The German

The German

I recently saw one of my regular patients. She is now in her late sixties. She was born in the former East Germany a few years after the end of the second world war, but her family had been able to move to West Germany. She had immigrated to the United States after getting married to an American soldier posted there.

She had two sons from this marriage. Unfortunately, her marriage ended in a divorce and she brought up her two sons on her own. She worked as a waitress.

The older son was single and lived with her. Her younger son had joined the army, but was murdered several years ago. She had no grandchildren and no other close family in the United States.

She had developed several medical problems, but kept working long hours as a waitress. On her most recent visit, I greeted her in German, “Gutten Tag Fraulein” (good day miss). I had learnt this from Google translate. Frau, not Fraulein, she corrected me. I am not so little anymore, and Fraulein is for the younger single women.

We laughed together. At the end of her visit, I asked her how her family made it to West Germany. I have read about the Berlin wall, and how many people were killed trying to cross the border in those days.

It was the early 1950’s she told me. The Russians and their East German allies were starting to close the borders as large numbers of East Germans were crossing into West Germany. The Berlin wall had not yet been built and crossing the border was still legally allowed if someone needed medical treatment on the other side.

Her mother came up with a plan. They had a family friend who was an ambulance driver who also wanted to defect. He would drive the family across the border in his ambulance on the pretext of getting my patient (who was seven at the time) medical care.

The family of five (my patient’s parents and her brother and sister) got in the back of the ambulance. The children were seated on a stack of down comforters. My patient’s skin was dyed yellow by her mother to make her appear to have jaundice and look sick. She also had a note from her family doctor.

The border in those days was manned by Russian soldiers. On the West German side were American soldiers. It was still the early days of the cold war and at that time she tells me the Russians and Americans were often friendly.

They got to the border and went through the check point. Just as they were about to get through, a Russian officer approached. The ambulance driver panicked and hit the accelerator. My patient was thrown at the back door of the ambulance and it opened and she fell out. She fell into a puddle and stained her dress. She remembers hitting her head and her mother screaming. The ambulance had stopped on the other side of the border. There were three Russian soldiers and perhaps twenty Americans, all heavily armed.

The little seven-year-old girl was not hurt, but the yellow dye was peeling from her skin and all the soldiers were watching. She picked herself up and walked across the border back to her mother. The Russians did not interfere.

Were you scared, I asked my patient? It happened so quickly, that she said that she did not have much time to think. Her family made a new life in West Germany, where she grew up. She eventually moved to the United States after her marriage.

What an amazing story, I said. She just gave me a smile.

                                          The Berlin wall under construction August 1961

The Virus of John Cunningham

The Virus of John Cunningham

A few years ago, I was seeing a new patient in the Infectious Disease clinic. It was an African American male in his early forties. He had recently been admitted to the hospital with pneumonia. This was also found to have advanced HIV infection. His pneumonia was treated and he had been referred to me for further treatment of his HIV infection.

He was an extremely nice man, but was not sure how or when he got the virus. He did not use drugs, held a steady job and was married with three children. His wife was negative for the infection even though he had likely been infected for many years prior to marrying her.

On the first visit, he was accompanied by his wife. She was Caucasian and much younger than him. She appeared very devoted to him and was quite concerned about him. They were accompanied by their youngest child, a two-year-old daughter.

I explained the disease to them in detail as well as the precautions that they need to take in order to prevent him from passing the infection to his wife. I then started him on a cocktail of medications after explaining their potential side effects.

My patient started his regimen. He was very compliant and his virus levels fell rapidly and soon became undetectable. His immune system also started to recover. I was quite excited and remember congratulating him on a subsequent visit.

However, one week after that visit, he came back to the clinic. Strange things were happening to him. His wife told me he could not remember things and was dropping objects. His speech had become slurred and he was having difficulty walking.

Alarmed, I admitted him to the hospital and ordered an MRI of his brain. His MRI showed multiple patchy white areas on his brain. These were the likely cause of his symptoms. At this point I thought it best to transfer him to our nearby teaching hospital, as they would have more facilities to make a diagnosis. A few days later, I received a call from the Infectious Disease Professor who was taking care of him. They had made a diagnosis of Progressive Multifocal Leukoencephalopathy or PML for short.

PML is a deadly disease that is associated with severe immunosuppression that occurs in advanced HIV patients. The disease is caused by a virus, known as the JC virus. JC stands for John Cunningham and is the name of the first patient in whom this virus was isolated. This virus is harmless in most people except those with advanced immune deficiencies, such as in cancer or HIV infection, in which case it can be fatal.

John Cunningham was the first patient in whom this disease was described. He was a 36-year-old military veteran who had developed a cancer. While receiving chemotherapy for the cancer, he developed inexplicable neurological problems and subsequently died. A virus was isolated from his brain tissue and was given his name. The year was 1970.

Fifteen years later, the JC virus made a resurgence amongst advanced HIV patients. It often surfaces when the immune system is starting to recover after HIV therapy is started, as it happened in my patient. There is no specific treatment. My patient continued to decline and was moved to a nursing home. He died there a few weeks later.

