your damn phone.” Finally, on the sixth ring, he answered. “Marc, find an ultrasound machine right now and meet me in Isabella's room. Don't ask me any questions. I'll explain everything when I see
you.” She drew a sharp breath, gestured toward the lobby and said, “C'mon, let's go.”

“What's going on?”

With a smile that couldn't be contained, she answered, “Well, if I'm right, you may have just stumbled across our first real clue for finding out what's causing GNS.”

University Medical Center
Birmingham, Alabama

One year ago, quite by chance, Dr. Mary Grandeson, director of toxicology services, stumbled upon the perfect hideaway. The small library in the old rehabilitation unit had, for all intents and purposes, been forgotten and abandoned. The furnishings were sparse, consisting of a black metal desk, two upholstered chairs and a saggy corduroy couch. In spite of the hint of must in the air, the small library was the perfect escape from the constant barrage of interruptions, and for Mary, the perfect place to work.

As all of the physicians who had been asked by the surgeon general to serve on the elite GNS task force had done, Mary had shelved all of her other projects in order
to devote herself entirely to the current GNS crisis. After her presentation at the CDC in Atlanta, she had heard from many of the attendees who expressed their strong conviction that the cause and the cure for GNS might very possibly come from her work in nanotechnology.

One of the few people who was aware of Mary's hideout was her senior research associate, Wright Zarella. Prematurely bald with curled shoulders, Wright had earned his M.D. and had completed a pathology residency in Minneapolis. Because of his special interest in the threat of nanotoxins and e-waste products, he applied to and was accepted to Mary's department as a Ph.D. candidate.

Working on her laptop, she barely noticed when he strolled into the library.

“I think I've come across something that might interest you,” he told her, pulling up a chair.

She barely looked up from her laptop. “I'm listening.”

He slid a manila file across the desk. She picked it up and shook her head. “Just how many of those awful sweater vests do you own?”

“I don't know,” he answered looking down at the sweater. “About a dozen I guess. You never said anything before.”

“That's because they're terrible,” she said with a quick roll of the eyes as she opened the file. “Toxicity of cosmetic skin care products? C'mon, Wright, we've been over this ground so many times it's trampled beyond recognition.”

“Well, there may be one small patch we missed. Keep
reading.” She looked at him with a measure of skepticism as she waited for him to continue. “A few years ago, when certain skin care product manufacturers began using nanoparticles, concern was raised that these particles could theoretically penetrate the skin and be toxic to the user.”

“I'm familiar with the theory. As you may recall, I'm the one who taught it to you. But the key word is
theoretical
, and as far as I know, nobody's ever been able to prove it.”

“That's true, but all of those studies were done on normal skin.”

“What other kind is there?”

“Well, being pregnant changes the hormonal balance in the body. Maybe that includes the skin,” he said with arched eyebrows. He pointed to the file in front of her. “Last month an article appeared in an obscure European medical journal. The research group is from Magdeburg, Germany. They studied skin penetration of nanoparticles, but with a slightly different slant. Instead of normal skin, they studied it in a number of different situations.”

“Like what?”

“Well, amongst others—pregnancy. Their conclusion was that these particles easily penetrate the skin.”

“Did they offer an explanation as to why?”

“Nothing definite. They can only speculate that the hormonal changes during pregnancy affect the normal skin barrier in some way that allowed these particles to pass through and get into the bloodstream.”

Mary slid the article from the folder. “What type of nanoparticles did they use?”

“They chose three; all of which are commonly used in cosmetic skin creams.”

Grandeson pushed her chair closer to the desk and then read every word of the article.

“This is a pretty small study group but it seems well done from a scientific standpoint.” She tossed the article back on the desk. “Assuming the study is correct and some of these nanoparticles can penetrate the skin. Even if they do, there's still no evidence they cause any harm.”

“But there's no evidence they don't.”

Grandeson exhaled gradually, stood up and strolled over to the only window in the room.

“So, you're postulating that a nanoparticle that has never been proven to be harmful can penetrate the skin of pregnant women and cause GNS.”

“I'm simply saying it's a possibility.”

“Okay, let's follow your logic pattern for a moment. I have two questions. The nanoparticles used in this research have been around in cosmetic products for the last five years or so. If they're the cause of GNS, why has it taken this long for the first cases to appear?”

Wright remained silent for a few seconds and then with a wrinkled forehead asked, “What's your second question?”

“Why have all of these cases presented within days of each other?”

“I have no answer for that one either,” he responded.

“Any idea of the type of cosmetic product we might be looking for?”

“Nope, but there are just so many new skin care lotions and other products hitting the market monthly. If we go back six months, it shouldn't be too difficult to come up with a list.”

Mary leaned forward and replaced the article in the folder. “I don't suppose we already have information in the National Patient Registry regarding the cosmetic products our GNS patients were using.”

“Unfortunately, none of the hospitals thought to include those questions in the basic family interview.”

“Before we send the whole country into a frenzy with a theory that may be nothing more than a good bedtime story, let's reinterview the GNS families here in Alabama regarding skin care and other cosmetic products.”

“You're talking about a few hundred patients, and time is something we don't have a lot of. We're going to need some help.”

She sent an easy nod in his direction. “You're an industrious young man, Wright. I'm sure you'll be able to muster all the assistance you'll need.”

With a dubious grin, he answered, “I'll put a questionnaire together for the families and run it past you before we get started.”

