40. The Infections

March 07, 2021


Michael Miller was 66 years old. I was on call on a Sunday when I met him. He was admitted at 8am in the ER and I got his chart about 3pm on the floor. Community-acquired pneumonia.

‘Good afternoon, Mr. Miller. I am Dr. Diaz, nice to meet you!’

‘Hi, Dr. Diaz.’ He smiled at me. ‘It’s nice to meet you too.’

‘So can you tell me about what brought you here, Mr. Miller?’

‘Well, I’ve been feeling tired for some days now. I’ve also had a fever and this bothering cough. It really feels like pneumonia again.’


‘Yes. You see, I have always been healthy. I go to the doctor every now and then for a checkup but I never needed medications or anything. That was until last year. Since then, this is the third time I feel like this.’

I checked his chart on my hand, there was no history of previous admissions. ‘And these 2 other times, were you admitted in a hospital?’

‘I was. But not here. I am from New Jersey, so I went to the hospital there. I am here visiting my kid.’ He pointed to a tall man coming into the room with a cup of coffee. ‘Dr. Diaz, this is my son, Eric.’

‘It’s a pleasure.’ He said as he shook my hand.

So Michael told me the rest of his story. He was strong as a bull, worked his whole life with construction, and built a good life for himself, his wife Edith, and his kids, Eric and Linn.  Basically, in his whole life the cases of pneumonia were the only 2 times he had to seek help.

‘Well, and the third time now.’ Michael laughed at me.

He hadn’t brought his discharge summaries with him, but Eric had some photos of it on his phone. Both episodes were treated successfully and didn’t have any complications. The only note in both documents was that he had anemia during his hospital stay which they recommended an investigation. So I asked Mr. Miller about it.

‘Oh yeah, they told me about that! They asked me to set up an appointment with my doc to check up on it. But honestly, Dr. Diaz, I haven’t gone yet.’

I thanked Michael and Eric and left the room. In the computer, I opened his chest x-ray taken on the ER: a consolidation in the left lower lobe, very consistent with his history and exam. And interestingly not in the same location as his other episodes. After that, I opened his labs. As expected, the anemia was there. But not only that, his kidney function wasn’t so great either. Was this all due to his infection? I wasn’t sure. Anyway his anemia was taking way too long. 

So I decided to stop by Michael’s bed once again before rounds. I was probably missing something.

‘Mr. Miller, is there anything else you have been feeling this past year? Anything at all?’

‘Your pain, dad.’ Eric said when his father couldn’t think of anything. 

‘Oh, that’s true.’ Miller sat on the bed. ‘I started feeling a lot of pain in my back you know.’ He pointed to his lower back. ‘This has been killing me. But it’s probably because of all the years I spent doing heavy work, right doc?’

Worth noting: these ‘Right, doc?’ questions are one of the trickiest to answer. I remembered the first time it happened to me, when I was a medical student. A mother of a child who had been vomiting for some time asked me before I discussed the case with the attending doctor -  ‘It’s probably nothing serious, right doc?’ - And dear God, it’s just so tempting to answer ‘Right.’ as a reflex, like I did to that mom. As soon as I said it I realized I actually did not know what her kid had and whether it was serious or not! I spent the next hour incredibly anxious wondering what my professor would say about the case. 

It was a terrible experience, but I learned my lesson.

‘I am not sure yet, Mr. Miller. But I’ll let you know when I do.’

I asked him some more questions about the pain and examined his back afterward. His pain was impairing his daily activities, it bothered him at night and seemed to be right in his bones of the lower back. I also questioned him about a possible loss of blood in his stool, but he denied it and added that he’d done a colonoscopy 2 years before with no changes.

In rounds, I presented Miller’s case. We began with the management of his pneumonia which seemed to be in a good direction. It probably wouldn’t take too long for him to get discharged.

‘So we’re settled on that.’ Lucy said. ‘But what is wrong with Mr. Miller?’ Peter and I looked at her. ‘We know what’s going on with him today, that is, his pneumonia. But we have to see the bigger picture. Tell me his problems.’

‘Well, his anemia.’ I started unsurely. ‘And his struggling kidney function.’

‘Go on.’ Lucy continued.

‘The back pain.’ Peter completed but Lucy didn’t seem satisfied.

‘There’s something you are both forgetting.’ Dr. Collins said, crossing her legs. ‘His infections. Michael was a healthy man, and suddenly he has 3 pulmonary infections in one year. We must ask ourselves why that is.’

Peter and I nodded.

‘So, anemia, kidney failure, bone pain, and recurrent infections.’ I said out loud and it hit me. I started going through his labs again and there it was. ‘His calcium is also a bit elevated.’ Lucy smiled seeing where I was going. ‘Multiple Myeloma.’

‘Precisely.’ She approved. ‘Let’s get him a serum protein electrophoresis for starters.’

So the answer was no. Michael’s pain wasn’t due to all the hard work. Little did he know that a couple of days later I would be telling him his bone marrow aspiration had confirmed his cancer. He, Edith and his kids were about to enter the chemotherapy struggle. Just like that.

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Dys: dysfunction; Infx: infection; prolif: proliferation; Tt: treatment.

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