Mercy

CHAPTER 48

Julie was in rough shape, so Lucy drove them to the hospital. On the way there, Julie tuned the radio to WBZ. A broadcaster reported breaking news of a homicide at Suburban West hospital. No names had been released, but the broadcaster said a suspect was currently in police custody.

Lucy took it all in. “I’m sorry,” she said to Julie.

“For what?”

“For ever doubting you.”

In transit, Julie used Lucy’s phone to call Allyson Brock. The conversation was tense, as expected. The snippets Lucy heard made it sound as if Allyson was more concerned for Allyson than anything else.

Julie ended the call with a look of disgust. “Well, I don’t think she set us up,” Julie said, “but I don’t think she cares what happens to us, either. Her biggest worry was that she was going to get arrested. I told her to wait for the police to show up, which they will, and tell them she gave Jordan her badge as a favor. It will back up Jordan’s story.”

“What’s the worst they can do to Allyson?” Lucy asked. “She’s already been fired from West.”

“That’s what I said. The most they can do is revoke her access privileges. Anyway, she’s going to try and figure out who the security guard was, when he was hired, who hired him, that sort of thing. Allyson still has the loyalty of the employees at West. She’ll get info. The guard told us it was his first day on the job, but I don’t know if that’s true or not.”

“If it is true,” Lucy said, “you realize that whoever pushed through his hire, or called in a favor, is probably the person who wanted you dead.”

They arrived at White a little after nine. It was dark, chilly enough for Lucy to lend Julie a warm jacket, which she wore in place of the bloodstained lab coat. And it was quiet. Everyone was with family, except for the sick and their caretakers.

Lucy parked in a rear lot reserved for staff and she and Julie made it to the lab without incident. A police officer, evidently unaware that Julie had been fired from White, waved as the two docs walked by. Jordan must have kept Julie’s name out of his conversations with the police. That would buy them some time.

The lab was empty, as expected for a holiday evening, and Lucy took her time getting the equipment set up. She enjoyed this part of the job so much that for a moment Lucy forgot where the sample had come from, and how it had come to her.

“The test is called an immunohistochemistry,” Lucy explained. “It’s a process we use to detect antigens, things like proteins, in tissue cells. We use this type of staining widely in the diagnosis of abnormal cells. Here we’ll be looking for a concentration of mast cells. I’ll be using immunophenotyping to understand the various proteins expressed in the cells.”

“Lucy, no offense, but I don’t think I care how you do it,” Julie said. “I just want to know what’s in that tissue.”

“No offense taken,” Lucy said with a shrug.

Others might have been put off by Julie’s candor, but Lucy appreciated it. No reason to explain something to someone not interested.

Julie used a website accessed from one of the lab’s computers to listen to news reports about Suburban West, while Lucy went about her work. She was not an expert in allergies by any stretch, though she knew sneezing and runny noses were symptoms. The reaction itself took place in the genes, and got expressed through the immune system. The process Lucy was using would allow her to identify the antibody in the tissue sample so she could reverse-engineer it into the corresponding allergy-causing antigen.

Gowned and gloved, Lucy prepared a sample by fixing the tissue in formaldehyde, and then embedded it in paraffin to maintain the natural shape. She used a machine called a microtome to section the tissue to five millimeters, a thickness required for the test. The slides she coated with a gelatin adhesive. The sections were dried in the oven.

“Staining and immunodetection is up next,” Lucy said after the initial tasks were done. Her voice was almost joyful; she so loved this work.

Julie was on the computer, no longer glancing at news sites about the murder, but instead researching causes of hives.

“What else did these patients have in common besides hives?” Julie asked.

“I’m not sure,” Lucy said, snapping off one set of gloves in exchange for another.

“Sam, Donald Colchester, Tommy Grasso, Albert Cunningham. There’s a thread we’re missing.”

“They’re all men,” Lucy said.

“More than that, I would think.”

“They were all in the hospital,” Lucy said. “Some were sicker than others.”

“Were they?” Julie sounded a bit animated. “Was Donald Colchester with his advanced-stage ALS really worse off than Sam? Or what about Tommy Grasso and his chronic COPD, and Albert Cunningham, suffering from the same? Each was living a marginal existence, including Sam.”

“I see your point.”

Julie fell silent, but some thoughts had begun to percolate.

