Good news

The first thing I noticed was how thin she was. She’d recently lost 10 pounds. Her appetite was off, she didn’t feel right, and she was worried. So she’d come to my hospital’s medical clinic.

On her narrow brown face, the wrinkles from age and weight loss disappeared when she smiled, which was often. Her clothing was worn but neat and hung loosely on her.

Mrs. Marsh was 65 years old and had never been seriously ill. Retired, she lived alone, spending most of her time with her partner of many years and her 2 grown daughters.

I liked her immediately and, while I smiled reassuringly as I asked the routine questions, her answers didn’t reassure me: heavy smoker, drank heavily years ago, never had a mammogram, nor a colonoscopy. This, added to older-than-age-60-with-unexplained-weight-loss, made my cancer alarms clang.

I examined her: clear lungs, no breast masses, a faint rash and small, scattered lymph nodes.

I told her I wanted to order some tests: a blood count, liver and kidney function tests, a mammogram and a Papanicolaou smear. She would return in three weeks.

Results trickled in: her mammogram was fine, as was her Pap smear.

When Mrs. Marsh arrived for follow-up, all the results were back.

“It’s nice to see you again,” I said. She was sitting on the examination table, her blue gown hanging from her shoulders. “How are you feeling?”

She smiled. “It’s good to see you, too. And I’m about the same, thank you.”

“The tests look good.” I explained that although we hadn’t found the cause of her symptoms, we had ruled out several potentially serious problems.

Image courtesy of iStock.com/Discha-AS

“Did you bring back the stool test cards?” I asked.

“Yes, I did.” She pulled out a Ziplock bag, opened it, then handed me three cards, each of which contained a couple of dabs of her stool.

I peeled open the back of the cards, then held my breath as I dropped a drop of developer on each one. Even a hint of blue means there is blood in the stool.

A ribbon of blue floated into view on each of the cards. Damn!

Mrs. Marsh’s worried face showed me what a terrible poker player I am.

“I’m sorry, but there’s some blood in your stool, and we need to make sure it’s nothing serious. I’d like to schedule a colonoscopy.” I explained the procedure and told her we’d do it as soon as possible.

The following Thursday morning, I arrived in the gastrointestinal suite as the gastroenterologist was starting Mrs. Marsh’s colonoscopy.

“A couple of internal hemorrhoids,” he said as I walked in. “That could cause the heme-positive stools, but of course we have to look at everything.”

Assuming hemorrhoids are the cause of bloody stool, without looking at the entire colon, is a great way to miss a cancer.

He removed a small polyp and sent it to the laboratory.

“The pathology’ll be back in a couple of days,” he said.

I called her two days later. “The polyp isn’t cancerous,” I told her.

“Oh, that is good news!” she said.

The day of Mrs. Marsh’s next appointment, I leafed through a stack of reports. I’d ordered a few other tests — shots in the dark, really — for completeness: tests for hepatitis, syphilis and HIV. I wasn’t expecting them to be positive, but I needed an answer. I was anxious; an oncology consult was the next step.

The hepatitis studies were negative, as was her HIV test. I had to flip through 15 more pages before I found her syphilis test: it was whoppingly positive.

Of course. The great imitator. Syphilis can cause a litany of seemingly unrelated signs and symptoms, including every one of Mrs. Marsh’s.

I was grinning from ear to ear. I love bacterial infections (most of them, at least) because they’re so treatable. Those of us who slog through swamps of diabetes, hypertension and atherosclerosis don’t get enough chances to cure things. There would be no oncology consults for Mrs. Marsh. Just a shot of penicillin.

“Good news,” I said, walking into the examination room and closing the door. “We’ve discovered what’s causing your symptoms.” I paused. “You have syphilis.”

First, she looked surprised. Then her face crumpled and she began to sob.

I reflected on my insensitivity. How could I imagine that syphilis would be good news? She wasn’t aware of my please-let-it-be-anything-but-cancer obsession. She didn’t share my love of infectious diseases. Who knows what syphilis meant to her and her partner — maybe the first inkling of infidelity; maybe even the end of the relationship.

I brought her a tissue box, then sat beside her on the edge of the table.

“You see, I’ve been trying to hide how worried I was that you had cancer,” I said. “And syphilis, while it doesn’t sound like good news, really is when compared with cancer, because it’s very easy to cure. Once we give you penicillin, you’ll be absolutely fine.”

She took a deep breath, then grabbed a tissue and began weeping again.

I was in the early months of medical residency. I was beginning to feel comfortable with out-of-control blood glucose levels, lungs full of fluid and chest tightness, but I was not yet accustomed to patients weeping inconsolably in examination rooms. And I felt terrible to have been, even partially, the cause of her distress.

I put my hand on her arm. “I’m so sorry,” I said. “This must be a surprise.”

She nodded, then shrugged her shoulders.

“Or maybe not,” I added.

She blew her nose, then looked at me.

“Six months ago, I was raped,” she said. “I’ve never told anyone.”

“No one?” I asked. “Not the police?”

She shook her head.

“Was it a stranger?” I asked, feeling new respect for this woman, for her strength and for the loneliness she must have felt throughout this experience. She nodded. Tears ran down her cheeks, but she was no longer sobbing.

“Mrs. Marsh, I’m so sorry. Is there anything I can do?”

She shook her head. “Dr. Feld, you’re very kind. I just wanted to forget it. And I had, pretty much. But this brought it all back.”

“Would you like to talk to someone about it?”

“I just did,” she said. “That was enough.”