Life Support (19 page)

"Well, was it?"

"No." He opened a door and flipped on the wall switch. It was an office furnished with a utilitarian steel desk, chairs, and a filing cabinet.

The office of a thoroughly organized man, thought Toby, looking at the neatly stacked papers, at the textbooks lined up on the shelf. The only personal touch to the office was an obviously neglected fern perched on the filing cabinet, and a photo on the desk. A teenage boy, shaggy-haired and squinting into the sunlight as he held up a prize trout. The boy's face was a clone of Dvorak's. She sat down in a chair by the desk.

"Would you like some coffee?" he asked.

"I'd rather have some information. What, exactly, did you find on autopsy?"

"On gross exam, nothing."

"No evidence of a stroke?"

"Neither thrombotic nor hemorrhagic."

"What about the heart? The coronaries?"

"Patent. In fact, I've never seen such a clean left anterior descending artery in a man his age. No evidence of infarction, fresh or otherwise.

It wasn't a cardiac death." He sat down behind the desk, his gaze so intense on hers she had to force herself to maintain eye contact.

"Toxicology?"

"It's been only a week. The preliminary screen shows diazepam and Dilantin. Both were given in the hospital to treat seizures." He leaned forward. "Why did you insist on the autopsy?"

"I told you. He was the second patient I'd seen with that presentation of symptoms. I wanted a diagnosis."

"Tell me the symptoms again. Everything you remember."

She found it difficult to concentrate while those blue eyes were so intently focused on her face. She sat back, shifting her gaze to the stack of papers on his desk. She cleared her throat. "Confusion," she said. "They both came into the ER disoriented to time and place."

"Tell me first about Mr. Parmenter."

She nodded. "The ambulance brought him in after his daughter found him stumbling around at home. He didn't recognize her or his own granddaughters. From what I gathered, he was having visual hallucinations. Thought he could fly. When I examined him, I didn't find any evidence of trauma. Neurologically, the only localizing sign seemed to be an abnormal finger-to-nose test. I thought at first it might be a cerebellar stroke. But there were other symptoms I couldn't explain."

"Such as?"

"He seemed to have some visual distortion. He had trouble judging how far away I was standing." She paused, frowning. "Oh. That explains the midgets."

"Excuse me?"

"He complained about midgets being in his house. I guess he was referring to his granddaughters. They're about ten years old."

"Okay, so he had distorted vision and cerebellar signs."

"And there were seizures."

"Yes, I saw you mentioned them in your ER notes." He reached for a folder on his desk and opened it. She saw it was a photocopy of the patient's Springer Hospital record. "You described a focal seizure of the right upper extremity."

"The seizures recurred on and off during his hospitalization, despite anticonvulsants. That's what the nurses told me."

He flipped through the chart. "Wallenberg hardly mentions them. But I do see an order sheet here, for Dilantin. Which he signed." He looked up at her. "Obviously, you're correct about the seizures."

Why wouldn't I be? she thought with sudden irritation. Now she was the one who leaned forward. "Why don't you just tell me which diagnosis you're fishing for?"

"I don't want to influence your memory of the case. I need your unbiased recollection."

"Being straight with me would save us both a lot of time."

"Are you pressed for time?"

"This is my night off, Dr. Dvorak. I could be home doing other things right now."

He regarded her for a moment in silence. Then he sat back and released a heavy sigh. "Look, I'm sorry for being evasive, but this has shaken me up quite a bit."

"Why? "

"I think we're dealing with an infectious agent."

"Bacterial? Viral?"

"Neither. " She frowned at him. "What else is there? Are we talking parasites?"

He rose to his feet. "Why don't you come down to the lab? I'll show you the slides."

They rode the elevator to the basement and stepped out into a deserted hallway. It was after seven now. She knew there had to be someone else on duty in the morgue, but at that moment, walking along the silent corridor, it seemed that she and Dvorak were utterly alone in the building. He led her through a doorway and flipped on the wall switch.

Fluorescent panels flickered on, the harsh light reflecting off gleaming surfaces. She saw a refrigerator, stainless steel sinks, a countertop with quantitative analysis equipment and a computer terminal.

