Bucks Montgomery Physician Summer 2021 - 17

" We have a problem. " Those words hit me like a bomb, and I
instantly felt sick, nauseous. I sat down and looked at the images
in disbelief. Where there was perfectly healthy brain tissue
5 months ago, there was now a very obvious single golf ball
sized tumor in her right Temporal lobe. I was horrified. GBM -
glioblastoma multiforme - was instantly at the forefront of the
differential. The radiologist patted me on shoulder and quietly
said, " I'm sorry. "
Breaking the news to my wife was the hardest thing I ever had
to do. Sure, I have done this many times in my career, but how
do I tell someone I love so much she has three months to live?
How do I go on from here?
It was a Friday, and I called my friend, a neurosurgeon, to
look at the images. He reiterated it looks bad, but of course we
needed a tissue diagnosis. Marla and I spent the weekend with
lots of family, lots of hugging, and lots of tears. Monday was
biopsy day.
The needle biopsy of the lesion went smoothly, but unfortunately
yielded only necrotic debris, and was thus non-diagnostic.
Somewhere Marla found a small stuffed zebra. This became
our symbol of hope and survival. We took it everywhere and it
never left our side. I kept telling her we need to hope and pray
for a Zebra, that this may not be GBM. Our mantra became,
" Pray for a Zebra. "
With the biopsy done, I made some calls and arranged for
an emergent neurosurgical consultation at a local University
tertiary care center. We were seen the next day. Again, after reviewing
the films, he told us this is most likely a GBM, we will
not go home but she will be directly admitted for a craniotomy
and resection 2 days later.
The very difficult situation I was in was trying to sort out if I
was thinking as a loving husband or Board-Certified Internist/
Hospice Physician. My head was spinning. Before the surgery,
Marla and I had many discussions about hospice care, and discussed
several times doing nothing more and just enjoying our
few months left. Yet something inside me kept telling me to
hold out hope; that little Zebra was haunting me. Was I being
foolish? Were her physicians writing in her chart, " unrealistic
expectations " ?
The 5-hour surgery felt like an eternity. The surgeon came to
me after, saying Marla was waking and speaking and moving
all extremities; he did note the optic chiasm was damaged, and
there would be a visual deficit. But would she recognize me?
Would she have all of our 40 years of memories? He too said
this appeared to be a GBM, but we need to wait for the official
pathology.
I went to see her in the NICU, and though distressed, over the
next few days I could see she was herself. I spent every minute
at her side; we held on to that little zebra, telling everyone to
" pray for the zebra. " After 7 days in the acute hospital, she was
transferred to an acute rehab facility where I was an Attending.
She had a significant weakness in her left leg and would need
to learn to walk again. Also, there was a complete left visual
field cut, and her coordination was impaired significantly.
Many of my colleagues stopped by to wish us well; many pulled
me aside and gave me that same pat on the shoulder with that
look you give someone at a funeral; the look that says, " My
condolences. " I refused to give up hope, foolishly I thought.
We still hadn't received the final pathology. So many of my
colleagues, physicians, nurses, and ancillary staff, who I have
known for many years, prayed for us. We told everyone about
our Zebra friend.
I will never forget the moment the call came from the neurosurgeon
at the University. It was 9 days after the surgery, and
I could hear the excitement in his voice. " I finally have some
good news for you guys! " He proceeded to tell me the pathology
came back as a Primary CNS Lymphoma! This happens
to be a very treatable and curable disease! I rushed back into
my wife's room and blurted out the news, telling her our Zebra
came through. We cried and hugged, it was going to be ok.
Now we are nearly 2 years later, and the follow-up MRIs show
complete clinical remission. The treatment is arduous, having
to go to the University hospital every 4 weeks for 4 days
of inpatient chemotherapy, for a year. Her recovery has been
remarkable; she walks normally and lives every moment to the
fullest. The only residual deficit is the field cut, and she can no
longer drive.
How did this rare disease happen? In my 25 years of practice,
I have not seen one case of it. It is a disease of the severely immuno-suppressed,
seen mostly in HIV and transplant patients,
neither of which fit my wife. She had Crohn's disease, and had
been receiving Remicade for 3 years. Though her CBC was
checked regularly and was normal, her oncologist checked her
CD4 count, which was severely depressed. Now I check the
CD4 count on all my patients getting TNF inhibitors.
My clinical experience throughout my career had shown me
miracles don't happen. But I have no other explanation for this.
Everyone praying DID make a difference. We go to bed every
night holding hands, knowing all too well we have been given a
second chance.
BUCKS AND MONTGOMERY COUNTY MEDICAL SOCIETIES 15
Bucks Montgomery Physician Summer 2021

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