Robin Cook: Vector

Jack laughed.

“And look at this guy,” Vinnie added, nodding to the corpse. “I don’t think he’s going to get to go to the prom.”

“Good memory,” Jack said. Jack had used that line when they’d started the plague case Vinnie had referred to earlier and it had become a staple of their black humor.

“And that’s not all I remembered,” Vinnie said. “While you were out there dicking around I looked for arthropod bites. There aren’t any.”

“Such recall!” Jack commented. “I’m impressed.” During the plague case Jack had told Vinnie that arthropods, particularly insects and arachnids, played an important role as a vector in the spread of many infectious diseases. Searching for evidence of their involvement was an important part of the autopsy on such cases. “Soon you’ll be taking over my job.”

“What I’d like to do is take over your salary,” Vinnie said. “The job you can have.”

Jack did his own external exam. Vinnie was right: there were no signs of bites. There was also no purpura, or bleeding into the skin, although the skin did seem to have a slightly dusky tint.

The internal exam was another story. As soon as Jack removed the front wall of the chest the pathology was apparent. There was frank blood on the surface of the lungs, a finding called hemorrhagic pleural effusion. There was also a lot of bleeding and signs of inflammation in the structures located between the lungs, which included the esophagus, the trachea, the main bronchi, the great vessels, and a conglomeration of Lymph nodes. This finding was called hemorrhagic mediastinitis, and it explained the wide shadow Jack had seen earlier on the X-ray.

“Whoa!” Jack commented. “With all this bleeding I don’t think this could be the flu. Whatever it was, it was spreading like wildfire.”

Vinnie nervously glanced up at Jack. He had difficulty seeing Jack’s face because of the reflection from the overhead fluorescent lights glinting off Jack’s plastic face screen. Vinnie didn’t like the sound of Jack’s voice Jack was rarely impressed by what he saw in the autopsy room, but he seemed to be now.

“What do you think it is?” Vinnie asked.

“I don’t know,” Jack admitted. “But the combination of hemorrhagic mediastinitis and pleural effusion rings a bell in the back of my mind. I’ve read about it someplace, I just can’t remember where. Whatever this bug is, it’s got to be something mighty aggressive.”

Vinnie instinctively took a step back from the body.

“Now don’t go freaking out on me,” Jack said. “Get back over here and help me get out the abdominal organs.”

“Yeah, well, promise me you’ll be careful,” Vinnie said. “Sometimes you work too fast with the knife.” He reluctantly stepped back to the table.

“I’m always careful,” Jack said.

“Sure!” Vinnie said sarcastically. “That’s why you ride that bike of yours around the city.”

As the two men concentrated on the case, other bodies began arriving. They were placed on their respective tables by the mortuary techs to await their autopsies. Eventually, the other medical examiners began to drift in. It was promising to be a busy day in the pit.

“Whatcha got?” a voice asked over Jack’s shoulder.

Jack straightened up and turned to look at Dr. Chet McGovern, his officemate. Jack and Chet had joined the office of the Chief Medical Examiner within a month of each other. They got along superbly, mainly because they shared a true love and appreciation for their work. Both had tried other areas of medicine before switching to forensic pathology. Personality-wise they were quite different. Chet wasn’t nearly as sarcastic as Jack, and he didn’t share Jack’s problem with authority.

Jack gave Chet a thumbnail sketch of the Papparis case and showed him the pathology in the chest. He even showed him the cut surface of the lung, which revealed minimal pneumonia.

“Interesting,” Chet said. “The infection must have been airborne.”

“No doubt,” Jack said. “But why so little pneumonia?”

“Beats me,” Chet said. “You’re the infectious disease expert.”

“I wish that were true,” Jack said. He carefully slipped the lung back into the pan. “I’m positive I’ve heard of this combination of findings.

For the life of me I can’t remember what it was.”

“I’ll wager you’ll figure it out,” Chet said. He started to move off, but Jack called after him, asking if he’d run into Laurie.

Chet shook his head. “Not yet.”

Jack looked up at the wall clock. It was going on nine. She should have been there an hour ago. He shrugged and went back to work.

The next order of business was to remove the brain. Since Jack and Vinnie worked together so frequently, they had established a routine of cutting into the head that didn’t require conversation. Although Vinnie did a significant amount of the work, it was always Jack who lifted off the skull cap.

“My, my,” Jack commented as the brain came into view. As with the lungs, there was a significant amount of blood on its surface. When this was seen in an infectious case, it usually meant hemorrhagic meningitis, or inflammation of the meninges to the point of causing bleeding.

“This guy must have had one wicked headache,” Vinnie said.

“That and crushing chest pain,” Jack said. “The poor fellow probably felt like he’d gotten run over by a train.”

“What do you have there, doctor?” a deep, resonant voice asked. “A burst aneurysm or a trauma victim?”

“Neither,” Jack said. “It’s an infectious case.” He turned and looked up at the imposing six-foot-seven silhouette of Dr. Calvin Washington, the deputy chief.

“How appropriate,” Calvin said. “Contagion is right up your alley. Have you got a tentative diagnosis?”

Calvin leaned over the table to get a better look. His massive muscled bulk made Jack’s stocky frame look tiny by comparison. As an athletically talented African-American giant, Calvin could have played professional football if he hadn’t been so eager to get to medical school. His father had been a respected surgeon in Philadelphia and he was determined to follow a similar career pattern.

“I hadn’t a clue until two seconds ago,” Jack said. “But as soon as I saw the blood on the surface of the brain it hit me. I remembered reading about inhalational anthrax a couple of years ago when I was boning up about infectious disease.”

“Anthrax?” Calvin gave a disbelieving chuckle. Jack had a penchant for coming up with outlandish diagnoses. Although he often turned out to be correct, anthrax seemed beyond the realm of possibility. In all Calvin’s years as a pathologist he had seen only one case, and that had been in a cattleman in Oklahoma, and it wasn’t inhalational. It had been the more common cutaneous form.

“At this point anthrax would be my guess,” Jack said. “It will be interesting if the lab confirms it. Of course it might turn out that this patient had a compromised immune system that no one knew about. Then the bug could turn out to be a garden-variety pathogen.”

“From sad experience I know better than to make a bet with you, but you’ve picked a mighty rare disease, at least here in the U.S.”

“Well, I don’t remember how rare it is,” Jack said. “All I remember is that it’s associated with hemorrhagic mediastinitis and meningitis.”

“What about meningococcus?” Calvin asked. “Why not pick something a lot more common?”

“Meningococcus is possible,” Jack said. “But it wouldn’t be high on my list, not with the hemorrhagic mediastinitis. Besides, there was no purpura, and I’d expect more purulence on the brain surface with meningococcus.”