Richard Mabry - Lethal Remedy

John could almost see the gears turning in Mark's head. "You know, you might want to be there as well. Here's the deal."

Sara heard the tap on her office door but didn't look up from the journal she was reading. "It's open." "Am I early?" Rip said from the doorway. Sara looked at the clock on her desk. Five minutes to five.

"No, you're fashionably on time. Come in and sit down." Rip eased into a visitor's chair and put a worn leather portfolio on the corner of Sara's desk. "I have some pretty interesting information on the patients who've developed problems after receiving Jandramycin." "Uh, let's wait just a minute. I sort of invited Mark Wilcox to join us. I hope that's okay." It seemed to Sara that a frown flitted across Rip's face. "I guess not. And John did vouch for him." "Did I hear my name?"

Mark said. He ambled in, shook hands with Rip and Sara, and took the other visitor's chair. "Is it still okay that I'm participating in this get-together?" "I was telling Rip that I invited you. And of course it's okay. We can use all the help we can get." "Good," Mark said. "Because I've asked John Ramsey to join us." As though on cue, John stuck his head in the doorway. Seeing that the chairs were occupied, he disappeared and returned in a moment with the chair from the secretary's desk in the outer office. After more explanations and more assurances that everyone was welcome, Sara said, "I'll start, I guess. I decided to call Jandra to see if I could get any information on possible late complications from Jandramycin. I thought they might have seen something in the preliminary animal studies." "And?" Rip asked. "No dice. I spoke with their research director, a Pharm D named Wolfe, who stonewalled me. At first he said I should check with Jack, since we're at the same institution. When I kept asking questions, he clammed up. He claimed that what I wanted to know was proprietary information. He even insinuated that I might be a spy from another pharmaceutical company." "Not unusual. Paranoia is the norm in the pharm industry. They're always looking over their shoulder for a competitor sneaking up on them," Mark said. "Did you talk with anyone else there?" "I got as far as the secretary of somebody named Patel, who's the CEO or COO, not sure of his title. What I am sure of is that she referred me right back to Wolfe. Wouldn't even let me talk with Patel." She picked up a pen from the desk and began to twirl it between her fingers. "I think Jandra is a dead end." Mark raised a tentative hand like a fifth grader with the answer to a problem. "Why don't I see if we can get any information from the New Drug Application Jandra has filed?" "Are NDA's public record?" John asked.

"No. Remember what I said about drug companies being paranoid. Keeping an NDA secret is supposed to prevent competitors from stealing information." Mark grinned. "But in my legal practice I made some contacts in Washington. Maybe one of them has connections with the FDA. I'll see what I can get." "If we suspect that Jandramycin is causing problems, shouldn't we contact the FDA directly and ask them not to act on Jandra's application?" Sara asked. Rip shook his head.

"And tell them what? We have no proof. All the clinical data here is locked up tight in Ingersoll's lab, guarded by Resnick like a dog watching over a bone. The preclinical trials were done by Ingersoll when he was doing a research fellowship at Jandra, so if there's any useful data in those records we'll never see it. Whatever the FDA has is a sanitized version of the truth, and we have no facts to refute it." Conversation stopped when John Ramsey's watch beeped. He shrugged and said, "Sorry, got to take my medicine. My doctor tells me it's important that I don't miss a dose." He looked at Rip and managed a weak grin. "Be right back." He pulled two pill bottles from his pocket and ducked out of the room. As soon as John was back, Rip pulled a sheet of notes from his portfolio. "I've managed to contact most of the patients who received Jandramycin. Of the ones I've contacted, all but three got the drug more than six weeks ago. Out of that group, six have what I consider serious conditions." Sara rose. "Let's move to the conference room for this." An hour later, names, symptoms, and pertinent lab data covered the blackboard in the conference room. "To summarize," Mark said, "we have six patients. They've developed various complications: neurologic problems, kidney failure, muscle weakness, excessive bleeding, and headaches with vision loss. Is there the common denominator?" "Let's put specific diagnoses on the groups where we can," John suggested. "Start with the neurologic problems.

Sara tells me she thinks her patient has Landry's ascending paralysis- what you younger doctors would call GBS or Guillain-Barre syndrome."

Sara wrote "GBS" and underlined it. "Kidney failure can be due to lots of things, so let's put that one aside," John said. "The same with muscle weakness and bleeding disorders. But the visual loss and headaches, associated with an elevated sed rate and some response to steroids suggest-" "Temporal arteritis," Sara almost shouted.

"Everyone agree with that?" There were murmurs of assent, so she wrote "Temp art" and circled it. "Is there a common thread to those two disorders, one that could also apply to kidney failure, muscle weakness, and excessive bleeding?" John and Mark looked at each other, and Sara could tell the answer was forming in their minds almost simultaneously. "Autoimmune disorder," they said in unison. "If we accept that," Rip said, "then let's see if there's a link to the others. Muscle pain and weakness?" "Polymyositis," Mark said. "It's autoimmune, and it fits." Sara wrote "Polymyo." "How about bleeding?"

Sara thought for a moment. "Rip, did the patient with bleeding have any purpura?" she asked, referring to the red or purple spots sometimes seen on the skin of patients with blood disorders. Rip checked his notes. "Yes. And that leads us to-" "Idiopathic thrombocytopenic purpura," Sara said, scrawling "ITP" on the board.

"And that's autoimmune." "That leaves kidney failure. Which autoimmune disorder can cause that?" John asked. They kicked that around for a bit and finally settled on kidney failure with an immune cause:

IgA-mediated nephropathy. Sara added "Imm neph" to the board. She stepped back, nodded in satisfaction, and put down her chalk. The discussion continued for a few minutes, but soon it was evident that they were in agreement. The complications from Jandramycin were autoimmune-the patients had literally become allergic to their own tissue. The effects were just manifested in different organ systems.

"Okay," Sara said. "We're dealing with an autoimmune problem. We don't know why, and we need to look at how that happens. But more important, how can we treat it? Steroids can help, of course, but their effect is temporary. Is there something that will reverse the process?" Rip shook his head and yawned. "We've got more work to do." He looked around the room. "But we're all dog-tired. Let's get some rest and reconvene here tomorrow night." They straggled out of the building and walked in loose formation across the nearly silent plaza toward the parking garage. Mark moved beside Sara and said, "I was hoping to take you to dinner. Is that offthe table for tonight?" Sara had to smile at the way Mark phrased his invitation. "I'm afraid so. I'm exhausted, and I'll bet you are." She slowed and half-turned toward him. "As for another night, why don't you wait until things settle down a bit? Then call me." All three men insisted on seeing Sara safely to her car, and soon she was on her way home. A few blocks from the medical center, she remembered that she needed cereal and milk. Sara was a creature of habit, and cereal for breakfast was one of them. She scanned the businesses around her. She was almost past the grocery store when she spotted it on the right. Sara swerved into the parking lot with only a light touch on her brakes. The squealing of her tires almost covered the sound of breaking glass. She screeched to a stop in the parking lot, looked behind her, and saw the rear window was shattered. Glass shards covered the backseat. To her right, a jagged hole marred the front passenger window. It took a few seconds for the reality of the situation to set in, and when it did, Sara seemed to implode upon herself like a blown-up balloon that's lost its air. She was vaguely aware of a number of people in the parking lot pulling out cell phones. A few eased toward her car, apparently afraid to approach too near for fear the shooting wasn't over. One man, braver than the rest, shuffled forward and called, "Are you hurt?" She shook her head. She was still sobbing, gripping the steering wheel in a death grip, when she heard the sirens approaching.