Chapter 186: What is this? (2)

Pneumonia, most likely due to a virus or endocarditis. Alternatively, it could be caused by some unknown third factor. Baruda and Suhyuk considered these three possibilities while observing Yoo Jisang’s condition. Their expressions were not good as they were lost in thought.

‘Why… Did I do something wrong?’

Ji-sang became nervous again at their reaction.

“Uh…”

“Don’t dawdle. You haven’t admitted him yet, doctor.”

Lee Hyunjong’s urgency left no room for hesitation. Honestly, despite his constant chatter, he had only hesitated for about two or three seconds, which was quite impressive. Although Ji-sang felt unfairly pressured, what could he do against Lee Hyunjong? Whenever Hyunjong attended a conference, it usually resulted in chaos.

“Umm… Yes. At admission, the patient’s issues included mitral valve replacement due to closed mitral stenosis, heart failure, insertion of a pacemaker, taking anticoagulants, recent worsening respiratory distress, fever, increased shadows on both lungs, hypoxemia with respiratory alkalosis, and hematuria.”

The patient was so challenging that even listing their problems took considerable time. Despite mentioning numerous issues, there were still some points he missed.

[Jisang-ssi didn’t mention anything about auscultation findings.]

‘Well… There might be heart murmurs or crackling sounds during breathing. Perhaps he didn’t mention them because he wasn’t aware?’

[I assumed this based on your previous handling of patients.]

‘Hmmm…’

While Suhyuk debated whether to defend his colleague, Ji-sang continued speaking without pause.

“Initially, I diagnosed it as pericarditis and heart failure leading to pulmonary edema and pneumonia. The diagnostic plan included echocardiography and blood culture tests. Sputum culture test and blood tests were also decided upon… For the treatment plan, we added diuretics to the existing medication regimen. Antibiotics such as Ceftriaxone with Azithromycin were administered. Oh, and X-rays were continuously monitored.”

Up to this point, Suhyuk’s and Baruda’s thoughts aligned closely with Jisang’s presentation. This indicated that Shin Hyun-tae had calmly handled the challenging patient without panicking.

“You went quite aggressive with the antibiotics. Uncharacteristic for someone from Infectious Diseases.”

‘The condition was truly dire. What if it worsened further?’

“Well… even I would have likely taken a similar approach based on experience.”

Ji-sang rapidly flipped through the slides. There was too much information to present due to the patient’s extended hospital stay. Doctors at university hospitals get annoyed if presentations exceed 20 minutes, even for fascinating cases. Everyone is busy, often sacrificing meal times to munch on tasteless sandwiches. It would be inappropriate to waste their time. As someone nearing their third year, Ji-sang understood this well.

“On day three of admission, the patient reported more severe symptoms than initially observed. Vital signs remained relatively unchanged… Culturing sputum samples yielded no growth or only skin contaminants. Blood cultures also showed nothing.”

At this stage, it wasn’t alarming to find no growth yet.

Typically, it takes more than a week to culture bacteria. However, worsening symptoms despite medication indicated something was off.

It wasn’t just Suhyuk and Baruda; most of the audience members sat up straighter, muttering, “What’s going on here?”

“Her white blood cell count increased compared to her initial levels. The CRP rose to 13.6, and arterial blood gas analysis consistently showed respiratory alkalosis. The X-ray…”

There were no significant changes in the X-ray results. After confirming this, many leaned back again from their forward-leaning positions.

Antibiotics don’t always provide immediate improvement. If there weren’t clear signs of deterioration, she could still be in the process of recovery.

The human body is mysterious, as some scientists might agree.

“On day seven of hospitalization, there were still no results from the culture test. There was no improvement in symptoms, but they did not worsen either, so we continued with the medication.”

“On day eight of hospitalization, no changes in vital signs or symptoms were observed. The culture test remained negative, and although CRP decreased slightly to 8.28…the X-ray showed evidence of disease progression.”

However, seeing no significant change even after seven days raised suspicions again. While Ceftriaxone and Azithromycin may not be considered top-tier antibiotics, they should have been effective against community-acquired pneumonia.

Furthermore, considering this patient had been transferred directly from the Infectious Diseases Department, it was unusual that no bacterial cultures were found despite not being treated with antibiotics beforehand.

The antibiotics aren’t working at all. Could it be viral pneumonia after all?

[It’s progressing too slowly for that. Considering the patient’s age, we should have seen some resolution by now.]

I guess it is dragging on, huh? Then could it be caused by some unique bacteria?

[I’m not sure.]

It seemed Shin Hyun-tae had grappled with similar concerns. He had retested the cultures and switched the antibiotics to a combination of piperacillin/tazobactam and ciprofloxacin. This regimen essentially bombarded the bacteria with a carpet bombing effect.

“Day fourteen of hospitalization… There is still no change in symptoms or sputum. The culture tests also show nothing growing.”

Yet there was no change in the patient’s condition.

“This is yesterday’s X-ray.”

