Author: Dr. O. Adeyi
*This is part three of a three-part series – make sure to read part one and two first to get the whole story!*
Once the biopsy from John Marshall was complete, Dr. Forrest quickly instructed the laboratory staff on how to process and a short while later, he had the slides under his microscope ready to form an opinion.
After carefully examining the biopsy, he placed a phone call to Dr. June Lee who was covering the liver transplant in-patient service for the day.
“Hi June,” Dr. Forrest greeted.
“Hey Bud, thanks for calling me quickly. I believe this has to do with John Marshall’s biopsy,” Dr. Lee replied.
“Yes, it does” said Dr. Forrest. “Your patient has a mild rejection alright, but I don’t think this is responsible for all the enzyme changes you’re dealing with. There is more hepatocellular injury than expected for the degree of rejection, as well as cholestasis that rejection would not explain. Have you reviewed all his medications, especially things like Septra …”
Oh yes,” Dr. Lee intercepted. “He is on Septra, as well on Ganciclovir, Cyclosporine, Prednisone, and a proton pump inhibitor.”
“Well, I would take him off Septra at this time and keep his immunosuppression.The current degree of rejection, given his HCV status, does not need steroid boluses. I believe most of these changes are from adverse reaction to Septra. Of course you also need to keep an eye out for early recurrence of HCV, especially the aggressive variant.”
“Thank you very much, Bud. I owe you one.”
“You’re welcome, June. Please let me know how this turns out in the coming days,” Dr. Forrest remarked as the conversation ended.
A week later Dr. Forrest and Dr. Lee sat together at the weekly transplant rounds to discuss difficult cases and treatment plan.
“Hey June, what happened with John Marshall?” Dr. Forrest asked just before the rounds began.
“He went home yesterday. His numbers came down nicely after we withdrew Septra. We had thought we would need to pulse him with high dose of solumedrol for rejection but this was not necessary after we got your report. Obviously it was the Septra. Thankfully we don’t have this problem often since almost all our patients are placed on Septra for prophylaxis, but when it occurs it gives a confusing clinical picture,” Dr. Lee explained.
“Well, drugs are funny things with the liver. There really is no good way to predict what they would do. How about the HCV aspect? Anything to worry about?”
“Not yet thankfully, but since we do protocol biopsies on all of our HCV patients, I’m sure you will be seeing a few more biopsies from Mr. Marshall. I never stop wondering what we’d do without you,” said Dr. Lee.
A little over a year after John’s transplant, Dr. Lee, Ms. Bends, and the entire clinical transplant team received an invitation to John’s 60th birthday celebration and his 25th wedding anniversary to Cheryl.
Also present was little Jordan, Danielle’s son who couldn’t seem to get enough of grandpa’s attention.
This story was a work of fiction, but we think it does a great job illustrating the valuable role of a pathologist in patient care. We’re working closely with every member of the healthcare team to make sure you get better.