“Whatcha got?” Chet McGovern asked, looking over Jack’s shoulder. Chet was also an associate medical examiner, having been hired in the same month as Jack. Of all the colleagues he’d become the closest to Jack, since they shared both a common office and the social circumstance of being single males. But Chet had never been married and at thirty-six, he was five years Jack’s junior.
“Something interesting,” Jack said. “The mystery disease of the week. And it’s a humdinger. This poor bastard didn’t have a chance.”
“Any ideas?” Chet asked. His trained eye took in the gangrene and the hemorrhages under the skin.
“I got a lot of ideas,” Jack said. “But let me show you the internal. I’d appreciate your opinion.”
“Is there something I should see?” Laurie called from table three. She’d noticed Jack conversing with Chet.
“Yeah, come on over,” Jack said. “No use going through this more than once.”
Laurie sent Sal to the sink to wash out the intestines on her case, then stepped over to table one.
“The first thing I want you to look at is the lymphatics I dissected in the throat,” Jack said. He had retracted the skin of the neck from the chin to the collarbone.
“No wonder autopsies take so long around here,” a voice boomed in the confined space.
All eyes turned toward Dr. Calvin Washington, the deputy chief. He was an intimidating six-foot-seven, two-hundred-and-fifty-pound African-American man who’d passed up a chance to play NFL football to go to medical school.
“What the hell is going on around here?” he demanded half in jest. “What do you people think this is, a holiday?”
“Just pooling resources,” Laurie said. “We’ve got an unknown infectious case that appears to be quite an aggressive microbe.”
“So I heard,” Calvin said. “I already got a call from the administrator over at the Manhattan General. He’s justly concerned. What’s the verdict?”
“A bit too soon to tell,” Jack said. “But we’ve got a lot of pathology here.”
Jack quickly summarized for Calvin what was known of the history and pointed out the positive findings on the external exam. Then he started back on the internal, indicating the spread of the disease along the lymphatics of the neck.
“Some of these nodes are necrotic,” Calvin said.
“Exactly,” Jack said. “In fact most of them are necrotic. The disease was spreading rapidly through the lymphatics, presumably from the throat and bronchial tree.”
“Airborne, then,” Calvin said.
“It would be my first guess,” Jack admitted. “Now look at the internal organs.”
Jack presented the lungs and opened the areas where he’d made slices. “As you can see, this is pretty extensive lobar pneumonia,” Jack said. “There’s a lot of consolidation. But there is also some necrosis, and I believe early cavitation. If the patient had lived longer, I think we would be seeing some abscess formation.”
Calvin whistled. “Wow,” he said. “All this was happening in the face of massive IV antibiotics.”
“It’s worrisome,” Jack agreed. He carefully slid the lungs back into the pan. He didn’t want them sloshing around, potentially throwing infective particles into the air. Next he picked up the liver and gently separated its cut surface.
“Same process,” he announced, pointing with his fingers to areas of early abscess formation. “Just not as extensive as with the lungs.” Jack put the liver down and picked up the spleen. There were similar lesions throughout the organ. He made sure everyone saw them. “So much for the gross,” Jack said as he carefully replaced the spleen in the pan. “We’ll have to see what the microscopic shows, but I actually think we’ll be relying on the lab to give us the definitive answer.”
“What’s your guess at this point?” Calvin asked.
Jack let out a short laugh. “A guess it would have to be,” he said. “I haven’t seen anything pathognomonic yet. But its fulminant character should tell us something.”
“What’s your differential diagnosis?” Calvin asked. “Come on, Wonderboy, let’s hear it.”
“Ummmm,” Jack said. “You’re kinda putting me on the spot. But okay, I’ll tell you what’s been going through my head. First, I don’t think it could be pseudomonas as suspected at the hospital. It’s too aggressive. It could have been something atypical like strep group A or even staph with toxic shock, but I kinda doubt it, especially with the gram stain suggesting it was a bacillus. So I’d have to say it is something like tularemia or plague.”