Shadow of Eden (19 page)

Shoving the paper aside, he asked, “Did you find those tracings on Rhonda Fowler?”

“Yeah. I dug all three up. They’re right here.” She slid the stack over to Steve.

Looking at the dates, Steve picked the last one and flipped through it. Dr. Goldstein’s patient had more disordered, incoherent background rhythms and the epileptiform discharges, called PLEDs, were lower in amplitude. Otherwise, it looked virtually the same as Shirley’s EEG.

Why hadn’t he seen them before? He reached up to his box and pulled down Shirley’s first tracing done the morning after he transferred her to the ICU. She had had a moderately disordered background pattern, but the sharp waves were not prominent. But now that he knew how the tracing had evolved, he could identify the incipient abnormality. Shirley’s disease had significantly progressed even in the last several days.

Steve leaned back in his chair. He needed a moment to integrate this new piece of information. He pulled his finger out of his mouth and looked at his paper cut. It still oozed blood. “Tell me what causes PLEDS.” He liked to teach and Doreen seemed to enjoy their Q and A sessions. As Doreen pondered his question, Steve mentally sorted through his diagnostic list, checking off the causes of PLEDs. He had already eliminated nearly all before today—but there was one possibility that had not made his original list—a glaring omission.

“PLEDs stand for periodic lateralizing epileptiform discharges.”

“Good.” Steve mumbled with his finger back in his mouth.

“Typically,” Doreen continued as if reciting from memory. “They are caused by widespread toxic or metabolic abnormalities in the brain.”

“Such as . . .”

Doreen thrust out her bottom lip. “Uhh, hypoxia, encephalitis, meningitis, abscesses, tumors . . .” She trailed off and pulled a piece of paper out of the pocket of her hospital-white slacks. “I looked this up before you got here because I knew you’d ask.” She smiled sheepishly. “But I couldn’t remember all of them.”

“You’re doing well.” As they talked, Steve reviewed his new diagnostic possibility.

“Vasculitis, severe MS, liver failure, kidney failure, Crutz-Jacob something or other. Did I mention tumor?

“Yes. But it’s Cruetzfeld-Jacob disease or CJD for short. Good, Doreen.”

“What is CJD?”

“It’s like mad cow disease.”

“Oh.” She responded, without sounding like she had understood it at all.

“Shirley may have something like CJD. I want you to look it up and give a report on it at our next section meeting.”

Doreen made a face.

“It’s the best way to learn,” Steve grinned with humor he didn’t feel.

“You’re such a slave driver.”

Steve stacked the paper EEGs as his mind seized the possibility that he now, just possibly, knew the cause of Shirley’s illness.
Could it be a prion disease?

In the rare, but well-known prion disease called Cruetzfeld-Jacob disease, prions spontaneously form in the brain, but almost always in an older person. Since it was infectious, young patients who developed Cruetzfeld-Jacob got prions from infected human sources like infected corneal transplants, growth hormone collected from infected human pituitaries, or from contaminated neurosurgical instruments since prions were immune to destruction, even by the intense heat of an autoclave. It seemed to Steve unlikely that Shirley had Cruetzfeld-Jacob.

Shirley’s specific symptoms were not all that similar to known prion diseases. That was why he had not seriously considered them before. On the other hand, it was progressing at a rate not unknown for other prion-based diseases. And with the PLEDS and without another more likely cause, a prion infection seemed worth exploring.

Was it a new human variant of mad cow disease? It was more likely now that it had been found in US cattle, but Shirley’s symptoms were different from the cases in England. She and Captain Palmer had progressed much faster than the typical mad cow patient. Furthermore, they had earlier psychological symptoms without the prominent gait and coordination problems seen in the English disease. The MRI scans were different, too. So while it might be a new mad cow variant, it seemed unlikely. He put that thought aside for the moment.

Importantly, each prion disease has something in common. They all have a protracted latency period from the time of exposure to the time of first symptoms, typically over a year or more. Could that explain why Eden had not caused symptoms during the clinical trials? The FDA only required the drug companies to follow patients thirty days after they participated in a trial unless something made it necessary to follow them for a longer period of time. If a drug caused a side effect beginning over a year after initial exposure, it would be nearly impossible to track it down, even with the FDA mandated post-marketing surveillance program. And worse, if Eden was just now starting to cause symptoms, there could soon be a flood of new cases.

Steve scrawled “prions” on a scrap of paper with a red grease pencil and stared at it a long time. How certain was he that Shirley’s illness came from prions? Reasonably certain, he thought, but without a confirmatory test, he couldn’t be absolutely sure.

The problem was, there were no commercial tests for prions. The usual means to make a diagnosis was for a post-mortem examination of the brain or, in rare cases, through a brain biopsy. Because of the one-hundred percent mortality from contracting the disease, and the impossibility of sterilizing their instruments after using it on contaminated brain tissue, most pathology labs were unwilling to do an examination of the brain, if there was any suspicion of a prion disease. Steve had no illusions about Banner Samaritan’s interest in doing a brain biopsy. Here, as in so many other similar cases, the diagnosis would have to be made only on clinical grounds.

