President Granger’s Non Hodgkin Lymphoma
Since Guyanese were informed of President Granger’s diagnosis, I’ve been inundated with calls and messages to provide a better understanding of what this means.
Mr. Granger was diagnosed with Non Hodgkin Lymphoma (NHL). NHL is a type of cancer of the blood. The blood is made up of many types of cell. They are red cells which provide energy, platelets which facilitate blood clotting and white cells that fight infections.
NHL is a cancer of the white cell. Many may be wondering what causes it. Risk factors include personal or family history of lymphoma or other prior blood malignancy, past radiation or chemotherapy treatment, use of immunosuppressive agents, organ transplantation, exposure to certain agricultural pesticides, hair dyes, and dioxins (eg, Agent Orange).
In contrast, the consumption of vegetables and fruit rich in antioxidants and regular routine residential ultraviolet exposure have been associated with a reduced likelihood of developing NHL. Infections associated with NHL include human immunodeficiency virus (HIV), human T lymphotropic virus type I (HTLV-I), Epstein-Barr virus (EBV), hepatitis C, Borrelia burgdorferi, Chlamydia psittaci, and hepatitis B virus (HBV).
The clinical presentation (symptoms) of NHL varies tremendously depending on the type of lymphoma and the areas of involvement. Some NHLs behave indolently with waxing and waning lymphadenopathy for years. Others are highly aggressive, resulting in death within weeks if left untreated. In typical cases aggressive lymphomas commonly present over a short period with a rapidly growing mass, fever, night sweats, weight loss. Indolent lymphomas are often insidious, presenting only with slow growing lymphadenopathy, enlarged liver and spleen or decreased blood cells.
What is concerning for most NHL patients would be the fever, night sweats and weight loss. This is likely what the President was experiencing what he described as “symptoms.”
So what about prognosis (chances of survival or recovery)? Multiple studies have demonstrated that the prognosis for NHL is far more dependent on the type of NHL. Whether it is the aggressive type or the indolent type. Aggressive types fare worse. Other factors which are not so important included age (older worse prognosis) presence of extranodal disease, performance status (how fit you are) and stage (how much it has spread).
Questions may be asked as to whether Mr. Granger’s NHL was missed in Trinidad when his doctors assessed him in May. The answer is I don’t know. What I do know is that when he went back to Trinidad a few weeks ago with symptoms, it is likely it was detected then. If he had those symptoms in May and he told his doctor but it was not investigated then that is negligent. If a patient of Mr. Granger’s age presents to me with fever and weight loss I would try to get to the bottom of it. I would have done a thorough examination, some basic blood tests and blood cultures using those blood culture bottles that are ridiculously absent from the Neonatal Intensive Care Unit. If that does not provide an answer then any well trained specialist, not one that only did a few years fellowship, would explore further. I would have done a CT scan of his chest, abdomen and pelvis looking for masses and abnormal growths. If those are seen then a biopsy is indicated. I would have also done a scan of the heart (echocardiogram) looking for infections. I would have also done PCR blood test for unusual viruses, bacteria and fungus. That’s what years of training teaches you to do. That’s why it should not be rushed.
Treatment of NHL is mostly with strong drugs called chemotherapy. So why can’t you see your President today? Why can’t he travel? The honest truth is that I’m not his treating doctor. I do not know but I can provide a professional opinion. It is likely that Mr.Granger is too weak to travel because his red blood cells are low (anaemia) or he has diarrhoea. Also it is likely his white cells are also low. Remember as discussed earlier I said that white cells fight infections. Well if they are not there then your immune system is compromised (immunocompromised). The bad bugs are now aware of this. When your immune system was strong they kept their distance.
How are such infections treated? Very strong antibiotics, antifungals and antivirals. Also the immune system needs a boost since it has been depleted by the chemotherapy. A drug called colony stimulating factor (G-CSF) is used to provide this boost. But most importantly the patient will have to be placed in an isolated room to protect them from infections. Doctors and nurses will have to wear special protective clothes so that they do not infect the patient. So it is obvious now, isn’t it. The patient can’t go on a plane because they will be exposed to infections in an enclosed plane where everyone is coughing and sneezing bugs. In my opinion that is the reason why Mr. Granger cannot fly. Yours faithfully, Dr. Mark Devonish MBBS MSc MRCP(UK) FRCP(Edin) Consultant Acute Medicine Nottingham University Hospital UK