A particularly rapid decline
It was late afternoon when Dr Jeremy Jaskunas, in his care, first met the patient. She brought a diary detailing the symptoms of the past few weeks, as well as a huge stack of results from all of her emergency room and lab visits. He put them aside to hear her tell her story of random pains, weakness and fevers. He was struck by how quickly this patient had transformed from an athlete training for a marathon to someone so weak and debilitated that she had to use a walker a few days before arriving at the hospital. On examination, her heart was pounding and her arms and legs were weak and tender.
Although the patient now has many abnormal lab results, the most striking are the liver, which within days has gone from near normal to over 20 times normal. Jaskunas ordered an ultrasound and then an MRI of the liver. Imaging revealed a shadow that darkens much of the liver’s uniform gray. It could be an infection, the radiologist reported, but it was most likely some form of cancer.
A final test
Even before Dr Saurabh Rajguru, an oncologist, met the patient, he had a good idea of ââwhat she could have. The abnormal red blood cells told her that something was wrong with her bone marrow, where blood is made. And an MRI of his brain showed abnormalities there, so it must have been a disease that could spread throughout his body. And finally, there were very few diseases that could progress as quickly as this one. She probably had some type of lymphoma, Rajguru told the patient and her partner. It was scary to hear those words spoken out loud, but for the anxious couple, it was a relief to finally be able to put a name to what she had been going through the past few weeks.
Lymphomas are cancers of the lymph nodes, Rajguru explained. They usually cause painless enlargement of these collections of white blood cells. There are many types of lymphoma, depending on the type of cell involved and how quickly these now abnormal cells reproduce. The diagnosis is usually made by testing the abnormal lymph node tissue, but in her case, they were all hidden deep in her abdomen. The next step should be a bone marrow biopsy, Rajguru said. And if that didn’t give them an answer, she would need a liver biopsy.
The next morning, the patient was taken to the operating room. She was lying on her stomach with curtains covering most of her body, leaving only a patch at the top of her butt exposed. After numbing the area, a radiologist inserted a large needle into her pelvic bone. It didn’t hurt, the patient told me, but the pressure was intense.
She got her answer later that day. She suffered from Burkitt’s lymphoma, a disease most commonly seen in children. It is one of the fastest growing tumors known, with a tumor cell doubling time of 25 hours. In oncology, Rajguru told me, they say that a doctor should never let the sun go down on a suspected case of Burkitt. The patient began chemotherapy treatment the next day.