18. The Follow-Up
'Johnny G!'
'Morning, Dr. Diaz.' John the security guard smiled. 'It has been a while.'
'Yes, it has! They changed my schedule of the outpatient clinic.' Then I thought about it for a while. 'But wait, I was still here this week, where were you?' I used to see John at the hall of the clinic every day I was there.
He smiled proudly. 'I am a father now, Dr. Diaz. I was on paternity leave.' He showed me a photo in his phone of the most beautiful baby boy ever. 'That's Adam.'
'Oh my God, congratulations John!' I smiled back. 'I am so happy for you. He looks incredibly like you.' And he did.
'Thank you, Dr. Diaz.' I made a mental note to get something for baby Adam.
Looking at the charts, I happily recognized the name of my first patient: Graham Holt. He had been my inpatient in Gastroenterology a couple of months before. Graham was admitted for an important liver lesion that had been palpated during one of his consultations with his family medicine doctor. Yeah, I said palpated. His CT scan was really suggestive of primary liver cancer, the workup was done and in no more than 3 weeks he was admitted in the hospital for hepatectomy followed by a liver transplant.
He was 55 years old and just the most pleasant guy. He spent a week I think in my wards and made my mornings lighter. He had a follow up scheduled with me that day in February. I didn’t remember that, so it was a nice surprise. I went outside to call him in.
‘Oh, my Lisa! The best doc in the state.’
‘Smart entrance, Graham.’ I laughed.
‘Well, you know me. I treat well those who take care of me.’ He winked.
‘Come on in.’ I said smiling.
He seemed well. In his usual good mood. He assured me he was taking all his meds after the transplant.
‘I didn’t miss a single pill. Scout’s honor.’
‘That’s good, Graham. And how are you feeling these days?’
‘I’m okay really. Nothing to complain.’
‘You know I’m gonna need more than that. Tell me, did you have any fever?’
‘Well… a couple of days ago Sheryl measured my temperature and said I had a slight fever.’ Sheryl was his wife. ‘Don’t remember how much though.’
I internally sighed. Damn it, I had high hopes that the answer to this first question was going to be a no. I looked at Mr. Holt. With all the immunosuppressants, it was reasonable to believe he was having an infection. But in a corner of my mind the hypothesis that he was rejecting the liver was still alive.
I filled him with a gazillion other questions trying to find any other symptom that could point me to some direction. Nothing. I started thinking that maybe Sheryl had made a mistake, maybe Graham hadn’t had a fever after all. Even though I wanted to be true, I doubted. Sheryl was incredibly devoted and responsible. She never missed anything.
As soon as I started my physical exam, I knew I would have to admit him that day. When he took off his shirt I could see a scattered rash starting to appear behind his neck and back. The rest of the exam was absolutely normal, but still, he deserved a proper investigation. As you can imagine, he wasn’t too happy about the idea of staying in the hospital.
‘Graham, I know it’s not what we want. But you know I wouldn’t suggest this if it wasn’t important.’
He stared at the floor for a while ‘Yeah, I know.’ He looked up. ‘Will you keep me company there at least?’
I smiled. ‘You bet.’
I still had one more day in my outpatient week, but I was working that weekend so I did keep my promise. Saturday morning I stopped by his bed. Sheryl was by his side as always and smiled when she saw me.
‘Oh dear, I am so happy to see you! God bless your heart. Graham told me how you admitted him on Thursday.’
‘Thank you, Sheryl. You know it’s my job, and I’m glad you are here with him. And how are you holding up, Graham?’
‘Well, almost the same. Had another fever yesterday, and the rash is now also on my chest. The only new thing is I started having loose stool. I’m not sure if it’s anything yet, probably because of the food here, but Sheryl thought you should know.’
Indeed he was having mild watery diarrhea. In the afternoon I went to check on his workup results. To my relief, his liver function tests were basically normal. But he had a pancytopenia and the cultures we collected on Thursday hadn’t grown anything. In my discussion with the second-year residents, we suspected of maybe a viral infection or drug reaction because of the rash, but the acute transplant rejection was not ruled out. I decided to go back to Graham’s room and examine him again. Head to toes. Maybe I was missing something.
The only extra information I found was that the rash was now on his palms and soles. Not much maybe, but still I decided to bring it up again with the 2nd year on call, Mike.
He thought silently for a while. ‘I’m wondering… What do you think about graft versus host?’
‘Actually, that sounds very likely.’
We ordered a skin biopsy which later confirmed the diagnosis of acute graft versus host disease. We increased his steroids and Mike helped me deliver the news to the family. The prognosis for this condition is far from great I have to say, but thankfully Graham responded reasonably well to the increase in the immunosuppressants. After 12 days, he was discharged from the hospital seeming way better.
I wish I could tell you more about him, about where he is now, if he relapsed or remained well. But after that, I changed rotations and didn’t hear from him again. We don’t always know the end of every patient we see. That doesn’t have to be true for our other relationships though.
The following week, I left tiny baby sneakers for baby Adam at the clinic.
‘Cause he better be a basketball fan when he grows up.’ I winked at John.
‘Thank you, Dr. Lisa.’ John smiled. ‘I will do my best.’
…
Want to know more about Graft Versus Host Disease?
Want to read a real case of Graft Versus Host Disease?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151675/
Clinical Board
Rx: reaction; GI: gastrointestinal.
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