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 residence he shared with three other priests. He gripped the handrail on either side of the stairs and forced his foot onto the first step. Slowly he pulled himself up the two flights of stairs to his rooms. His trip home to Boston from a conference in Asunción, Paraguay, had been rough. It was an overnight trip, but he hadn’t been able to sleep at all. Now all he wanted to do was take off his Roman collar and lie down.

When he finally made it to his rooms, he looked into his bathroom mirror. His face was bright red and shiny with sweat. The red continued down his chest and onto his belly. His whole body ached. He crawled gratefully beneath 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 chills confirmed what he already suspected: He was sick. And that worried him.

Six years earlier he felt this bad after a flight. He went to the hospital and was diagnosed with non-Hodgkin’s lymphoma. Treatment had been brutal. The seven months of chemotherapy killed the cancer but also destroyed his body’s ability to make any blood for himself. He was rescued with stem cells — the cells that create the blood he needed — harvested from his own body before he started the treatment. He had been disease-free since then but knew that recurrence was possible. It was a low-level anxiety he faced with every subsequent symptom. Before the cancer, he might have just toughed it out. Not now.

He called Dr. Peter Zuromskis, his longtime primary care physician. He hated to bother him on a Saturday, but he thought this was important enough to merit the call. “Go to the emergency room,” the doctor told him after hearing of his trip and fever, rash and whole-body weakness. “You need to be seen.”

Trouble Carrying His Suitcase

One of his housemates drove him to the emergency department at Beth Israel Deaconess Medical Center. It was dark outside by the time he passed through the busy E.D. and into a room in the hospital. He repeated his story a half-dozen times to various doctors, nurses and trainees as he was poked, prodded, stuck and imaged for hours. The priest was grateful for the quiet of the small room where he was finally able to rest.

Dr. Martin Kaminski was the hospitalist on the night shift. He introduced himself and asked the patient to tell his story, listening as the man described his trip, his weakness, his rash, his fever. His temperature was 102 when he arrived at the hospital but had come down with acetaminophen and IV fluids. When the patient got to the end, Kaminski had a few more questions. Had he used insect repellent while in South America? No, the priest recalled. A fellow priest gave him a wristband that was supposed to keep the mosquitoes away. He hadn’t felt any bites while there. He drank only bottled water, he added. Did he leave the city or go for hikes in wooded areas? Had he been in contact with any domestic or farm animals? No, he was too busy to leave the hotel where the conference was held.

Kaminski asked if he had any body aches. He did. And earlier, his right hand felt achy and a little weak. He had trouble carrying his suitcase. On the ride home, his neck felt strangely weak, as if his head had suddenly gotten 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 could suggest meningitis. But the patient demonstrated that he could. He was worried, the priest told Kaminski. He had felt this sick only once in his life — and that time was diagnosed with lymphoma. Could it have come back? In the E.D., the hematology-oncology team recommended a CT scan of his chest, abdomen and pelvis, but he hadn’t had it yet. Kaminsky told the anxious man that he thought an infection was much more likely than cancer. But they would know more after the CT scan.

A Bite on His Ankle?

As he examined the priest, Kaminski noted that his rash was on his back and arms as well as his chest. It looked like a sunburn, and the red skin paled to near-white when Kaminsky pressed his finger into the bright-colored skin on his chest, indicating that it was some kind of inflammation in the skin rather than blood leaking from the vessels below it. There was a tender red nodule 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 obvious. 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 had been reported where he’d been, in Asunción. The disease usually isn’t fatal but can cause an arthritis that can last months or even years after the infection is gone.

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

Lingering Aches and Fatigue

The patient felt better by the next day and was eager to go home. The fever and weakness were gone, and the rash was fading. Only the achiness remained. His doctors still weren’t sure what he had. The only thing known at that point was that this was not a recurrence of his lymphoma. The CT scan showed a couple of enlarged lymph nodes in his chest, but the radiologist thought those were most consistent with an infection. The scans of his abdomen and pelvis, where his original cancer had been located, looked fine.

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

As for the patient, although the fever was gone by the time he left the hospital, the fatigue and body aches hung on. His head felt cloudy; even reading was hard. Over the following weeks he felt better, but not well. He went to see Zuromskis and described his persistent malaise. What else could this be? Zuromskis smiled. He was confident this was chikungunya. But the test was negative, the patient reminded him. “That test was negative then,” he replied. If he repeated the test now, the doctor felt certain it would be positive.

Those first results showed the priest’s immune response to each of the infections they looked for. If he had ever been exposed to that bug before, the test looking for the antibody would read positive immediately; the template to fight off that bug would have already been made by his immune system and stored away. If, instead, this was a first infection, it would take days for the body to gear up and create the bespoke antibodies, tailored to this specific invader. It might have been negative while he was in the hospital, but Zuromskis was sure it wouldn’t be negative now. He sent the tests for the suspected viruses. The results 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 pains lasted for months. It’s only recently that he has been able to take on the stairs with his old vigor and speed. And yet, despite the infection and his history of cancer, he is, he tells me, a healthy man.

Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis:Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write her [email protected].