I thought hard about this patient’s treatment and if I could have done anything differently. There was nothing I could find. I spoke to his distraught wife afterwards and did my best to comfort her. She would now have to bring up their three children on her own.

John Cunningham would never have imagined that his name would become immortal by being given to the cause of the very illness that took his life, and that of many others.

                                           White patchy areas of PML on an MRI of the brain.

The Mule

The Mule

It was another day as an Infectious Disease physician. I had received a consult call from the Intensive Care Unit (ICU) at our local hospital. It was for an infection of the abdomen.

The patient had an interesting history. He was a Hispanic man in his forties. He had developed a sudden onset of abdominal pain and then collapsed unconscious. He was rushed to the Emergency Room.


In the hospital, he had a CT scan of his abdomen. The radiologist spotted something unusual. His report said that the abdomen was full of small round objects, which the radiologist thought may contain an illicit substance. One of these objects possibly had ruptured causing the abdominal pain and collapse.


He was rushed to emergency surgery and multiple bags containing a white powdery substance (likely illicit drugs) were removed. One of those bags had ruptured leading to an acute overdose and infection in the abdomen. He had to have a colostomy after those bags were removed. He was smuggling drugs, and was what is known in popular slang as a “Mule”. The Police were also called and they called in the State Bureau of Investigation (SBI).


It transpired that he had just returned from a trip to Colombia. He did not speak English, so a Spanish interpreter had to be used. When I saw him, he was not very co-operative. He had a colostomy in place and was awake and alert. I gave advice on antibiotics and I left.

Two days later the United States government shut down. It was one of those unusual occasions that the congress did not agree with the president and did not approve the funding to keep the government running. At that time, our hospitalist team that was taking care of this patient had asked me to give final antibiotic recommendations as they were planning to discharge the patient.

It was at this point that I got a call from our patient’s nurse. It was a request to speak to me from an SBI agent that was assigned to this patient. I went over to the hospital. The SBI agent was a smartly dressed young man. He was exceedingly polite.

He asked me if the discharge could be postponed. He explained to me that because the patient had a colostomy, they could not take him to a regular prison at discharge. He would have to go to a hospital prison. The nearest one was several hours away, and because the government had shut down, they were not accepting any new inmates. If the patient was discharged into his custody, he had nowhere to take the patient.


I told him that I would speak to the hospitalist team. The hospitalist doctor met me and asked me very directly if there was any indication for continued hospitalization from a medical perspective. I told him that I could think of none. He told me that he had other sick patients waiting for beds and he had no choice but to discharge the patient.


I went back to the SBI agent and told him the news. He was quiet for a while, then said that he would have to release the patient. This information distressed me and in an attempt to reassure me he said - “don’t worry, we are going to keep a very close eye on him”.

Later, I was speaking to one of his nurses, and she told me that she had heard (I am not sure from whom), that the drug lords would be punishing our patient for losing the drugs. Those drugs were several bags of heroin, with a street value of over half a million dollars. What kind of punishment, I asked? Oh they will probably kill him or his family members in Colombia if they can't find him, she replied.

The patient was discharged with his colostomy in place. He never showed up for his follow up appointments. I often wonder as to how he did.

                                                             CT Scan of a drug mule.

The Branded Felon

The Branded Felon

A new patient came into the infectious disease clinic to see me. He was a young man in his early thirties. He had been to multiple doctors for a rash. This rash was thought to be an infection and had come on spontaneously. It started on his shoulder and slowly started getting bigger. He had been put on multiple antibiotics, but they made no difference.


Then he developed a similar lesion on his nose, which also started getting bigger. Alarmed, he sought out an Infectious Disease doctor and came in to see me.


I examined him. The areas on both his nose and shoulder were red and angry looking. They looked like an obvious infection, but  he had not responded to antibiotics. The other unusual thing was the lesion appearing on the nose in an area completely separate from his shoulder.


The first thing I did was take a detailed history. He worked as a construction worker. About two weeks prior to developing the first lesion, he had been involved in digging up an old road. He had encountered pieces of rotten wood that had to be cleared. He had also inhaled a lot of dust at that time.


I suspected a possible fungal infection called blastomycosis. This is often found in rotten vegetation. When inhaled, it can cause a pneumonia, but in rare cases it can instead go to the skin. The only way to confirm this and make a diagnosis was a biopsy. I explained this to him.


He was agreeable to this but was concerned about the cost. He did not have any health insurance. I told him that the biopsy was absolutely necessary for a diagnosis and he consented to it.


I proceeded to do a biopsy of his shoulder lesion. As I was doing so, I asked him why had he not tried to get health insurance? He then said - “I used to have health insurance”. He told me further that he had been a computer programmer with a good job. What happened, I asked?


I met a girl online he said. They developed an online relationship. She lived with her parents and decided to run away from home to come and live with him. Her parents called the police and she was quickly traced to his home. She was only fifteen years old.


My patient told me that he had thought she was seventeen. He said that he never got into a physical relationship with the girl. However, when confronted with her angry parents, the girl changed her story and accused him of kidnapping her.


