“Let me explain slowly.”
I have a duty to properly explain why this disease matches the patient’s current condition.
“I found it while looking through case reports… It seems like that rare disease.”
[Yeah. Go ahead.]
I let out a deep sigh and opened UpToDate and other disease information sites.
Rationally.
I’m a doctor.
Not some shaman diagnosing by intuition.
Reasons.
Evidence.
Evidence!
That’s everything.
“Let’s see here, medical records.”
Received symptomatic treatment (*treatment focused on symptom relief) for a cold at a local clinic, but no improvement.
Hospitalized at a regional secondary hospital with presenting symptoms of extreme systemic fatigue, multiple arthralgia and myalgia, and weight loss over three months….
I scrolled down.
The screen was packed with all kinds of lab results.
“At first, white blood cells were at the lower normal limit, platelets normal, but hemoglobin was down to 8.2….”
Simultaneously checked vitamin B12, folate, and thyroid function tests were all normal.
“The secondary hospital must have suspected infection at first.”
[Yeah. Probably. But I’m a bit busy right now. Let’s talk later.]
“Ah, yeah. Okay.”
That’s better for me.
I’d been given time to properly deduce.
CRP (*C-reactive protein), ESR (*erythrocyte sedimentation rate), and even ferritin were all values indicating severe inflammation.
Hmm.
‘The secondary hospital gave antibiotics.’
Records showed they’d administered 3rd-generation cephalosporin and macrolide antibiotics, considering pneumonia and sepsis.
Microbial culture tests and respiratory virus panel tests had come back, but….
Nothing.
Even the high fever and respiratory symptoms hadn’t improved.
‘They responded to steroids, relapsed when tapering the dose, and that’s how they ended up at our hospital.’
Click—
I opened UpToDate again.
The diagnostic criteria section for ‘VEXAS syndrome.’
Somatic UBA1 gene mutation in myeloid cells (*somatic UBA1 gene mutation in bone marrow cells)
Hmm, this can only be confirmed with genetic testing.
Can’t verify that immediately, so pass.
‘Anemia is found almost universally. Progressive thrombocytopenia may also be observed.’….
“…Near-universal finding.”
Found in almost all patients.
Check.
The patient was anemic.
I returned to the chart.
‘There was severe bilateral periorbital edema on the face.’
And the patient showed a cytokine-mediated inflammatory state.
That’s why steroids were given….
‘Did the condition improve again?’
But hemoglobin remained stuck at 8.4.
‘And the macrocytosis wasn’t corrected at all.’
Click—
Eye pain discovered on hospital day 15. Ophthalmology consult: scleritis.
Click—
Right ear chondritis.
Click—
Skin rash suspicious for neutrophilic dermatosis.
And macrocytic anemia.
The letters VEXAS floating on the UpToDate screen overlapped with the patient’s records with perfect precision.
‘The anemia’s worsening again. At this rate…’
If frequent relapses occurred even on maintenance doses exceeding 10 mg of prednisolone, and the steroid dependence was this strong, then this was unquestionably different from ordinary autoimmune diseases.
But wait, why am I even looking at someone else’s patient like this?
Anyway.
‘It looks like VEXAS.’
The bastard who left that comment had recognized it in one second.
From just a few lines of patient information.
Even though I was simply cheating off that answer sheet, I’d had to go through all this shit just to realize the answer was correct.
Doubt had turned to conviction.
‘Yeah.’
I picked up my phone again.
…
**
…
After conveying the information that way, I could only breathe easy once I heard Kang Taejin answer in a bright voice.
Whew….
Deciding to reason through the business with the gallery once I got home, I was waiting for Kang Taejin in front of the elevator on the floor where the hospital’s internal medicine residents’ office was located.
Kang Taejin trudged out.
“Hyeonjae.”
“What.”
“I got shut down.”
…?
What?
“You got shut down?”
“The third-year Nam Seunghyeon thinks I saw something weird somewhere. I laid out the logic, but… No, this looks right at a glance. Not responding to antibiotics, heavily dependent on steroids, relapsing polychondritis with macrocytic anemia. This is exactly VEXAS.”
I thought for a moment, then reached a conclusion.
“Taejin.”
“Yeah.”
If the front gate is blocked, you climb the wall.
‘Which department is in charge? Autoinflammatory disease… this is rheumatology territory.’
Since we got shut down by an internal medicine resident, there was only one way, wasn’t there?
Go direct to the rheumatology professor.
It was no different from suicide.
A mere first-year bypassing the chief and fellow to call the professor directly was a frontal assault on the hospital hierarchy.
But it didn’t matter.
There was a patient who needed saving, and in my head was the way to save them.
I found the name of the rheumatology professor on duty.
“Let’s call the professor.”
“What?”
“I said let’s go direct to the professor.”
Kang Taejin was appalled at my suggestion.
“Hey, no matter what….”
“We finally caught a clue to the diagnosis of a patient who’s been hospitalized for weeks. Are we going to let it slip?”
“That’s… no, I guess not.”
I caught my breath.
Hoo.
[Rheumatology Clinical Assistant Professor Choi Youngjun]
Ssshh, okay.
“Taejin.”
“Yeah?”
“You’re going to explain, right?”
“Ah, um… yeah. I’ll do it. I rotated through rheumatology first.”
I watched Kang Taejin take out his phone.
Kang Taejin pressed the call button with a trembling hand.
[…Hello.]
A voice steeped in fatigue.
Kang Taejin opened his mouth calmly.
“Professor, hello. I’m terribly sorry to call at this late hour. I am Kang Taejin, a first-year internal medicine resident.”
