Rachna [name changed] is a spritely woman in her fifties. Barring some aches and pains in her joints, she is healthy. A former nurse, she eats well, does yoga every day and works 10-hour shifts at a hospital lab in Dubai.
One day, she came down with a fever. A fever that lasted a month. It took another month to discover the cause. And that required consultations with eight doctors: three internal medicine specialists, a gastroenterologist, a rheumatologist, an oncologist, a pulmonologist and an ENT surgeon. It also called for two spells of hospitalisation and several rounds of blood tests, a chest X-ray and numerous scans, including several CT scans, a PET scan and many ultrasound scans (sonography). Three courses of antibiotics and a course of steroids were unable to rein in her fever.
Here’s Rachna’s two-month ordeal in her words:
When I had a fever, I was sure that it was due to UTI (urinary tract infection). So I took a broad-spectrum antibiotic and drank Ural (a urine alkaliniser), and went to work. I became very worried when the urine turned brown, so I went to the Emergency, and they insisted on admitting me to the hospital. The RT-PCR test for COVID-19 was negative.
After the first day at the hospital, I was told that the urine culture returned negative for infection. But my fever became worse. Nausea and vomiting followed; I couldn’t eat anything. The medicines kept my temperature down, and once its effects wore off, the fever roared back. It was tiring. There was no energy left in me. I lay exhausted, unable even to watch television.
The lab reports were scary. The parameters were way over the threshold. The CRP (C-Reactive Protein) level had gone through the roof; Ferritin levels were high; LDH too, ESR was elevated, so was D-Dimer. Since I had contracted COVID-19 a year ago, the doctor was worried about the D-Dimer levels; so anti-coagulants were pumped into my veins.
LAB TESTS: WHAT ARE THEY
■ CRP (C-reactive protein) is produced by the liver, and its level rises when there is an inflammation since the body tries to heal by sending a “response team” of proteins.
■ Ferritin is a blood protein that stores iron in the body. High levels of iron may point to infection, liver disease, rheumatoid arthritis, overactive thyroid, or some types of cancer.
■ LDH or lactate dehydrogenase is an enzyme found in almost every cell of the body. The LDH test looks for signs of damage to the body’s tissues since the enzyme is released into the blood when cells are damaged or destroyed.
■ ESR or erythrocyte sedimentation rate is a blood test to find out the inflammatory activity in the body.
■ D-Dimer is one of the leftovers from a protein that clots blood after an injury. A D-dimer test can help rule out the presence of a serious blood clot.
■ RT-PCR or reverse transcription-polymerase chain reaction test detects the genetic material of the coronavirus.
— Source: WebMD and Mayo Clinic
Three days later, my temperature hasn’t subsided. It remained a high-grade fever. The doctor said the antibiotics were not working, so he prescribed a stronger one. That didn’t work either, and the lab reports continued to worry the doctor and me.
One week had passed, I was still suffering. There was no let-up in fever, and my appetite never returned after repeated bouts of vomiting. I felt drained, mentally and physically. I just wanted to go home.
A gastroenterologist came into the picture since my liver enzymes showed abnormal readings. He suspected issues with my liver or the bile duct, and ordered a CT scan. But that came out clean, much to my relief.
The internal medicine specialist changed the antibiotic to a broader-spectrum one. That too didn’t help, so he opted for steroids. Dexamethasone did the trick. My fever snapped. The vomiting stopped, and I started to eat. I was hungry again. Ravenous, actually.
So what was it? COVID-19 reinfection was the final diagnosis. Asymptomatic, I was told, since the RT-PCR test came negative. And I was moved to an isolation ward. I’m fully vaccinated, but reinfection was a possibility. Particularly since I worked at a hospital lab. Strangely, I was released from the hospital the next day. “I know you couldn’t wait to go home,” the doctor said as he wrote my discharge summary.
I was glad to be home, but something wasn’t alright. So I decided to see another doctor: another internal medicine specialist at a clinic. He patiently listened to my fever story and went through the lab reports. Looks like COVID-19 reinfection to me also, he said, adding that I don’t have to worry since the fever is no longer there.
But the fever returned two days later, a day after I completed my course of Dexamethasone. I had rashes too; it vanished after a day. When I called the doctor at the clinic, he said I have to be admitted to a hospital. So he referred me to another internal medicine specialist, the third one I had consulted in three weeks.
MEDICINES: KNOW THEM
■ Antibiotics are medicines that help stop bacterial infections.
■ Broad-spectrum antibiotics act against a wide range of disease-causing bacteria, in contrast to a narrow-spectrum antibiotic.
