Mystery Diagnosis Part II

By the time we walked into the offices of Otolaryngology/Head and Neck Surgery at UCSF Mt. Zion on a sunny November morning, Steve and I had been reduced to sacks of nerves. After two days of dread and anticipation, I was fully expecting to hear the worst and that I would more than likely be ushered into surgery that same week. However, instead of my imagined scene of the somber, seasoned attending sitting us down to deliver the news, it was a bubbly physician's assistant who entered with the results of my MRI.

She told us that the lump in my neck was not a tumor, but a grossly enlarged salivary gland and that my symptoms were the result of extreme inflammation. Although in truth this news was an enormous relief, ultimately the MRI results only raised more unanswered questions: What could cause this kind of inflammation? WHAT DO I HAVE?

More tests were ordered. This time the blood tests were aimed at a panel of inflammatory markers. I was also sent to undergo a Fine Needle Aspiration biopsy, wherein a long needle is inserted directly into the affected gland (multiple times) and cells are aspirated for histological staining and culture. Aside from feeling like a pin cushion, my general state of mind improved. I was once again hopeful for a simple and quick resolution. We ordered the Thanksgiving turkey; life moved on.

The following week we returned to ENT to hear my test results. The blood tests showed a number of inflammatory markers were elevated, indicating a possible autoimmune condition. This did not entirely surprise me, as I had already learned from the Internets of a condition that fit my symptoms known as Sjogren's Syndrome. Sjogren's is an autoimmune disorder that affects the moisture-producing glands of the body. The most common symptoms are dry mouth and dry eyes. It is actually the second most common autoimmune disease in the U.S. following Rheumatoid Arthritis. There is no cure, and the only prescribed treatments are those used to alleviate symptoms (artificial tears, chewing gum to induce salivation, etc.) Although I would never have complained to a medical provider about dry mouth or dry eyes, I suppose they have always been on the dry side; I had just assumed it was still in the realm of normal.

Although the prospect of a possible autoimmune condition was daunting (particularly to an immunologist), I would have been somewhat satisfied by that diagnosis, given that it is a simple answer to my looming question. Unfortunately, I had only heard the beginning of my lab results. The pathology reports from my FNA biopsy had also returned, and the cultures were growing some kind of mycobacteria. If you haven't heard of mycobacteria, perhaps you'd recognize Mycobacterium tuberculosis aka the bacteria that causes TB. I was immediately sent to be tested for TB.

Most people have had a few TB tests in their lives, wherein a bolus of BCG is injected under the skin to see if a reaction occurs 48 hours later. I had had a TB test fairly recently, just before Ruby was born, as it is routine to test pregnant women for TB. The test was difinitively negative, with no reaction whatsoever. I couldn't imagine how I could have possibly come into contact with TB in the time since Ruby was born. We had barely travelled at all outside the bay area, with the exception of one trip to Santa Monica and one trip to Maui. I never even take public transportation, which is the only place I can think of where one might unknowingly contact high-risk individuals. I had rotated in TB lab, but that was more than 5 years ago during my very first rotation of graduate school, and any exposure I had during that time would surely have been picked up by the TB tests I had had since then.

I returned to student health to have my TB test administered. The nurse told me to come back in two days to have the test read but that if it was positive, I would probably be able to tell by the following day. I left fully expecting the test to be negative. The next morning, I woke up to find a swollen mass the size of plum on my forearm.

TO BE CONTINUED ...