Lined up on a shelf were jars of human organs, suspended in preservative. The faint tang of Formalin hung in the air.

He crossed to one of the microscopes and flipped on the switch. It had a teaching eyepiece, they could both examine the field at the same time.

He put a slide under the lens and sat down while he focused. "Take a look."

She pulled up a stool. Bending her head close to his, she peered into the twin eyepiece. What she saw looked like white bubbles in a sea of pink.

"It's been a long time since I took histology," she admitted. "Give me a hint."

"Okay. Can you identify the tissue we're looking at?"

She flushed with embarrassment. If only she could rattle off the answer. Instead she was painfully aware of her ignorance. And of the silence stretching between them. With her face pressed to the eyepiece, she said, "I hate to admit it, but no, I can't identify this."

"It's no reflection on your training, Dr. Harper. This slide is so abnormal the tissue is hard to recognize. What we're looking at is a slide of Angus Parmenter's cerebral cortex, PAS stained. The pink is background neuropil, with the nuclei stained purple."

"What are all those vacuoles?"

"That was exactly my question. Normal cortex doesn't have all those tiny holes."

"Weird. It looks like my pink kitchen sponge."

He didn't respond. Puzzled, she raised her head and saw that he was looking at her. Dr. Dvorak?"

"You saw it right away," he murmured.

"What?"

"That's exactly what it looks like. A pink sponge." He sat back and rubbed his hand over his eyes. Under the harsh lab lights, she saw the lines of fatigue in his face, the shadow of dark beard. "I think we're dealing with a spongiform encephalopathy," he said.

"You mean like Creutzfeldt-Jakob disease?"

He nodded. "It would account for the pathologic changes on the slide.

As well as the clinical picture. The mental deterioration. Visual distortion. Myoclonic jerks."

"So they weren't focal seizures?"

"No. I think what you saw was startle myoclonus. Violently repetitive spasms, set off by a loud noise. It can't be controlled with Dilantin."

"Isn't Creutzfeldt-Jakob extremely rare?"

"One in a million. It tends to strike the elderly on a sporadic basis."

"But there are clusters of cases. Last year, in England�"

"You're thinking of mad cow disease. That seems to be a variant of Creutzfeldt-Jakob. Maybe it's the same disease, we're not really sure.

The English victims got infected by eating beef with the bovine spongiform strain. That was a rare outbreak, and it hasn't been seen since."

Her gaze shifted back to the microscope. Softly she said, "Is it possible we have a cluster here? Angus Parmenter wasn't the first patient I saw with those symptoms. Harry Slotkin was. He came in weeks before Parmenter did, with the same presentation. Confusion, visual distortion."

"Those are nonspecific signs. You'd need an autopsy to confirm it."

"That's not possible with Mr. Slotkin. He's still missing."

"Then there's no way to make the diagnosis."

"They both lived in the same residential complex. They could've been exposed to the same pathogen."

"You don't catch CJD the way you catch the common cold. It's transmitted by a prion. An abnormal cellular protein. It requires direct tissue exposure. A corneal transplant, for instance."

"Those people in England caught it from eating beef. Couldn't it happen here? They could have shared a meal�"

"The American herd is clean. We don't have mad cow disease."

"How do we know that for certain?" She was intrigued now, feverishly pursuing this new line of thought. She remembered that night in the ER, when Harry had come in. Recalled the clang of the steel basin crashing to the floor, and then the sound of Harry's leg rubbing against the gurney. "We have two men from the same housing complex. Presenting with the same symptoms."

"Confusion isn't specific enough."

"Harry Slotkin had what I thought were focal seizures. Now I realize it might have been startle myoclonus."

"I need a body to autopsy. I can't diagnose Harry Slotkin without brain tissue."

"Well, how certain are you of Angus Parmenter's diagnosis?"

"I've sent the slides to a neuropathologist for confirmation. He'll examine the sections under electron microscopy. The results may take a few days." Quietly he added, "I'm just hoping I'm wrong."

She studied him and realized she was seeing more than weariness in his face. What she saw was fear.

"I cut myself," he said. "During the autopsy. While I was removing the brain." He shook his head, gave a strangely ironic laugh.