Lucy returned to her work. Detecting the target antigen with antibodies was a complex, multistep process. When the samples were ready, Lucy applied an alcian blue dye and began to examine the mast cells under a microscope, looking for antibody-antigen interaction. Anything stained purple meant presence of an epitope-an antigen recognized by the immune system.

Lucy saw something, all right, and it surprised her greatly.

“Julie,” she said. “Do me a favor and run a search for meat allergy.”

“Excuse me?”

“A meat allergy,” Lucy repeated, her eyes glued to the microscope lens. The slide showed evidence of an antibody binding to a sugar carbohydrate found in beef, lamb, and pork called alpha-gal.

Julie clicked a few websites. “There’s an article here about alpha-gal.”

“That’s it,” Lucy said. “Summarize for me, please.”

“It talks about a tick bite causing an unusual reaction to meat,” Julie said.

“Go on.”

Lucy had not looked up because her microscope was revealing a fascinating world, one of profound vastness constrained to a tiny slice of human tissue.

“The allergy produces a hivelike rash,” Julie noted with some excitement. “In some people it can cause an anaphylactic reaction. Why do you want to know this? Did Albert Cunningham have an alpha-gal allergy?”

“Read on,” Lucy said.

“It says the allergy is only found in people bitten by the lone star tick, which is mostly in the southeast, though it’s been appearing farther and farther north, especially Long Island.”

Lucy was listening intently while looking at her slide.

“People bitten by the ticks develop antibodies against the alpha-gal sugar,” Julie said. “But it’s a delayed reaction, sometimes up to eight hours after ingesting meat, so they aren’t always aware of the connection between a case of hives and the meat they ate.”

This inspired Lucy to abandon her microscope and come over to Julie, who did not look away from the computer screen.

“The symptoms of the allergy range from the minor, like itching, to the more major, like hives and even anaphylaxis with weakness, swelling of the throat and tongue, and difficulty breathing.”

“No fatal heart attacks like Kounis syndrome?” Lucy asked.

Julie entered a keyword search into a medical database using the terms “Kounis syndrome” and “alpha-gal.” There was plenty of information about allergic reactions resulting in myocardial infarction, but nothing specifically linking Kounis syndrome to alpha-gal. And yet according to the antibodies in the stain, Albert Cunningham had suffered an alpha-gal allergic reaction. But an alpha-gal allergy alone did not trigger a heart attack, so Lucy wondered if another agent played a role in the event, a combination of alpha-gal and something else.

Julie read on. “This is interesting,” she said.

Lucy leaned in closer.

“The cancer drug cetuximab produced a similar reaction in people who were later found to be alpha-gal allergic. Some people being treated with cetuximab showed severe hypersensitivity reactions. Doctors found these drug reactions were localized mostly to the southeastern United States. Researchers were able to link allergies to cetuximab to patients who were bitten by the lone star tick.”

“So for those patients, receiving a dose of cetuximab was like ingesting red meat.”

“Exactly,” Julie said. “Was Albert Cunningham ever given cetuximab?”

“I can test the tissue to see.”

“I wonder what would happen to someone who was made alpha-gal allergic by a tick bite and then given a large dose of cetuximab?”

Lucy looked thoughtful. “It would be like ingesting pounds and pounds of meat,” she said, “but in a concentrated form. The body would become overwhelmed trying to fight off the allergy.”

“Overwhelmed to the point the heart suffers a massive allergic coronary?”

A heavy pall settled over the lab.

“Let me test for the drug.”

Julie was smart to have taken the sample from the liver. It was the best tissue for use in postmortem toxicology, because it was where the body metabolized most drugs and toxicants. The process of testing was complex and required every bit of Lucy’s expertise. But a specific toxicology screen could detect cetuximab. The drug was so unusual it would never have been picked up on a typical tox screen.

It took a couple of hours. Julie spoke with Trevor and Paul on the lab phone, but told them nothing of her ordeal. When the results came back, Lucy was shocked, but not entirely surprised.

Albert Cunningham’s tissue showed a huge quantity of the cancer drug, far greater a dose than would ever have been prescribed.

“Did Albert have head or neck cancer?” Julie asked, referring to the two most common cancers the drug treated.

Lucy had access to the Suburban West medical records system as a result of the merger. She made a quick scan of Albert’s record.

“No. He did not have cancer.”

Julie gasped. “Then Albert was murdered. He was somehow made alpha-gal allergic and dosed with a high quantity of cetuximab to induce a fatal allergy-triggered heart attack.”

“You know what this means, don’t you?”

“Yeah, it means Sam was murdered too.”