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Photo by Chris Ware
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It’s not every day that a patient enters the exam room with a diagnosis so rare that it’s never appeared in medical literature. This is one of those cases.
Jack (not his real name)—who lives in Irvington, works nearly full-time in the investment field, and played tennis until his recent illness sidelined him—describes himself as “an energetic, focused businessman and family man.” Bothered by muscle and joint pain, Jack went to see his internist in January. “Basically, I was aching all over,” he says.
Jack’s internist found a tiny amount of abnormal antibody protein in his blood and referred him to Dr. Matthew Weissler, a specialist in hematology and oncology at WestMed Medical Group. “Everybody has antibodies in their blood to fight infection,” Dr. Weissler says. “Sometimes, white blood cells produce defective antibodies, like junk floating around in the blood.” But those antibodies often disappear.
Finding no other worrisome indicators, Dr. Weissler suggested that Jack quit the cholesterol-lowering statin medication he had been taking because it can cause muscle pain and weakness. Jack did. The doctor also recommended that he schedule a follow-up appointment to check the protein level in his blood and reassess his symptoms. Jack, however, did not return immediately, thinking the pain would disappear. “But it didn’t.”
By June, when he saw Dr. Weissler again, “he was clearly a different man. He was wasting away. He was gaunt, tired, weak.” He had anemia and his fingers swelled to the point that “they looked like sausages.” Jack’s symptoms were reminiscent of polymalgia rheumatica, an inflammatory disorder that causes muscle pain and stiffness, so Dr. Weissler sent his patient to see a rheumatologist who confirmed the diagnosis. While the exact cause of polymalgia is unclear, it generally is associated with immune system problems, genetic factors, and some triggering event, such as an infection.
Dr. Weissler also ordered blood tests and found that the abnormal antibody protein was still there. That was like a “tell” in poker, Dr. Weissler notes, when a player’s behavior hints at the hand he’s holding. “That’s the body’s ‘tell’ that something was wrong,” he says. The testing also revealed a minute quantity of abnormal white blood cells in Jack’s blood. “That, coupled with the anemia and the weight loss and the joint pain and his whole general decline, told me that I needed to look for malignancy in his body, specifically a blood cancer,” Dr. Weissler explains.
A bone-marrow biopsy revealed that Jack’s body harbored an indolent lymphoma, a very slow-growing and often symptomless cancer. The typical course of action for this type of cancer is to watch and wait.
The dual diagnosis was stunning because lymphoma is rarely seen in combination with polymyalgia rheumatica. Dr. Weissler found only three cases in the world’s medical literature, and all three of those were aggressive lymphomas, not the indolent type that Jack had.
Jack has begun a course of prednisone, a steroid given to treat polymyalgia rheumatica and other conditions, and he’s doing well. But, because his condition is associated with—and probably caused by—his lymphoma, there’s a possibility that it may not resolve with the usual treatment. If his symptoms flare again, Dr. Weissler says he will attack the lymphoma with a combination of immunotherapy to block the growth of the cancer cells and standard chemotherapy.
“It’s definitely the most unusual case I’ve seen,” Dr. Weissler says. “It involved so many different parts of medicine.”
