"I'm driving you crazy?" Robert called after her in disbelief.
For a moment he was indecisive. Then he muttered, "Jesus Christ!" Rolling up his window, he drove off without looking back.
With her hands shoved deep into her raincoat pockets, Marissa walked along the Esplanade that bordered the Charles River. It was another overcast day. The color of the river was gunmetal gray. Puddles dotted the walkway.
Marissa walked as far as the Arthur Fiedler-shell, then crossed over to Arlington Street. At the corner of Arlington and Boylston she took the T out Huntington Avenue to her pediatric clinic.
Marissa entered the building through a back door. She wasn't interested in talking to anyone. With effort she climbed the fire stairs, then snaked through several exam rooms, making her way to her office. Closing her door, she didn't bother to turn on her light. She was confident no one knew she was there, and as depressed as she was, she wanted to keep it that way.
She didn't bother to check her messages for fear the results from her pregnancy test had already been called in. Instead, she sat and brooded at her desk. Never had she felt- so isolated and alone. Except for Wendy, she couldn't think of anyone to talk with.
After an hour, she began to entertain the idea of seeing some walk-in patients to take her mind off things, but then she quickly realized she was still too distraught to concentrate All she could think about was the Women's Clinic.
When the telephone rang, she lifted the receiver off the hook before the first ring had completed. It had startled her.
"Hello?" she said.
"Dr. Blumenthal?" a woman's voice asked.
"Yes," Marissa said.
"This is the lab over at the Memorial," the woman said.
"We have your beta human chorionic gonadotropin level. It was only two mg/ml. We can do another in twenty-four or thirty-six hours if you'd like, but it doesn't look good."
"Thank you," Marissa said, her voice completely flat. She wrote down the value, then hung up the phone. It was exactly as she feared: a result just like Wendy's. She wasn't pregnant!
For a moment Marissa merely stared at the figure she had written on her scratch pad. Then her vision blurred with tears of grief. She was so tired of it all. She began to think of Rebecca Ziegler again and the troubles that drove the poor woman to suicide-if it was suicide.
Suddenly the phone rang again. Marissa grabbed the receiver with the ridiculous hope that it was the lab at the Memorial calling to say they had made a mistake. Could she be pregnant after all?
"Hello?" Marissa said.
"The operator told me you were in," the receptionist explained.
"You have a visitor down here in the main reception.
Should I..
"I can't see anyone," Marissa said. She hung up the phone.
Almost immediately it rang again. This time she ignored it. After nine rings, it stopped.
A few minutes later there was a knock on her door. Marissa didn't move. There was a second knock, but she continued to ignore it, hoping whoever it was would go away. Instead, she saw the knob turn. Marissa faced the opening door, ready to snap at whoever dared disturb her. But when she saw Dr. Frederick Houser's portly figure at the threshold, she softened.
"Is there something wrong, Marissa?" Dr. Houser said. He was holding his wire-rimmed glasses in his hand.
"A few personal problems," Marissa said.
"I'll be all right.
Thank you for your concern."
Undeterred, Dr. Houser stepped into the room. Marissa could see that someone was with him. With some surprise, she immediately recognized Cyrill Dubchek.
"I hope I'm not intruding," Cyrill said.
Flustered, Marissa stood up, straightening her hair.
"Dr. Dubchek told me you and he worked together at the CDC," Dr. Houser said.
"When the receptionist called me to say that you weren't seeing visitors, I thought it was time for me to intervene. I hope I've done the right thing."
"Oh, of course!" Marissa said.
"I had no idea it was Dr.
Dubchek. Cyrill, I'm so sorry. Come in, sit down." Marissa gestured toward an empty chair. She hadn't seen Cyrill for several years, but he'd not changed one iota. As usual he was impeccably dressed and was still as handsome as ever.
Thinking of her own appearance, Marissa became acutely selfconscious.
She knew she looked as terrible as she felt, especially with all her recent bouts of tears.
"I think I'll let you two have some privacy," Dr. Houser said tactfully. With that, he quickly left and closed the door.
"He told me you've been having quite a time with this infertility treatment," Cyrill told her.
"It has been a strain," Marissa admitted. She collapsed into her desk chair.
"Only moments ago I learned that the last embryo transfer was not successful. So I'm afraid I've been cryingagain.
I've been doing more than my share of crying over the last few months."
"I'm so sorry," Cyrill said.
"I wish there was some way I could help. But you look fine."
"Please!" Marissa said.
"Don't look at me. I can't bear to imagine what I look like."
"It's a bit hard to have a conversation without looking at you," Cyrill said with a sympathetic smile.
"Although it is true you look as if you've been crying, you still look as pretty as ever to me."
"Let's change the subject," Marissa said.
