14. The Farmer
I met Luke on a winter Monday, at the outpatient clinic. It was a regular day there, I left home earlier so I wouldn’t be late because of the snow, and ended up getting there too early. Something that wasn’t so rare I have to say. Either way, I decided to take an extra time reading the charts while waiting for the patients to arrive.
He was maybe the 5th chart I read. Luke Jones was 57 years old and was referred to the clinic by Dermatology. Huh. He consulted in Derm for investigation of a persistent rash and was sent here when one of the residents there found a blood sugar of 190 mg/dl while reviewing Mr. Jones’ exams. And that was it really. Nothing else on his papers.
I got to him in the middle of the morning. He came to the office walking slowly, I remember thinking he looked a little bit older, tired. Even so, he was well tidy with a plaid shirt and jeans.
‘Hi, Mr. Jones! I am Lisa Diaz, your doctor today.’
‘Hi, Doctor.’ He held out his hand to greet me. ‘Call me Luke. Thank you for seeing me.’
‘How can I help you today, Luke?’
He told me that he lived on a far-away farm with his family. Luke had been a farmer since he could remember. He noticed a skin rash on his groin and legs about 8 months before, when his kids insisted he should schedule an appointment with a dermatologist. So 4 months later he got to the Derm Clinic of Brooklyn’s Hospital.
‘Dr. May was very nice to me. She and a colleague looked at my rash and told me they were not sure what it was yet. So they gave me a prescription for a cream and also some pills, Dr. May said they were steroids I think.’
‘I see. And did the rash get better with the treatment?’
‘No, not really. Sometimes it seems like it's going to get better in one place but then it just appears again in other spots. So they decided to order a biopsy last week, but they told me the results may take a while.’
I asked Luke about his general health. He said he didn’t know about any medical condition and never had any complaints, but he also said he hadn’t been seen by a doctor in years. That’s why Dr. May requested some blood work for him and found his hyperglycemia, for which she sent him there. On his review of systems, he told me he had lost about 12kg (26.5 lbs) in the last year. The red flag that no one wants to hear. He also had persistent diarrhea which he attributed to his age.
On his physical exam, I couldn’t help but notice how weak he was. With his plaid shirt off his thinness was even more evident. Apart from that, he had cheilitis on the corners of his mouth and the rash as he had described. Itching cutaneous eruptions with scaly borders especially on the groin area, but also on his legs. Add to that the diarrhea, weight loss, and apparently recent-onset diabetes.
You can probably guess that cancer popped on my mind. I thoroughly went through all the exams Mr. Jones had already taken on his initial workup and decided to request the ones I thought was missing. I first requested an abdominal ultrasound, and as soon as I saw the hypoechoic mass in the tail of the pancreas, I requested the CT scan with contrast. You know what they say, don’t mess with the pancreas.
When the results came back, we already had a solid idea of what was happening. The CT scan showed a tumor in the pancreas. That combined with sky-rocketed glucagon levels on the blood and the characteristic necrolytic migratory erythema that came back on the biopsy made Glucagonoma a very likely diagnosis. I started Luke on Octreotide to improve his symptoms while he went through all the staging workup.
Sadly, his cancer was found to be metastatic already.
Three months later, Luke was on a bed in my ward. His diarrhea had improved with the treatment and he made sure to spend all of his time with the people he loved. I had met basically all of his family by then. They were there every day until he passed. Everybody on the floor loved him, including Jane. He always received us with a smile and said a prayer in the morning.
For two weeks Luke was my company in that ward. He made the other patients laugh and hope. When I tried to explain to him more about his condition he said he wasn’t really interested.
‘What matters, Lisa, is what I do from now on.’
‘You already are a great father, Luke. And husband.’
‘Well, you know, it’s always...’
‘Yeah, I know.’ I laughed. He said that to me every day.
‘It’s always a good day to be a better person.’
…
Want to know more about Glucagonoma?
Want to read a real case of Glucagonoma?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4769757/
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