Error in Diagnosis (23 page)

Thirty minutes before President Stephen Kellar was to make his national address, Renatta Brickell was escorted into his office by one of his assistants. He sat behind his desk, his eyes intently focused on the pages of his speech. A few moments later, he looked up and saw her. He glanced around the Oval Office at the harried group of aides and technicians.

“May I have a few minutes, please?” he asked them as he stood up and escorted Renatta to the couch. “My address is only twenty minutes long. I thought I should speak a bit longer but Carmondy and the rest were opposed to the idea. What do you think?”

“I think the length is fine, sir. It covers all the key points without belaboring or skimming over any of them.”

He flipped through the pages, making little eye contact with her.

“I know you've looked over the text but I'd like to read a part of it aloud to you.” He reached for a glass and took two quick sips of water. “From the beginning, my administration has viewed the safety of both the mothers and the fetuses as paramount in importance. We have invited the leading scientific and religious minds in the country and individuals from all walks of life to attend meetings and fact-finding sessions. Every one of those participants has searched his or her soul in evaluating this difficult moral dilemma. Ultimately, this decision has to be left to the families, their consulting physicians and spiritual advisors.” He looked up. “What do you think?”

“It's well phrased, Mr. President.”

Just then, one of his aides entered the room.

“Ten minutes, sir.”

“Thank you.” He turned to Renatta. “Is there anything else you can think of?”

“No, Mr. President. I wouldn't change or add a word. It's an excellent speech.”

Kellar stood up and walked back to his desk. The cameras and lighting equipment had been in place for hours. He picked up the phone and told his administrative aide to send everybody back in.

“Any last-minute thoughts?” he inquired, his face just slightly flushed.

Renatta was taken back. President Stephen Kellar's calm but stalwart confidence was conspicuously absent.

“Sir, in a few minutes the people of this country are going to know how seriously their president is reacting to this catastrophic outbreak. They'll know as a result of
your efforts, thousands of scientists, doctors and other health care professionals are doing everything humanly possible to stop the spread of this disease.”

“I wish I shared your unbridled optimism,” he said with a wrinkled brow.

Renatta again wished Kellar luck and then exited the Oval Office to watch his address with other key members of his team. She wasn't an expert on the political process; she was a doctor. But at the moment she was convinced that President Stephen Kellar was five short minutes away from making the most important address of his career.

After watching the president's speech at Mike's house, Jack and Madison headed back to the hospital.

“What do you have planned for the rest of the evening?” he asked her.

“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.”

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.”