My patient was arrested and was faced with a lengthy trial and the possibility of many years in jail. He agreed to a plea bargain and admitted to inappropriate contact with a minor. He spent a few months in jail and then was released.

Unfortunately, he now had a criminal record and was a convicted felon. Even worse he was considered a sex offender and placed on the sex offender’s registry. In other words, wherever he moved to, his neighbors would be informed of his conviction. I guess this was the modern day equivalent of the middle ages custom of permanently branding a person for his crime.


He lost his job and consequently his health insurance. The only work he could find was as a construction worker digging up old roads. Nobody wanted to hire a person with his kind of record.


I finished up his biopsy and started him on anti-fungal medications. His biopsy confirmed the diagnosis of blastomycosis, and he responded to treatment. Three months later, his lesions were almost completely resolved. I have not seen him since.


I hope he is doing well today.

Blastomycosis lesion on the back.

The Ethiopian

The Ethiopian

There was a time that I used to volunteer at a local inner city free clinic. This was a clinic set up to serve people with no insurance and inadequate access to healthcare. This sometimes included recent immigrants.

I found my time at the free clinic very rewarding. The patients were often very appreciative. Most were routine and straight forward primary care patients. There was however one patient I remember that was particularly challenging.

She was a young woman in her twenties. She had immigrated from Ethiopia recently to join her sister in the United States. She herself was divorced and single, but was also a new mom with a six-month old daughter.

She was sick when she saw me. She had tremendous fatigue. She was jaundiced and had a protuberant belly, suggestive of advanced liver disease. She told me that she had developed an acute liver infection in Ethiopia while she was pregnant. She had seen doctors there but told me that they had been unable to come to a diagnosis.

She delivered a healthy daughter and subsequently came to the United States. Unfortunately, she found out that she did not qualify for Medicaid and she was unable to work or get any type of health insurance. She lived with her sister who brought her to the free clinic.

Her case intrigued me as I have an Infectious Disease background and had also grown up in Africa. I took a detailed history on her. It seemed that she had developed some type of a liver infection possibly a viral hepatitis. However, for viral hepatitis to cause liver failure in such a short time was unusual. There were also parasitic infections endemic in that part of Africa such as “Schistosomiasis” of the liver that could over time cause liver failure.

Through the free clinic, I was able to test her for the common viral hepatitis A, B and C. These were all negative. The Schistosomiasis test was a send out test to the CDC which I tried to order, but was unable to do so. I however treated her empirically with an anti-parasitic medication. If this was from a Schistosomiasis infection, there was a possibility that her liver could improve after treatment.

There was another condition that is known as hepatitis E. It is widespread in parts of the third world including southern Asia and parts of Africa. It usually causes a very mild and self-limiting disease in most people.

However, hepatitis E can cause severe liver disease leading to liver failure in two types of people. One, people with immune deficiencies such as cancer, the other – pregnant women!

This was a well described phenomenon. This otherwise mild disease could cause severe liver disease leading to liver failure in pregnant women. Could this young woman have had that? I tried to test her for it, but there was no commercially available test that I could find. I would have to arrange to send the blood to the CDC.

Even if her liver disease was from hepatitis E, there was no specific treatment. Unable to make a diagnosis or offer any treatment, I referred her to our local public University Teaching Hospital, which often provides care for such uninsured patients.

I never saw this young lady again. I often wonder about what happened to her. I hope that this lady is doing well today.

For Family

For Family

In the course of my work as a physician I meet many remarkable individuals. Many of these people have made sacrifices for the sake of their family. This takes many forms and one afternoon I saw two different aspects of this.

 The first patient was an elegant widowed lady in her fifties who had been having trouble with anxiety lately. She had been widowed as a young woman in her early thirties. Her husband had died of cancer. She tells me that on his deathbed, she held his hand and promised him that she will take care of their children.

 At that time, she had three small children, the youngest of which was three years old. She worked hard as a single parent, working two jobs. She even went back to college and successfully graduated. She put all three children through college. Her older daughter and son were married with children.

 She worked a good job, and lived by herself in her own home. She had never re-married. Her children and grandchildren did spend time with her, but she often found herself alone at home. She felt that her children and grandchildren did not need her as much anymore.

 The second patient was an equally elegant woman in her sixties who was also having trouble with anxiety. Her husband had suffered a stroke and required her to be a full time caregiver at home. Added to that, she took care of her father who was in his nineties and also totally dependent on her. She was under a lot of stress because of this. She felt that she was needed all the time as neither her husband nor her father could function without her.

 In the space of one afternoon, I saw two remarkable women. One had sacrificed the best years of her life to give her children a good upbringing. Now that they were independent and with their own families, she was feeling a little left out. She however relished the success of her children. She would not have it any other way.

 The other woman was devoting her every waking minute taking care of her disabled husband and elderly father. When, I suggested a nursing home for them, she shrugged her shoulders and said no, she will take care of them as long as she has the ability to do so. She would also not have it any other way.

 One felt like she was not needed as much, and the other felt that she was excessively needed. My opinion is that both these women are very much needed and make our world a better place to live. They are also making a big difference to their families.

 I feel a deep sense of gratitude and respect for both these remarkable women.