An unusual variant
But highest on Unia’s list of suspects was an unusual version of Guillain-Barré syndrome (GBS), known as the Miller Fisher variant. GBS is also an autoimmune disease, usually caused by an infection. Antibodies made to fight the infection mistakenly attack the nerves that control movement, usually starting with the legs and ascending to the body. In the Miller Fisher variant of GBS, the disease affects the nerves that control the muscles of the head and neck, as well as those of the feet and legs, causing double vision and difficulty swallowing.
Unia ordered the blood test that looks for this version of GBS. But the results can take weeks. Meanwhile, the neurologist also decided to treat him without this evidence. Treatment involves suppressing the wayward immune system – first with steroids and then, if necessary, with intravenous immunoglobulin (IVIg), an infusion of antibodies that block the destructiveness of GBS
New developments in cancer research
Map 1 of 6
Progress in the field. In recent years, advances in research have changed the way cancer is treated. Here are some recent updates:
Chemotherapy. A quiet revolution is underway in cancer treatment: a growing number of patients, especially those with breast and lung cancer, are sparing the dreaded treatment in favor of other options.
Leukemia. After receiving a new treatment called CAR T-cell therapy more than a decade ago, two patients with chronic lymphocytic leukemia saw the blood cancer disappear. Their cases offer hope for people with the disease and create some new mysteries.
esophageal cancer. Nivolumab, a drug that unleashes the immune system, was found to extend survival times in patients with the disease who participated in a large clinical trial. Esophageal cancer is the seventh most common cancer in the world.
The patient had just finished his last day of treatment when the hospitalist Dmitry Opolinsky took over his care. Opolinsky asked him how he felt. Much better, the patient exclaimed, then exploded in a fit of cough. Unia had warned Opolinsky that the patient wanted to feel better, but that his examination hadn’t really changed since his arrival. Still, it often takes a week or two for improvement after the IVIg. They had to give him time.
While he waited for his patient to get better, Opolinsky kept his eye on the results that were still trickling in. His vitamin B12 was normal. So were the other vitamin deficiencies he was tested for. The biggest disappointment came from the Mayo Clinic, where the neuroimmunology lab is looking for evidence of one of dozens of paraneoplastic syndromes. They were all negative. This was probably GBS, although the patient was no better almost a week after treatment.
The next day, Opolinsky got a text to call a number he didn’t recognize. The voice, deep with a hint of Irish accent, identified itself as Dr. Andrew McKeon, co-director of the Mayo Clinic lab. “Oh yeah, we got those results yesterday,” Opolinsky told him. “All negative.” Actually, McKeon said, that result was wrong — or rather, incomplete. There was a newly discovered antibody identified by McKeon’s lab a few years earlier, still so new it hadn’t yet made it onto the automated result form used in testing. This patient had a very strong positive for this antibody, which attacks something known as neuronal intermediate filaments in the brain. “If he smokes,” McKeon predicted, “he has small cell lung cancer. If he isn’t, he probably has Merkel cell skin cancer.”
The patient had never smoked, so Opolinsky focused on the possibility that he had this rare form of skin cancer. What Opolinsky remembered from his training was that Merkel cell carcinoma was an aggressive form of skin cancer caused by sun damage and spread much faster than most other skin cancers. He looked at the images on the Internet, which showed a bluish-red lump, usually found on the head or face. He didn’t find any of these strange growths, but he ordered a CT scan to look for metastases. There, deep in the patient’s left forearm, was an enlarged lymph node — about the size of a lime. Opolinsky rushed to the patient to feel the mass, but although he knew it was there, he could not find it. But the surgeons were able to, and removed a mass that tested positive for Merkel cell carcinoma. After his surgery, a PET scan revealed that he was free of cancer.
It took some time and an immune-suppressing medication, but slowly the patient started to recover. That was last summer. Today he can walk, but only with a walker. And he still coughs a lot. But he is hopeful that he will be back on his tractor in the spring, even if he has to get on it from the porch.
Lisa Sanders, MD, is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a resolved case to share, write to Lisa.Sandersmdnyt@gmail.com.
This post He could barely walk and he saw double. What was wrong?
was original published at “https://www.nytimes.com/2022/02/16/magazine/merkel-cell-carcinoma.html”