Richard Mabry: Lethal Remedy

"Give me the names, and we'll give them something to take their mind offthat witch hunt." "I've got to tell you. I'm not really comfortable with what you've done already. Dr. Miles could have been hurt or killed by a gunshot." "Not if the person behind the trigger had better aim." He struggled to keep his voice level. "I said to scare her, put a couple of bullets through the car window behind her. Instead, the shots almost hit her. That wasn't my fault." "And ramming Pearson's car-" "Pure incompetence. There are teenagers offthe street who'd be able to boost a car, follow someone, and sideswipe their vehicle just enough to run them offthe road. And they'd know not to choose a location that would involve hitting a concrete wall. Again, not my fault." Idiots. The whole world was populated with idiots, and the worst ones were the ones he had to work with. "Now get those other names. Call me back and we'll arrange something to distract them." "I really don't like-" "It doesn't matter what you like. You're ours, bought and paid for. Don't ever forget it." The informant was saying something, but he hung up, cutting him offin mid-sentence. Stay focused. Remember what's at stake. I can't stop now. Not when success was so close.

Morning rounds on the internal medicine floor of University Hospital found Sara frowning over Randall Moore's chart. Rip had started him on nafcillin yesterday, and he'd had four IV doses of two grams each since admission, but his fever remained high. True, it was early, but she'd be a lot happier if there was some evidence he was responding to treatment. If this were a run-of-the-mill Staph infection, even MRSA, she'd expect some improvement. Every hour that went by without that improvement made it more likely her patient was infected with The Killer, Staph luciferus. "How's our guy?" Rip slid into the chair beside her and peered over her shoulder. "Still febrile?" She handed over the chart. "I'd be a lot happier if his temp were a bit lower. Think it might be… " She let the words trail off, hesitant to give voice to her fears. "I'm afraid so. We might have a preliminary culture report today, although tomorrow seems more likely. And once we know for sure, the fun begins. Should I give him Jandramycin, knowing there's a chance he might get a severe late complication?" "Can't you simply inform the patient and let him make that decision?" Rip shook his head. "It's not as simple as that.

Ingersoll categorically denies that Jandramycin therapy carries any risk. And, based on what you've told me, the people at Jandra say the same thing. So if we tell Moore about the possible complications, there's no foundation to back up our story. Besides that, if Ingersoll finds out, I can kiss my fellowship good-bye." "But if we don't tell Moore, and he's one of the unlucky ones-" "Then there's another lawsuit against the medical center and a bunch of doctors, us included," Rip said. "Yeah, this is a tough call." "Excuse me, do you both have a moment?" Lillian Goodman stopped several paces away, apparently not wanting to invade the space of the two doctors who sat with their heads together. Sara motioned her to the chair on the other side of her. "Have a seat. We were just talking about Randall Moore's case. You really dodged a bullet when you asked me to see him yesterday." Lillian made a dismissive gesture. "I'm really sorry I got you involved. In retrospect, I should have called Donald Schaeffer over to see him." "Don't worry about it," Rip said. "Besides, I think we can agonize over his treatment plan as well as the department chair could. Maybe even better." Lillian leaned across to address her remarks to both Sara and Rip. "You guys do know that-" Sara stopped her with an upraised palm. "Yes, we know he's suing you and half the staffof the medical center. But that doesn't make any difference to me, and I believe Rip feels the same way." "Suit? Has another lawsuit been filed?" John Ramsey slid into the chair beside Rip. "I'm seeing more of those since coming here than I ever saw in forty years of private practice." "No, this is the same one you and I know about,"

Lillian said. "Sara, do you want to tell John what's going on?" John sat quietly while Sara explained the situation. When she finished, he said, "Wow. I guess the best thing would be that the culture comes back as something other than Staph luciferus. Even MRSA would be better, I suppose." "It would, but I'm not betting on it," Rip said.

Lillian held out her hand in silent request, and Rip passed her the chart. "What are you looking for?" he asked. She thumbed through until she found the history sheet Moore had filled out when he first entered the clinic. "I'm looking for something in his history." Lillian frowned, flipped a page, frowned again. "Here it is. He has a history of hay fever and asthma, and both parents are allergic." "What does that mean?" Rip asked. "I'll give you my theory. Realize, this is all supposition," Lillian said, "but it makes sense to me, and it's all we have to work with right now. I began with your finding that about 15 percent of the people receiving Jandramycin ended up with late autoimmune complications. That's about the percentage of people in the U.S. with allergy." "Yes," Rip said. "But so what?" "I decided to look for a connection, and I think I found it. I took the original name of the experimental compound that became Jandramycin and searched for the components Ingersoll could have been working with to develop it. I started with 848… "

John listened quietly as Lillian laid out what she'd found and knit together her hypothesis. Jandramycin stimulated a patient's immune system to form antibodies against Staph luciferus. Natural antibodies attacked the bacteria, destroying them and preventing them from multiplying. The action of this drug was different from that of other antibiotics, drugs that attacked bacterial cell walls or stopped their metabolism, but the end result was the same. The patient recovered. Unfortunately, in patients with an underlying predisposition to allergy, the drug also did something to the immune system that turned it upon itself, making antibodies to the patient's own organs. For some reason, this was only seen in allergic patients.

And he was allergic and had been treated with Jandramycin. The only question in his mind was which autoimmune disease he'd be stricken with, and how severe it would be. "Assuming your hypothesis is correct," Rip said, "this still doesn't tell us how we can modify the process in vulnerable patients so they don't develop autoantibodies."

"Let's approach this logically," John said. "What do we use to treat autoimmune disorders?" "Corticosteroids" came the reply from three mouths almost in unison. "But that's a temporary measure at best. The patient with temporal arteritis may have to receive multiple courses of ste roids as the symptoms recur. Steroid therapy doesn't cure rheumatoid arthritis. It only alleviates the symptoms," John said.

"What else?" "Antimetabolites," Sara suggested. "Methotrexate, for instance." "Again, a temporary measure," John said. "What if there were something that, instead of cleaning up the symptoms they produce, could block those antibodies from attacking the person's own tissues in the first place?" Rip shook his head. "That would be perfect, but unfortunately we don't have such a drug." Lillian and John exchanged glances. Maybe being older did translate into being wiser and able to think outside the box. In response to a faint nod from Lillian, John spoke up again. "I have a suggestion. Omalizumab." He told them what he had in mind. Perhaps this compound, developed specifically to block the antibodies responsible for hay fever and asthma, would neutralize the abnormal antibodies made by the patients who'd received Jandramycin. John watched expressions in the group change as disbelief gradually gave way to the realization that it might actually work.