■ Steroids are often hormones made by the human body function. Artificial steroids used for treatments fall into two main types: corticosteroids and anabolic-androgenic steroids (or anabolics).
■ Dexamethasone is a low-cost steroid sometimes used to treat asthma, cancer and rheumatoid arthritis. It is also found to reduce deaths in hospitalised coronavirus patients.
— Source: WebMD and Annals of infectious diseases
The fever story was retold and the lab reports scrutinised again. The rashes, the salmon-coloured rashes, caught the doctor’s attention. All this points to AOSD, he said. Still’s Disease. Adult-Onset Still’s Disease, to be precise. An auto-immune disease, more like arthritis.
But we have to confirm it, he said, adding that several other diseases also exhibit similar symptoms. There was one problem. After three courses of antibiotics, one course of steroids and anti-inflammatory drugs in my blood, the lab reports may not be accurate now. First, let’s treat your fever before you see a rheumatologist, the doctor said.
Another week at a new hospital. The fever broke, and after two days without a running temperature, I was discharged from the hospital. A rheumatologist dropped in to check, and I called on her a week later.
She narrowed it down to five possible diseases, including Still’s. Hodgin’s lymphoma was another. Never mind the fact that I was a nurse. The thought of cancer can send shivers down anyone’s spine. I was scared and angry. Angry at the thought of cancer returning to my family. Nine years ago, my husband had battled lymphoma.
The rheumatologist called for a PET-CT scan. It’s not only to diagnose cancer but also for other auto-immune disorders, she added in an effort to ease my fears. The thought of radioactive sugar coursing through my body kept me awake.
The PET scan showed three glowing lymph nodes: one near my shoulder and two in my chest. That was enough for the rheumatologist to despatch me to an oncologist, who turned out to be a cheerful person. She was quick to dismiss the lymphoma fears saying we can’t be sure till we do a biopsy. But you have lost weight; seven kilos in a month is too much, she said. (Drastic weight loss is one of the symptoms of cancer).
THE SCANS: WHAT THEY TELL YOU
■ A CT scan or computed tomography scan allows doctors to see inside a body. It uses a combination of X-rays and a computer to create pictures of organs, bones, and other tissues.
■ PET scan, also known as positron emission tomography and PET-CT, is an imaging study that shows how a human body is working. A radioactive substance (glucose) is injected into the bloodstream, and the PET scan machine picks up its radiation to provide images.
■ Ultrasound scan, or sonography, is an imaging method that uses high-frequency sound waves to produce images of structures within the body.
— Source: WebMD and Mayo Clinic
I was referred to a pulmonologist, who said the nodes in the chest are too tiny to yield a sample. So excising the node near the shoulder should be enough to do a biopsy, he said. And that’s how an ENT surgeon joined the scene. The surgery barely lasted an hour, but wait for the results felt like years. Actually, it came in a matter of days.
Are you scared? The surgeon asked while I waited for the biopsy results. I shrugged, unable to speak. You don’t have to worry. It’s not cancer, he said. A huge wave of relief swept over me.
I barely heard him say sarcoidosis (a small collection of inflammatory cells in lymph nodes). No treatment required, he added.
THE DISEASES: WHAT ARE THEY?
■ Arthritis is a broad term that covers a group of over 100 diseases. “Arthritis” means “joint inflammation”, which is a reaction to disease or injury.
■ Adult-Onset Still’s Disease is a rare type of inflammatory arthritis that features fevers, rash and joint pain.
■ Lymphoma is cancer that affects lymphocytes (infection-fighting cells), which are found in the lymph nodes and other parts of the body.
■ Sarcoidosis is an inflammatory disease that affects multiple organs in the body, but primarily the lungs and lymph glands. It may be a type of autoimmune disease, but the exact cause is unknown.
— Source: WebMD and Mayo Clinic
Three months had elapsed since the mystery fever hit me. It hasn’t returned. A scar near the collarbone is a reminder of my 30-day battle with fever. Forty more days were spent chasing the cause.
Who knew a fever could wreak so much misery?
— As told to Shyam A. Krishna, Senior Associate Editor
THE DOCTORS: WHO ARE THEY?
■ A rheumatologist specialises in the treatment of arthritis and other musculoskeletal conditions and systemic autoimmune diseases.
■ An oncologist diagnoses and treats cancer.
■ A gastroenterologist treats digestive disorders.
■ A pulmonologist is a doctor who diagnoses and treats diseases of the respiratory system.
■ ENT specialist or an otorhinolaryngologist is a physician who treats diseases of the ear, nose, throat, face, head and neck.
— Source: WebMD and Mayo Clinic