27
MARCH 26, 2010
FRIDAY, 12:33 p.m.
FRIDAY, 12:33 p.m.
When Laurie got back to her office with the
wine cork-sized en bloc tissue sample, she put it on her desk in
full view so as not to delay getting it to John. Meanwhile, she
fell back to examining the toxicology slides. Although she was now
confident that Kenji had been murdered with a toxic agent, she
still felt obliged to make sure there was no pathology in the brain
to explain the seizure. After all, whatever toxin had killed him
could also have been responsible for stimulating an existing
pathological lesion, rather than causing the seizure inherently. It
wasn’t a serious issue, but it might influence her search for the
toxin if she did find something. Besides, she wanted to be both
complete and accurate for what she thought was going to be a
triumphal presentation to Lou and Jack, and anyone else who might
like to listen.
While she methodically searched the slides, she was
able to multitask by trying to come up with what the specific toxin
might have been. She assumed it was a neurotoxin, as she’d decided
earlier, of which there were many different kinds in snakes,
scorpions, aquatic mollusks, and even certain fish. With that
thought in mind, she turned away from the brain slides temporarily
to go online to review neurotoxins. Because she’d come to assume
her two cases were people of Japanese ancestry, the one toxin that
jumped into her mind was tetrodotoxin, possibly the most infamous
toxin in Japan, since it was associated with multiple episodes of
illnesses and deaths in unlucky sushi and sashimi lovers. The toxin
came from bacteria associated with a number of creatures, including
a particular puffer fish whose flesh was considered a delicacy in
Japan. The problem was that the flesh could contain tetrodotoxin at
particular times of the year, whereas it is usually confined to the
fish’s viscera, such as its liver and skin.
Laurie focused her search on tetrodotoxin, with the
idea of seeing if it could cause convulsions when administered
parenterally, meaning by injection. As she skimmed several of the
articles, refreshing her general knowledge of tetrodotoxin, she
recalled that it was a useful compound and was used rather
extensively in medical research and even in clinical medicine. In
clinical medicine it was used to treat cardiac arrhythmia and also
as a pain reliever in extreme situations, such as in cases of
terminal cancer and debilitating migraines. She thought this was an
important issue in that it meant the drug was commercially
manufactured, hence readily available. There were many other
neurotoxins that were quite exotic and extremely difficult to
obtain.
“Yes!” Laurie suddenly said, and snapped her
fingers as she read that tetrodotoxin could, when injected, cause
convulsions, which wasn’t the case with the other classes of
neurotoxins. Continuing on in the same article, she also was
reminded of tetrodotoxin’s impressive toxicity: Two
hundred-thousandths of an ounce could kill a
one-hundred-and-seventy-pound person. Laurie whistled at such a
figure, realizing tetrodotoxin was one hundred times more poisonous
than potassium cyanide.
While marveling over tetrodotoxin’s lethality,
Laurie’s eyes wandered over to the institutional clock hanging on
the wall over her file cabinet. It was nearly one p.m. Knowing John
DeVries would surely be back to toxicology, she grabbed the sample
bottle and headed to the elevator.
When Laurie walked into John’s bright, spacious
windowed corner office, which contrasted so sharply from his
previous windowless cubbyhole, she could certainly understand how
it could improve one’s mood. John was just donning a fresh white
lab coat as she appeared at the door. His secretary had yet to
return from her lunch.
For a moment Laurie just stood there, transfixed by
the man’s metamorphosis. He was still tall and thin but no longer
gaunt, and his former academic pallor had been replaced with a
brush of color across his cheeks, making him look ten years
younger.
“Ah, Miss Laurie,” he said, catching sight of her.
“I’m afraid there’s been no change from this morning: no toxins or
poisons or drugs.”
“Did you run another sample?”
“Well, no,” John admitted. “Not yet. We’ve been
busy with a number of overdoses from last night.”
“Well, I have some news that I’ll clue you in on,”
Laurie said, dropping her voice in a playful fashion. “But you’re
not to tell anyone else until I have my mini-press conference later
this afternoon.”
“I promise,” John said.
Laurie went on to tell John about her discovery
from the security tapes that her case represented a robbery and
that she had reason to believe he’d been murdered in the process
with a toxin delivered with some sort of air gun. As she expected,
John was immediately intrigued.
“You got all this from security tapes?” he asked.
He was impressed.
“I did,” Laurie said. “With a dollop of inference.
