24. The Good Soldier


I was having coffee in the cafeteria while waiting for rounds. Kate was still busy with her patients and I couldn’t find Jax or Peter so I was by myself at one small table. I had gotten to the hospital early as usual and my patients’ cases were pretty straightforward except for one. Gordon Palmer.

I had been racking my brain for days to find out what was wrong with Gordon. And nothing came up. He was a 25-year-old white male with crew-cut dark hair. I met him on a Sunday right after he was admitted. But let’s back it up a little.

Gordon was a fine young man with nothing to complain of - health-wise anyway. Athletic as he was, he decided to join the army when he was 18. By the time he turned 24, Gordon was an exemplary soldier respected by his peers and appreciated by his superiors. He turned out to be a skilled shooter, natural leader, and fast learner. Yes, he was that good. I had the opportunity to hear all of it from many of the soldiers and the captain who came to visit him in Brooklyn Hospital. 

A couple of months before Gordon was admitted, his buddies noted he started coughing frequently. None of them were too worried though because the good soldier had one fault: he smoked. So everyone, including Gordon, blamed the cigarettes for the coughing fits. That is, until the day they brought him to the hospital.

Gordon was alone in his morning run when the coughing started. Around one hour later his roommates went looking for him. It was time to report for duty and Gordon hadn’t shown up. 

‘He was never late.’ One of his colleagues told me. ‘Something had to be wrong.’

‘We started following his trail until we found him lying on the floor. His white shirt was covered with blood.’

So they quickly brought him to Brooklyn Hospital which was the closest one to their military base. At the ED, Gordon started waking up but he looked pale and out of breath. Initial workup showed hemoglobin of 7 and bilateral pulmonary infiltrates on chest x-ray. He confessed to the ER doctors he had been coughing up blood for over two weeks.

After being stabilized he was brought to the floor, where Dr. Rivers and I started looking for some answers. We thoroughly went through his history and examined him from head to toe. The anemia was the only abnormal finding in his blood work and could be explained by his blood loss through the lungs. So he underwent a bronchoscopy which was clean, and a CT scan, which showed diffuse ground glass opacities. 

So there I was at the cafeteria. I had just seen Gordon again and he told me he had another bleeding episode the day before. I talked to the Pulm Team and they hinted that Gordon would likely need another bronchoscopy to look for lesions since his bleeding recurred. I sighed. Something was off, I could bet the second bronchoscopy would be clean like the first one. 

Lost in my thoughts, I missed Jax sneaking up and startling me.

'Jerk.' I rolled my eyes and he smiled satisfied with himself.

'What's up, Liz?  Why do you have that look on your face?' He said as he sipped my coffee and frowned in disapproval. 'Why do you ruin your coffee with cinnamon?'

'Because it tastes good.' I said taking my coffee back. 'And I am trying to figure out what my patient has.'

'Alright.' Jax glanced at his watch. 'You have 5 minutes. What's the case?'

I started quickly summarizing everything I knew about Gordon.

'Ok, so why is he bleeding?'

'The million dollar question.' I answered.

'Yeah, but you know. His coagulation is fine, there are no apparent lesions in the bronchoscopy, so maybe there’s something microscopic going on in these vessels.’ 

'Hum, maybe. But only in the lungs? Why isn't he bleeding anywhere else?'

Jax shrugged. 'Maybe he is, and we just didn't check.'

He took a couple more sips from the coffee he had criticized and took off.

I got up to walk towards rounds but decided to stop by Gordon's room once again. I found him hopping on the bed.

'Oh, hi, Dr. Diaz. I wasn't expecting to see you again so soon. How can I help you?'

I silently laughed in my mind. He would say that to me every morning even though I was the one supposed to help him.

'I'm just checking in on you.' I said. 'Speaking of, did you bleed from anywhere else, Gordon?'

'No, ma’am.'

He started getting up from the bed again.

'Where are you going, Palmer?'

'To the bathroom. I am sorry, I just remembered I forgot to flush.'

'No, stay! I got it, don't worry.'

I walked to the toilet and frowned. Was that blood? The urine in the toilet looked quite reddish. I flushed it and went back to the room.

'Gordon, is there any blood in your urine?'

'No, ma’am.'

'is your urine always reddish like that?'

'Sometimes. Depends on what I eat. Do you think that’s blood?'

'I see. I’m not sure yet. We'll get your urine tested today ok?'

'Yes, ma’am.'

I rushed for rounds while checking my phone to find his urine test from admission.

‘I’m so sorry.’ I said when I found Kate and Dr. Rivers waiting for me.

‘No worries, Lisa. Shall we start?’ Dr. Rivers answered.

Kate went first presenting one of her patients and when my turn came I decided to start it off with Gordon. Since we had been discussing his case for some days, I didn’t need to present the whole story from the top. I gave a brief summary of Gordon’s hospital stay so far and finished with my latest finding:

‘And this morning I noticed Gordon seems to be having macroscopic hematuria, so I ordered a urinalysis to confirm it.’

‘Hmm, this is interesting, Lisa. Did you check his previous urinalysis?’ Dr. Rivers asked.

‘Yes, it had slight proteinuria and rare erythrocytes.’

‘So that’s something we can work with. Alveolar hemorrhage is one thing, but accompanied by hematuria is a whole other thing. Renal function?’

‘Normal at admission, but slightly decreasing since. We’ll see today’s results.’

‘Okay, and what are you thinking?’

I froze at the question. I couldn’t think of anything. And then I remembered whatever Jax had told me.

‘He could have something in his vessels.’ I started unsurely. ‘Wegener’s could affect lungs and kidneys!’ I continued more confident.

‘True, very good, although he’s a little younger than the average age. What other condition affects vessels of lungs and kidneys in young adults?’

‘Goodpasture Syndrome.’ Kate answered.

‘That’s correct. Antibodies against basement membranes cause a small vessel vasculitis with bleeding. I think it fits pretty well, so let’s run the tests.’

Gordon underwent all sorts of blood tests and the diagnosis of Goodpasture was confirmed with anti-GBM antibodies in the serum and kidney biopsy. He was started on treatment with plasmapheresis, corticosteroids, and cyclophosphamide and eventually was discharged for outpatient follow-up.

‘Thank you for your service, Dr. Diaz.’ He saluted me before he left the hospital.

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Clinical Board
RPGN: rapidly progressive glomerulonephritis; IF: Immunofluorescence; Ab: antibodies; Tt: treatment; Immunosup: immunosup: immunosuppressants.

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