"Then I'll tell you why I stopped by," Cyrill said.
"I had to fly up here on other business, but early this morning one of the people over in bacteriology came to my office with the news that there has been one other concentrated area of TB salpingitis cases like the ones you are interested in."
"Oh?"
"The location surprised me," Cyrill said.
"Would you care to guess?"
"I don't think I have the mental strength," Marissa: said.
"Brisbane," Cyrill said.
"Australia?"
"Yup, Brisbane, Australia. It's part of what they call over there the Gold Coast."
"I'm not even sure where on the Australian continent Brisbane is," Marissa confessed.
"It's in Queensland, on the east coast," Cyrill said.
"I've been there once. Charming city. Great climate. Lots of new high-rises along the beach south of the city. It's an attractive area."
"Anybody have any thoughts as to why there would be a concentration there?" Marissa asked. As far as she was concerned it might have been Timbuktu.
"Not really," Cyrill admitted.
"There has been some increase in TB in general, especially in those countries allowing significant immigration from Southeast Asia. Whether the Brisbane area has gotten more than its share of boat people, I haven't the foggiest. There has been some increase -in TB here in the U.S. above and beyond what could be expected with immigration from endemic areas, but I believe that's secondary to drugs and AIDS rather than any change in the pathogenicity of the bacteria.
At any rate, here's a paper on the cases in Australia."
Cyrill handed Marissa a reprint of an article that appeared in the Australian Journal of Infectious Diseases.
"Apparently the author is a pathologist who found twenty-three cases similar to those you've described. It's quite a good paper.), Marissa began to flip through the article. It was hard for her to get excited. Australia was halfway around the world.
"The fellow from bacteriology told me something else," Cyrill continued.
"He said that there was a case of disseminated TB at the Memorial. I mention it only because the patient is a twenty nine-year-old woman from a well-to-do Boston family. Her name is Evelyn Welles. The demographics of the case jumped out at me, I thought it might interest you as well. So there you have it."
"Thank you, Cyrill," Marissa said. She tried to smile. She was afraid she was about to start crying again. Seeing an old friend was reanimating her fragile emotions.
Cy
rill stayed for another fifteen minutes before he insisted he had to leave. He had to be back in Atlanta that evening.
After Cyrill had departed, Marissa's depression returned. She sat at her desk for a long time without doing much of anything.
At least she didn't cry. She just stared out the window at the deteriorating day. But eventually she began to think of the, information
Cyrill had brought her. She glanced down at the journal article. She'd read it later. Meanwhile there were things she had to do. Picking herself up, she pulled her coat back on and forced herself to drive to the Memorial.
The patient, Evelyn Welles, was in isolation in intensive care, with a chart that reflected the difficulties of her case; it weighed five pounds. Marissa had little difficulty finding her. Nor did she have trouble finding the resident attending to her care. He was a slight fellow from New York City with intense eyes and nervous twitches. His name was Ben Goldman.
"She's in bad shape," Ben admitted upon Marissa's inquiry.
"Really bad. Moribund. I don't expect her to last much more than another day. We've got her on maximum chemo but it doesn't seem to be doing anything."
"It's definitely TBT' Marissa asked as she peered through the glass of the woman's intensive-care cubicle. She'd been intubated and was on assisted respiration. A fully gowned and masked nurse was in the cubicle giving moment-to-moment care. Multiple
IV lines snaked down from clusters of bottles above her head.
"No question," Ben said.
"We've gotten acid-fast bacilli from everyplace we've tried: stomach washings, blood, evena bronchial biopsy. It's TB all right."
"Any idea of the epidemiology of the case?" Marissa asked.
"Oh, yeah," Ben said.
"Some interesting facts have turned up.
Apparently she visited Thailand about a year ago and stayed there for several weeks. That might be a factor. But more important, we've picked up a heretofore unrecognized immunodeficiency condition. The blood boys are working on it. So far it's thought to be secondary to an undefined collagen disease. A combination of the travel and her depressed immune response could be the explanation."
"Have you been able to talk to her at all?" Marissa asked.
"Nope," Ben said.
"She was comatose when she was brought in. Probably got some brain abscesses. We haven't felt it worth the risk to take her to the NMR or the CAT scan."
Marissa absently flipped through the thick chart. Despite these reasonable explanations of the patient's condition, she had a feeling that Evelyn Welles' TB could be related to the TB salpingitis cases. As Dubchek had suggested, maybe it was her age and social status.
Has much of a GYN history been obtained?" Marissa asked.
"Not much," Ben admitted.
"In view of her overwhelming infection, parts of the work-up have been left superficial. What we got on systems review, we got from the husband."
"Do you know if she's ever been seen at the Women's Clinic in Cambridge?" Marissa asked.