By the way, do you recall a famous assassination that happened in
London involving a Bulgarian diplomat? He was killed by a toxin
that was shot into him by a pellet gun hidden in an
umbrella.”
“Absolutely,” John said. “It was ricin. Are you
suspecting your case was a copycat?”
Laurie nodded. She was impressed not only that John
remembered the case but that he’d also remembered the specific
agent involved. “I believe it was a copycat, to a degree.”
“Are you then suggesting we should be looking for
ricin?”
“No, I don’t think ricin was involved, because the
victim convulsed, and ricin does not cause seizures. But from
watching security tapes, I know one of two perpetrators was
carrying an umbrella. Because the subway station was so crowded, I
wasn’t able to actually see the umbrella used, but after the
attack, when the victim was lying on the concrete, one of the
attackers appeared to partially open the umbrella and cock it to
get it to fully close. My sense is that the umbrella was some kind
of air gun like the one involved in the case in London.”
“What about an entrance wound?”
“Good question,” Laurie commended. “I found one
today when I redid the external exam. I’m embarrassed to tell you
why I didn’t find it yesterday. There’s a small entrance wound on
the back of the victim’s leg at the juncture of the leg and the
gluteal mass.” Laurie held up her sample. “And this is an en bloc
excision of the track, which seemed to be about an inch
long.”
“Perfect,” John responded. He reached out for the
bottle, held it up, and glanced in at its contents. “If the agent
was not ricin, do you have any idea at all what it could have
been?”
“Actually, I do,” Laurie said. “I think it might
have been tetrodotoxin.”
John stopped looking in at the tissue sample and
switched his attention to Laurie. “Do you have any specific reason
to suspect tetrodotoxin?”
“First, I think whatever was used would have had to
have been a neurotoxin,” Laurie said. “Whatever it was, it
definitely caused a convulsion. It was a short convulsion but a
real one, both because it was seen by the nine-one-one caller and
because I saw it on the security tape. Tetrodotoxin is known to be
able to cause seizures when it is injected internally. This
afternoon when I looked into neurotoxins, I didn’t notice any
others associated with convulsions. Second of all, the stuff is
manufactured on a regular basis, so it’s available. And third of
all, and this is the least scientific, but I believe my patient is
Japanese, and Japanese have a long history with the toxin, thanks
to puffer fish.”
“Sounds promising,” John agreed with a laugh. “All
except the last part.”
“Now for the ninety-nine-dollar question,” Laurie
said. “When can we run it?”
“Why am I not surprised,” John said, humorously
throwing up his hands in mock despair. “I suppose you want it ASAP,
like tomorrow, as if you are the only ME in this organization and
we are sitting around up here, twiddling our fingers.”
“I’d love to have it today,” Laurie said with a
smile. “It would be my coup de grace for this afternoon
revelation.”
John threw back his head and laughed. “I suppose I
never can please you. You’re always in such a hurry. But tell me,
you used the pronoun ‘we’ when you asked when it could be run. Was
that a literal we or a figurative we?”
“Literal,” Laurie said without hesitation. “I was
pretty handy around the lab in college and in biochem in medical
school. If one of your techs or yourself could throw me some hints
now and then, I believe I could muddle through it. As soon as I
finish the rest of the case’s histology slides, I have a free
afternoon.”
John regarded Laurie for a beat, wondering if it
was a good idea to let an amateur loose in his lab or a recipe for
disaster. In favor of allowing her to work there for the afternoon
was that he liked her and respected her enthusiasm and dedication,
and the fact that she had always appreciated his work and had
frequently told him so.
“Have you ever used an HPLC/MS/MS, otherwise known
as a high-performance liquid chromatography with tandem mass
spectrometry unit, before?”
“I have,” Laurie said. “During my residency
training I spent some time in the lab as an elective.”
“Also, we’ll need some actual tetrodotoxin, which I
don’t have here, but they’ll have next door at New York
Hospital.”
“I’ll be happy to run next door to get it.”
“All right, why not?” John said with sudden
resolve. “I tell you what we’ll do. I’ll have one of my techs start
by using a sonicator to turn some of this tissue sample into
organic slurry. When you come back, I’ll let you do the extraction
with either n-butanol or acetic acid. I’m not sure which, but I’ll
decide by the time you get back. Sound okay?”
“Sounds perfect,” Laurie said, flashing John a
thumbs-up sign before spinning on her heels to head back to her
office. She now had true motivation to finish up with the histology
slides.