“Sounds good. Our next meeting's in Atlanta in a few days. It would be nice if we had some preliminary information on this stuff to present.”

“Shouldn't be a problem.”

He jumped to his feet and headed for the door.
Grandeson closed the lid to her laptop. Her mind was doing backflips, wondering if there could be any possibility Wright was onto something. There were hundreds of brilliant minds in the country working tirelessly to solve the enigma that was GNS. All of them were feeling the mounting pressure from countless national and state medical organizations and elected officials to come up with an answer. You couldn't turn on the television or pick up a newspaper without being inundated with the latest GNS horror stories. Mary was no different than millions of other people in the country—the usual joy of the holiday season was conspicuously missing from her life.

Her eyes drifted to the far wall. She thought about her pregnant sister in Oklahoma she had been calling twice a day since the first case of GNS was reported. She was five months pregnant and, so far, perfectly healthy. Staring at a framed photograph of her sister and her on a ski vacation, she wondered if Wright could possibly be correct, which would mean the solution to GNS had been staring her in the face right from day one.

By the time Jack and Madison reached Isabella's room, Marc had already powered up the ultrasound machine and applied a generous layer of jelly to her lower abdomen.

“I'm all set,” he said, selecting one of the probes that hung from the side of the machine. “It might help if I knew what I was I looking for.”

“I want to see her ovaries,” Madison said, looking over her shoulder at Jack. “What side did you say her pain was on?”

“Her right.”

She looked back at Marc. “Start on the left.”

“She's very thin. We should get a pretty good view,” he said, using a practiced touch to tilt the probe in various directions and angles across her abdomen. “There,” he said, gesturing at the screen. “There's the left ovary. Size
and appearance seem fine. Looks like a normal ovary to me.”

“I agree,” Madison said. “Let's have a look at the uterus and then the right ovary.”

Marc eased the probe toward the right. “The uterus appears normal.”

To Jack's untrained eye, the blending of the gray, black and white shades and shadows looked more like a complex weather map than the female reproductive organs.

It took Marc only a few seconds to locate the right ovary. He was still making the final adjustments to sharpen the image when Madison jumped forward. “There it is,” she said, pointing to the central portion of the screen. “It's not the biggest ovarian tumor I've ever seen, but it's real and it's right there.”

Marc held the probe perfectly still. “I'd say it's about two centimeters.”

“Three,” she stated with certainty “Make sure you get some good pictures.”

“Have I ever let you down before?” he responded with a broad smile.

Feeling invisible, Jack asked, “What are you guys talking about?”

“Isabella has a tumor on her ovary,” Madison explained. “Some of these tumors produce large amounts of hormones, which are the exact same hormones that normal pregnant women produce. So, it would seem likely from a hormonal standpoint that there's no difference between Isabella and every woman in the country with GNS.”

Marc's grin widened. “So, if we measure the hormone levels in Isabella's blood . . .”

“We might be able figure out exactly which one made her and the other women susceptible to GNS. Let's get a gynecologist down here right now. I want this tumor out as soon as possible.”

“Anybody in particular or whoever's on call?” Marc asked, reaching for his phone.

“See if Schiller's available. If he doesn't answer, leave a message for him to call me on my cell.”

Jack tapped his chin a few times, and then, with a note of caution in his voice, said, “I'd agree this is an important discovery, but I'm not sure it means we've hit the mother lode.” Marc and Madison stopped what they were doing and then shifted their collective gaze to Jack. “Well, even if your hormone theory's correct, it just means that GNS is associated with a high level of some hormone. It doesn't mean it's the cause.”

“I don't think you're getting this,” Madison said. “If we remove this tumor and Isabella recovers, it will mean that the other women with GNS don't need Vitracide or any other dangerous drug Hollis Sinclair might suggest. They'll get better on their own once their hormone levels are back to normal.”

“But that wouldn't happen until their pregnancies come to an end . . . in one way or another.”

“Obviously,” Madison said.

“But . . . for those women who haven't reached their twenty-sixth week . . . well, aren't those babies too small to survive?”

“I know where you're going with this, Jack. I don't think now's the best time for us to enter into a moral debate on the pros and cons of termination. Every physician in the country who's trying to cure this disease believes we're going to start seeing a lot more deaths in the days to come.”

“I understand that, but don't you think we should at least think about the—”

“When we encounter the moral bridges, well . . . we'll just have to jump off them then. Right now all I care about is getting this tumor out of Isabella.”

Jack took a steady look at Madison. It was clear to him she had nothing more to say regarding his concerns. It was at that moment that her cell phone rang.

“Hi, Jeff. Thanks for calling back. I was hoping you had a few minutes to come over to the ICU. I'm taking care of a pretty sick fourteen-year-old with GNS. We just discovered she has an ovarian tumor, which I'd like to have removed as soon as possible.” A few seconds passed and she said, “That's great. No, I consider this urgent. I'll wait for you.” She quickly tapped in another number. She covered the mouthpiece and looked over at Jack and Marc. “Schiller's on his way. I'm going to call Helen Morales and fill her in.”

Jack wondered if in her excitement, Madison had overlooked one obvious reality: If removing Isabella's tumor didn't work, Hollis Sinclair's theory that Vitracide therapy, even with its dangerous side effects, was the only way to cure GNS would dramatically gain credibility.