"Sure don't," Ben said.
"But I'll be happy to ask the husband when he returns. He comes in every night around ten."
If she has been seen at the clinic, it would be great if you could ask the husband to get a copy of her record," Marissa said.
"And one other thing. Could you manage to do a smear of her vaginal secretions to see if there are any TB organisms there as well?"
"Sure," Ben said with a shrug of his narrow shoulders.
Marissa paid the taxi driver while sitting in the backseat, shoving the money through the Plexiglas divider. It was dark and raining harder now than it had been earlier so that when she emerged from the cab, she ran in an effort to keep from getting soaked.
Inside her house she took off her damp coat and hung it in the laundry room. Avoiding the kitchen, she went directly to her study. Although she hadn't eaten all day, she wasn't the least bit hungry. And though she was exhausted, she wasn't about to sleep. The visit to the hospital and the plight of Evelyn Welles had renewed her terror as much as it had reawakened her curiosity.
"It's almost nine," Robert said, surprising Marissa by his presence.
She had not heard him. He was standing in the doorway, comfortably dressed, arms crossed. His tone and expression reflected his usual irritation of late, "I'm perfectly aware of the time," Marissa said as she sat down and turned on her reading lamp.
"You could have called," Robert said.
"The last I saw of you was when you jumped out of the car in front of the Science Museum. I was about to call the police."
"Your concern is touching," Marissa said. She knew she was being confrontational, but she couldn't help it.
"In case you are interested, I'm not pregnant."
"I guess I didn't expect you'd be," Robert said, his voice softening. He shrugged his shoulders.
"Well, no one can fault us
L31 for not trying. Unfortunately it's another ten thousand dollars down the drain."
"Give me strength!" Marissa whispered to herself "Are you hungry?" Robert asked.
"I'm famished. What about going out for some dinner Maybe it will do us some good. After all, we should celebrate your legal victory. I know it doesn't make up for your not being pregnant, but at least it's something."
"Why don't you go by yourself," Marissa said. She was in no mood to celebrate. Besides, she was certain her "legal victory," as he put it, was nothing but a clever cover-up. She also wanted to lash back at his reference to the ten thousand dollars. But she didn't have the strength to quarrel.
"Suit yourself," Robert said. He disappeared from the doorway.
Marissa got up and closed the door to her study. A few minutes later she heard the muted sounds of Robert in the kitchen making himself something to eat.
Marissa had half a mind to go after him. Maybe she should try to communicate with him. Then she shook her head. She knew she could never make him understand, let alone share in her concern for the incidence of TB salpingitis. With a sigh, Marissa sat down on the love seat and began reading the article that Cyrill had given her. He was right; it was a good article.
The twenty-three cases of TB salpingitis had been seen at a Brisbane clinic that sounded similar to the Women's Clinic. The name of the clinic was Female Care Australia, FCA for short.
Similar to the five cases Marissa knew in Boston, all the patients in the Australian series were in their twenties and early thirties.
They were middle class and married. All except one was Caucasian.
The exception was a Chinese woman of thirty-one who'd recently emigrated from Hong Kong.
The ring of the phone startled her, but she kept reading, deciding it was probably for Robert anyway.
Reading on in the article, Marissa noted that the diagnosis had been made by the histology of fallopian tube biopsy alone since no organisms had been seen or cultured. Chest X-rays and blood work had ruled out fungi and sarcoid.
In the discussion portion of the paper the author hypothesized that the problem was arising from the influx of immigrants from Southeast Asia, but he didn't elaborate on any possible mechanism.
"Marissa!" Robert shouted.
"The phone is for you! Cyrill Dubchek!"
Marissa grabbed the phone.
"Sorry to bother you so late," Cyrill said, "But when I returned to the CDC I got some additional information you might find interesting."
"Oh?" Marissa said.
"These TB salpingitis cases aren't confined to the U.S. or Australia," Cyrill said.
"They have been showing up in Western Europe as well, with the same wide distribution pattern. There have been no clusters like the one in Brisbane. Apparently there have been no reported cases as yet in South America or in Africa.
I don't know what to make of this, but there you have it. If I hear any more, I'll call ASAP. But now you've got my interest. Let me know if you begin to develop any theories."
Marissa thanked him again for calling and th
ey said their goodbyes. This new bit of information was extremely significant.
It meant that the incidence of TB salpingitis could no longer be dismissed as a statistical fluke. It was occurring on an international scale. Even Cyrill's curiosity was now piqued. For the moment Marissa forgot her grief, anger, and exhaustion.
Marissa considered the possibilities. Could TB have somehow mutated to become a venereal disease? Could it have become a silent infection in the male like some cases of chlarnydia or mycoplasma?
Robin Cook 1990 - Vital Signs Page 18
