It’s funny how songs can trigger memories. For example, when Peggy Lee’s “Fever” recently played on my car radio, I thought of a long-ago patient whom I’ll call Jerry Rivers.
Jerry had fever, all right—but it wasn’t the sizzle of passion. Ten years ago, when I first met him, the trumpeter who helped launch the “cool jazz” movement of the 1950s had been hitting 101 degrees Fahrenheit for weeks. His internist had already sent out routine blood, urine, and stool cultures. No answers there. Nor had abdominal scans revealed a hidden abscess. From the moment we met, I knew Jerry had no ordinary bug.
Across the Formica desk of my small exam room, the frail but animated 74-year-old—his head and torso lightly bobbing—gazed at me, perplexed. “I don’t get it,” he said. “When that staph infection gave me fevers last year, my doctors figured it out right away.”
Jerry’s casual comment belied a complex medical history. Decades earlier, like many musicians of his era, he had experimented with heroin and picked up hepatitis C. In the time since then, the virus had silently scarred his liver. More recently, Jerry’s spleen had started to destroy red cells and platelets, those minuscule bloodborne bits that stanch bleeding. His doctors concluded that his spleen—large and flecked with calcium deposits—harbored a lymphoma.
As a result, six months before we met, Jerry underwent a splenectomy, only to suffer a post-operation bout with Staphylococcus aureus, that notorious invader of hospital wounds. Fortunately, strong antibiotics quickly cured the infection. Or had they?
To add to my challenge, minus a spleen Jerry was now vulnerable to certain encapsulated bacteria—Streptococcus pneumoniae in particular—which are normally coated by antibodies produced by the spleen prior to being eaten by white blood cells. His missing spleen also predisposed him to exotic bugs like the malaria parasite. But truth be told, Jerry’s simmering illness didn’t suggest an aggressive culprit like staph or pneumococcus, and he had never traveled to any place where he could plausibly have contracted malaria.
Back to basics. As Jerry once again felt his forehead for warmth, I started scanning his chart, so extensive that it filled two large volumes. Most of its notes dealt with his hepatitis C infection, which was rapidly progressing. Of course, I already knew that from Jerry’s physical exam, which had revealed classic signs of liver disease: fluid in the abdomen, reddened palms, and small, spidery veins on the skin.
“Hmm, here’s something interesting,” I said, suddenly looking up. “I just found a CT scan from last year that shows a calcified lymph node near your heart and some pleural scarring. Did you test positive for tuberculosis as a kid?”
“No,” Jerry replied. “Not that I remember.”
His answer didn’t reassure me. Because TB was widespread during the first half of the 20th century, many people in Jerry’s age group were unknowingly exposed in their youth. Years later, when old or debilitated, such patients could experience an unfortunate reactivation of long-dormant infections. On the other hand, if tuberculosis were the cause of Jerry’s protracted fever, by now I would have expected more abnormalities to show up on his chest X-ray. The film from a week earlier had been clear.
Frustrated by the simultaneous lack and abundance of clues, I closed Jerry’s chart and filled out requisitions for additional blood and urine tests that might detect TB or certain fungal organisms and thus pinpoint the source of his fever. This slow-going approach wasn’t my preference, but my original plan—to admit him to the hospital and pursue an aggressive workup—had been vetoed by the patient.
Soon, however, we were back to Plan A. Jerry’s fevers had accelerated, his tests again yielded no leads, and he was so weak that he needed a wheelchair to get around our medical center. Declining hospitalization was no longer an option.
Once settled in his room, Jerry received a local anesthetic while a medical resident drew a sample of bone marrow from his posterior ilium, an easily accessed pelvic bone. I had the specimen sent for cultures and pathology. Unlike with some cases, I didn’t have to twist any arms to get the procedure done. Jerry’s oncologist also wanted the bone marrow exam to rule out recurrent lymphoma.