"I've cut open a thousand skulls. Worked on bodies with HIV, hepatitis, even rabies.

But I've never cut myself. Then I get Angus Parmenter on the table, and it looks like natural causes. A weeklong hospital stay, no evidence of infection. And what do I do? I cut my finger. While I'm working on the goddamn brain."

"The diagnosis isn't confirmed. It could be artifact. Maybe the slides weren't prepared correctly."

"That's what I keep hoping." He stared at the microscope, as though regarding his mortal enemy. "I had my hands around the brain. I couldn't have chosen a worse time to nick myself."

"It doesn't mean you're infected. Your chances of actually getting the disease have to be extremely small."

"But still there. The chance is still there." He looked at her, and she couldn't contradict him. Nor could she offer any false reassurance.

Silence, at least, was honest.

He turned off the microscope lamp. "It has a long incubation period. So it will be a year, two years until I know. Even at five years, I'll still be wondering. Waiting for the first signs. At least it's a relatively painless end. You start with dementia. Visual distortion, maybe hallucinations. Then you progress to delirium. And finally you slip into a coma . . ." He gave a weary shrug. "I guess it beats dying of cancer."

"I'm sorry," she murmured. "I feel responsible . . ."

"Why?"

"I insisted on the autopsy. I put you in a hazardous position."

"I put myself in that position. We both do, Dr. Harper. It comes with the job. You work in the ER, someone coughs on you, you catch TB. Or you stick yourself with a needle and you get hepatitis or AIDS." He removed the slide and set it in a tray. Then he pulled a plastic cover over the microscope. "There are hazards to every job, just like there are hazards to getting up in the morning. Driving to work, walking to the mailbox.

Boarding a plane." He looked at her. "The surprise isn't that we die.

The surprise is how and when we die."

"There could be some way to stop the infection at this stage. Maybe a shot of immunoglobulin�"

"Doesn't work. I checked the literature."

"Have you discussed it with your doctor?"

"I haven't mentioned this to anyone yet."

"Not even your family?"

"There's just my son, Patrick, and he's only fourteen. At that age, he's got enough things to worry about."

She remembered the photo on the desk, the shaggy-haired boy holding up his prize trout. Dvorak was right, a boy of fourteen was too young to be confronted with a parent's mortality.

"So what are you going to do?" she asked.

"Make sure my life insurance is paid up. And hope for the best."

He stood up and reached for the light switch. "There's nothing more I can do."

Robbie Brace answered the door wearing a Red Sox T-shirt and ratty sweatpants. "Dr. Harper," he said. "You got here quick."

"Thanks for seeing me."

"Yeah, well, you're not exactly catching us at our finest hour.

Bedtime, you know. Lots of whining and bargaining going on."

Toby stepped in the front door. Somewhere upstairs, a child was screaming. Not a distressed scream, but an angry one, accompanied by the sound of stamping feet and the crash of something hard hitting the floor.

"We are three years old and learning the meaning of power," explained Brace. "Man, don't you just love parenthood?" He latched the front door and led her up a hallway, toward the living room. Once again she was impressed by how big he was, his arms so muscular they could not hang straight from his shoulders. She sat down on a couch, and he settled into a well-worn recliner.

Upstairs the screaming continued, hoarser and punctuated by loud, dramatic snuffles. There was also a woman's voice speaking, calm but determined.

"It's the clash of the titans," said Brace, glancing upward. "My wife, she stands a lot tougher than I do. Me, I just roll over and play dead."

He looked at Toby and his smile faded. "So what's this about Angus Parmenter?"

"I've just come from the ME's office. They have a preliminary diagnosis, Creutzfeldt-Jakob disease."

Brace gave an amazed shake of his head. "Are they sure?"

"It still needs confirmation by a neuropathologist. But the symptoms do match the diagnosis. Not just for Parmenter. For Harry Slotkin as well."

"Two cases of CJD? That's sort of like having lightning strike twice.

How could you possibly confirm it?"

"Okay, we can't confirm Harry's case because there's no body. But what if two residents from Brant Hill did have CJD? It makes you wonder if there's a common source of infection." She leaned forward. "You told me Harry had a clean bill of health on his outpatient record."