“First-year? What is it?”
There was puzzlement and slight irritation mixed in the voice over the receiver.
“I… it’s regarding the patient with chart number 26110134.”
[Hold on. Read me that chart number again.]
“Patient 26110134.”
[So why this patient?]
I shaped my mouth: V.E.X.A.S.
Say it.
Say it.
“In my opinion….”
Kang Taejin took another deep breath.
The bridge back is already burned, isn’t it?
Go straight.
“I’m calling because VEXAS syndrome is suspected.”
Silence.
[……What? VEXAS? Did you report to your senior?]
The voice was trembling.
“Ah, yes… Nam Seunghyeon told me to rule out the basics first, but the patient’s symptoms fit so perfectly. I think you may need to come see for yourself… Before that, are there any test orders I should place first?”
[I’m coming now. Wait there, Dr. Kang.]
Click—
The call ended.
Kang Taejin looked at me, trembling.
“Is this really okay?”
“Well… if we’re fucked, we’re fucked together. Classmate love, country love.”
Crazy bastard. A real crazy bastard.
What had I just done?
A mere first-year ER grunt had egged on his internal medicine friend to bypass a lofty third-year and called the professor directly.
The moment Professor Choi Youngjun dismissed what Kang Taejin and I said as bullshit, I’d be branded an ignorant crazy bastard in this field, and that would be the end.
I looked around.
I could feel several staff members glancing at me.
Their eyes held a mixture of emotions.
That bastard’s got serious guts, huh?
He’s going to get torn apart like a dog soon; how entertaining?
Eyes like that.
Five minutes passed.
Ten minutes passed.
That time felt like ten years.
I fiddled with my phone and anxiously stared down the hallway with Kang Taejin.
Cold sweat ran down my spine.
Had the professor decided it was a first-year’s delusion and ignored it?
When all sorts of worst-case scenarios were rampaging through my head.
The elevator doors slid open, and a man walked out.
A man who looked to be in his late thirties to early forties.
A young professor radiating an aura that screamed, *I am not a slave like the rest of you.*
Rheumatology Clinical Assistant Professor Choi Youngjun.
Professor Choi Youngjun glanced around and walked straight toward me.
My heart dropped.
“Dr. Kang Taejin?”
“Ah… I am, uh, Han Hyeonjae from Emergency Medicine.”
“Ah. Dr. Kang Taejin?”
“I’m Kang Taejin, first-year internal medicine!”
Kang Taejin glanced at me.
Oh.
Is he telling me to run?
He’s got sense.
“Why is an EM friend here?”
The atmosphere turned slightly chilly.
Kang Taejin deliberated, then barely opened his mouth.
“Actually… this friend was the first one to mention VEXAS.”
Professor Choi rolled his eyes and looked at my ID badge.
“…Dr. Han Hyeonjae?”
“Yes! Professor! I am Han Hyeonjae!”
I bowed at ninety degrees.
Professor Choi Youngjun half-acknowledged my greeting and headed toward the inner ward station.
“What are you doing? Aren’t you coming, Dr. Han Hyeonjae?”
Ah, shit.
I’m not… the kind of person who belongs in there.
Unable to say that, I just followed him in.
Professor Choi Youngjun began meticulously examining everything from the previous hospital’s records to the notes Kang Taejin had just scribbled after hearing from me.
Is my diagnosis correct?
No, it wasn’t even my diagnosis to begin with.
Just a comment from some dead medical researcher whose face I didn’t know.
What if this is all wrong?
After examining the patient for some time, Professor Choi straightened up.
“Hmm….”
“Dr. Han. VEXAS—this is a disease that was only properly defined a few years ago. You seem very interested in keeping up with the latest knowledge?”
My mind went blank for a moment.
Interested?
I don’t give a damn.
Latest knowledge my ass.
I can barely remember what I ate yesterday.
But how could I say all this was thanks to some crazy gallery that appeared in my head?
My mouth, perfectly socialized through a year of training, instinctively spat out the right answer.
“Yes! That’s right! Professor! I’ve always had a keen interest in rheumatologic diseases, so I look up related papers whenever I have time! Of course, I believe we must constantly acquire new knowledge!”
Such fluent flattery and lies spilled out that even I got goosebumps.
Professor Choi Youngjun snorted and gave a brief laugh.
Whether it was scorn for a pathetic wretch or encouragement for a promising one.
“Yes, that mindset is good.”
Before I knew it, Professor Choi was putting in orders and various tests.
“Send for a bone marrow biopsy, Sanger sequencing (*Sanger sequencing), and NGS (*next-generation sequencing). Let’s send these.”
A first-year resident.
And an emergency medicine resident at that, pinpointing a rare rheumatology disease, summoning the professor, and making these tests happen.
An incident worthy of becoming an ER legend itself.
Having finished all his orders, Professor Choi Youngjun tightened his gown and turned back to me.
“You said Han Hyeonjae, right?”
“Yes, Professor.”
“You did well for now. It’s difficult to confirm with clinical symptoms alone… but it fits. Non-response to conventional immunosuppressants, chondritis, histiocytoid skin lesions, macrocytic anemia. From what I see, the clinical symptoms are consistent with VEXAS.”
With those words, Professor Choi coolly left the ward as abruptly as he had arrived.
I blankly stared at the end of the hallway.
As all the tension left my body, my legs trembled.
A feeling of something hot filling my empty chest.
[Gallery of Dead Medical Researchers]
Now, it was time to figure out how to properly make use of these crazy bastards.