Worse, it had deteriorated further. The extent of the disease had increased.

“Hmm.” At that moment, Lee Hyunjong nodded while stroking his chin.

This was why Shin Hyun-tae brought this X-ray to him immediately yesterday. Honestly, despite having heart issues due to underlying conditions, Lee Hyunjong wasn’t directly related to the current symptoms. It was likely because Lee Hyunjong was considered the best internal medicine doctor among those known by Shin Hyun-tae.

“I’ll take this case.”

Lee Hyunjong did not disappoint Shin Hyun-tae’s expectations. After pondering for several minutes, he gave a sly smile and took on the case. He also reassured them that the patient would undoubtedly recover fully before discharge.

“Wouldn’t you agree, Soohyuk?”

Lee Hyunjong hoped Suhyuk was at his level as he looked towards him. Anyone with even a slight understanding beyond medicine would know how absurd it was to compare himself, already established in his field, with a mere intern.

“Hmm… It seems plausible right now.”

“Yes, indeed. Good.”

However, Suhyuk and Baruda had been receiving excessive expectations since their first year of residency. It wasn’t just baseless expectations; they possessed exceptional abilities as well. Naturally, this led to a competitive spirit between them.

‘Firstly, these X-rays…the progression is suspicious. Why does it keep spreading?’

“It keeps spreading…”

‘Yes, it’s spreading… Wait? Hold on.’

“It starts from the lower leaves and continues upward. Here is how it appears when arranged chronologically.”

Suhyuk used Baruda’s data to list the X-rays from admission day up to fourteen days later. As he did so, a clear pattern emerged.

‘The medication has no effect whatsoever. It just keeps advancing upwards.’

“Not only that, but it spreads symmetrically on both sides.”

‘The progression was unaffected by antibiotics. Moreover, it is symmetrical on both sides.’

[A virus can often invade both sides, but it wouldn’t be this symmetric.]

‘Yes, this… This isn’t an infection. The cause isn’t due to an infection.’

Regardless of whether it was a virus or something else, infections typically respond to antibiotics. It would be different if the patient had no immunity at all, but that wasn’t the case here. If their immune system were compromised, they likely wouldn’t have survived until now.

The patient’s immune system might be slightly weak, but having a normal immune response meant that the worsening condition couldn’t be attributed to an infection.

Then what could it be? What was the root cause?

‘What were the symptoms again…’

[The patient has dyspnea symptoms. The NYHA classification worsened from Class II to III upon admission.]

‘NYHA…’

It referred to the New York Heart Association’s classification system for heart failure severity. This notation was likely due to the patient’s underlying condition.

‘Does this really have something to do with the heart?’

[Pardon me? I find it difficult to grasp the intent of your question. Please be more specific.] In full diagnostic mode, Baruda responded more formally than usual, focusing entirely on analyzing Suhyuk’s brain activity. Although initially awkward, Suhyuk had become adept at continuing the conversation under these circumstances.

‘Typically, when someone complains of shortness of breath, we suspect respiratory issues.’

[Correct.]

‘This patient was classified using the NYHA criteria due to underlying heart disease… In fact, it’s actually a lung problem.’

[Lungs only?]

‘Yes. Look closely. There is no change in the heart from the echocardiogram or X-ray images. Blood pressure and pulse rate remain constant as well. At least, the inserted pacemaker appears to be functioning normally with good positioning.’

[I see. I agree. Let’s shift our focus from the heart to the lungs.]

In response to Suhyuk’s request, Baruda compiled a list of diseases related to the patient’s lung condition. Since fever was also present, most possibilities pointed towards pneumonia. Suhyuk then eliminated all conditions that could be affected by antibiotics.

As a result, only a few diagnoses remained.

[Autoimmune disease? Wegener’s… It is possible but has less than a 0.1% chance of appearing so suddenly.]

‘The X-ray findings also differ. In Wegener’s, there should be lymph node enlargement at the entrance to the lungs. Moreover, Wegener’s typically invades other organs rather than rapidly affecting just the lungs.’

[Then what do you suspect the most? There is no condition with more than a 1% likelihood according to the database.]

In such situations, Suhyuk relied on his intuition as a diagnostician - a mysterious ability often referred to as a ‘hunch’, which Baruda couldn’t yet comprehend fully. Using this skill, Suhyuk grasped onto one particular diagnosis amidst scattered possibilities in his mind.

[Drug-induced Lung Injury…?]

It wasn’t the disease Baruda suspected, but Suhyuk was almost certain about it. Lee Hyunjong read the conviction in Suhyuk’s eyes.

“Here, here! Soohyuk has something to say!” Simultaneously, Lee Hyunjong raised Suhyuk’s hand with excitement on his face.

Finally, Shin Hyun-tae understood why Lee Hyunjong insisted on presenting this case at the conference.

‘Jongi… He is trying to make Director of Medicine position for our Soohyuk… Trying to bring attention to him.’

If that was the reason, enduring humiliation was fine. Finally, Shin Hyun-tae managed a smile.