Steve pondered the bigger question last. If the brain disease was caused by prions, was Eden responsible? Eden was a short chain of fifteen amino acids. How was that linked to a prion, a huge protein? He would have to work on that part, too.

He pulled out his cell phone to tell Marty about his new concerns.

Chapter 39

I
t was a dingy morning sky that greeted Mallis as he walked through the door to his high-rise Arlington condo and glanced out the plate glass windows. The unbroken gray overcast that stretched to the horizon did nothing to dampen Mallis’ mood.

He was still riding high from his operation two nights before. He, Doug, and Joe had driven back to San Francisco after which Mallis had taken a walk down Turk Street in the tenderloin district. The young whore had been especially gratifying, although he doubted she would be working again for at least a week, maybe two, while she healed.

After a shower, and with his day’s first cup of hot green tea, Mallis sauntered into his study and turned on his computer. In a minute, he found what he was looking for: the San Francisco Examiner’s article about a tragic homicide-suicide in the Lake Tahoe area. The prominent UCSF physician apparently killed his wife and daughter before shooting himself in the head. Mallis smiled. He scanned the article for any mention of a suspicion of homicide, but there was none. Even if the police suspected foul play, Mallis knew they would never trace it to him.

He dialed his secure phone.

“Morloch.” A crisp deep voice answered.

“Hello, Vicktor.”

“Kirk.” Morloch’s voice warmed. “How are you?”

“Fine.”

“And our project?”

“Complete, as promised.”

“Loose ends?”

“None.”

“Wonderful.” Mallis could hear soft music in the background and pictured Vicktor with one of his women lounging in bed. “Good job.”

“Thank you. Vicktor. You should know that your Dr. Tobias is trouble.”

“How so?”

“His conscience is eating him alive.” On the way back home, Mallis’s technicians had alerted him about a priority event—and he had listened to the recording of Tobias’s bathroom confession to his wife.

“I thought he might be. A security risk?”

“I believe so, yes.”

“Then, contain it.”

“Roger.”

“This one is close to home, Kirk. It must be surgical and natural. No collateral damage.”

“Of course.”

Chapter 40

P
resident Dixon hung up the phone and found himself breathing a little fast. In fact, he realized, he felt winded and took several deep breaths, but that didn’t make it better. He loosened his tie and unbuttoned his top shirt button, but that didn’t help either. He pushed his chair back from his desk and stood up. For some reason he felt . . . nervous?

Maybe it was the coffee. Unlikely, since he had drunk only one cup this morning, several hours ago. And his headache was back. Maybe he needed more, not less caffeine.

Dixon glanced down at his day’s agenda filled with back-to-back meetings, and fought down the rising anxiety. While he sometimes felt a little claustrophobic on crowded airplanes, he had never felt it in the Oval Office. His chest began pounding with a mounting panic that fueled a powerful impulse to get away. He needed to leave and get outside where he could breathe.

He looked at his schedule again. He had a half-hour break before his next conference. It was his scheduled time for calling congressmen to lobby for his budget, but . . .

Walking out to his secretary, he announced, “Joan, I need some fresh air. Let’s go for a ride in your car.”

Joan, sure that he was joking, inquired, “What, you want a run through Mickey D’s?”

“I’m not kidding. I’d like to leave right now.”

Secret Service Agent Rhodes, standing behind him, politely coughed. “Sir, I don’t think we can allow that.”

Dixon swung around and looked levelly at him. “You’re welcome to come along, Agent Rhodes. We’ll only be about twenty minutes. Come on Joan.” He started walking towards the door. Joan looked helplessly at Rhodes and stood up.

Having made his decision, Dixon felt relieved, happier, almost giddy. He stepped outside into the brisk air and realized a car ride would be just what he needed to clear his mind—and pray.

Rhodes had no option, but to tag along. “Foxhound is moving. He plans to take Mrs. Pascal’s car out on a joy ride.”

There was a pause on the other end. “We have no time for jokes, Mr. Rhodes.” Then he heard, “Oh, shit.” He visualized the controller checking the President’s transponder screen to see that the President was indeed moving away from the Oval Office. Rhodes wondered what he should—or could—do when Agent D’Agostino joined him.

“Stay with him while we rustle up an escort,” the controller instructed. “We’ll hold him at the booth.”

“Roger,” Rhodes said, his face creased. This was a new side to Foxhound, an unwelcome one.

Arriving at Joan’s car, parked in the underground White House garage, the President got in the front passenger’s seat, leaving the two agents to scramble into the back.

Rhodes tried again. “Sir, this is not safe.”

“Okay, I’ll put on my seatbelt. Joan has a superb driving record. I’m sure we’ll do just fine.”

“I mean this is not a bulletproof car, you don’t have your vest on, and our escort is just forming up.”

“I hardly think the assassins of the world are waiting for the President to emerge in his secretary’s car.”