Chapter 2

Episode 2 Vexas Syndrome (2)

"……Bastard."

A curse escaped my lips naturally. It felt as if all the strength was draining from my body. This was reality. I was just a "bastard who hasn't even filled a year and is writing web novels."

"…Ha, fuck."

A hollow laugh burst out. Yes, they say when things are too absurd, you just laugh. A crazy bastard who picked up a case report? A bastard writing a novel?

In that moment, my mind cooled down completely.

'No, wait. What if that bastard is right?'

Everyone in the hospital knew Nam Seunghyun was an asshole, but he was a 3rd-year Internal Medicine resident. His accumulated depth of clinical practice and experience was on a different level compared to a 1st-year Emergency Medicine resident like me, who just ran around the ER. To his eyes, I might have genuinely looked like an idiot acting up with some clumsily picked-up knowledge.

What if this isn't VEXAS? What if that "Dead Medic Gallery" is just a delusion created by my own brain, and it only seemed to match by pure coincidence? Then right now, I am holding onto a patient with a disease that doesn't even exist, while getting completely humiliated to my face by a 3rd-year Internal Medicine resident.

"Bullshit…."

Right, let's calm down for now. Don't start cursing; be rational. You're a doctor, fuck. Not a shaman making diagnoses by gut feeling. Evidence. Proof. Evidence! That's all that matters.

I picked up the stack of the patient's previous hospital records that had been tossed into the corner of the duty room. It was a chunk of poorly resolved PDF files barely linked as scans to our hospital's EMR (*Electronic Medical Record).

"Let's see, these fucking records."

Symptomatic treatment for a cold at a local clinic, but no improvement.

Hospitalized at a secondary hospital for 10 days of antibiotic therapy and various tests, but the fever continued.

"The fever didn't drop even after being flooded with antibiotics…. The possibility of an infectious cause is low."

I scrolled down. All sorts of lab results were densely packed. Hm. Hm?

"…Uh?"

I narrowed my eyes. It was a part I had just skipped over, thinking it was just 'mild anemia' when I first glanced at the chart. Hb (*Hemoglobin) 11.8. But the MCV (*Mean Corpuscular Volume, the average size of red blood cells) value next to it caught my eye. 102.5. Fuck. The normal range goes up to 100. This is clearly macrocytic anemia. It's not just regular anemia. Anemia caused by chronic disease in general inflammatory situations is mostly normocytic. But this is macrocytic.

"They missed this? No, it's not that they missed it; they just didn't know what it meant."

My heart started thumping again. As if possessed, I picked up my cellphone again and opened Up-to-date. This time, I opened the diagnostic criteria section for 'VEXAS syndrome'.

Somatic UBA1 gene mutation in myeloid cells.

Well, this can only be known by doing a genetic test. Since it's impossible to check right now, pass.

'Anemia is an almost universal finding. Progressive thrombocytopenia may also be observed,' it said….

"…Near-universal finding."

Meaning it's found in almost all patients. This fuck, even the first button is matching perfectly.

I went back to the chart. Radiology printout sheet. Chest PA, Abdomen CT.

Chest PA & CT: No lesions in the lungs, no lymphadenopathy.

Abdomen & Pelvis CT: No intra-abdominal abscess or hidden cancer findings.

"Right, since the images are clean, everyone was lost. It's not cancer, and it's not pus."

Abscess, tuberculosis, and cancer—the common causes of FUO (*Fever of Unknown Origin)—were being ruled out. What's left is either a rheumatic disease or another rare inflammatory disease.

Lastly, I thoroughly searched the nursing record. There are many times when the answer lies within the records meticulously written by nurses and the charting scribbled by doctors.

Day 2: Complained of bilateral pinna swelling and tenderness. Reddish changes observed.

Day 5: Multiple erythematous papules on the chest and back. Dermatology consultation, differential diagnosis for drug eruption, differential diagnosis for neutrophilic dermatosis. Biopsy not performed.

Day 8: Reported that the patient's nose is swollen and painful. No clear lesions on physical examination.

"Fuck, Eureka!!!"

Without realizing it, I slammed my fist down on the duty room desk. Auricular polychondritis. Nasal chondritis. A skin rash suspected to be neutrophilic dermatosis. And macrocytic anemia. The symptoms of VEXAS floating on the Up-to-date screen overlapped with the patient's records exactly, one by one.

'Are you an idiot? Looks like VEXAS.'

The bastard who left that comment recognized this in a single second. Just by looking at a few lines of patient information. Even though I had simply cheated from that answer sheet, I had to throw all sorts of a fit just to realize that the answer was correct.

Doubt turned into certainty. Nam Seunghyun, that bastard. If I give up now, I really become an idiot. An idiot doctor who got intimidated by hierarchy and customs and turned away from the correct answer right before his eyes.

'Fuck it, tell them to screw off.'

I picked up my cellphone again. If the front gate is blocked, I'll just have to climb over the wall.

'Which department is in charge? Autoinflammatory disease… this is the rheumatology domain.'

Since I got rejected by the Internal Medicine resident, isn't there only one way? To pitch it directly to the Rheumatology professor.

It was no different from a suicide mission. A mere 1st-year calling a professor directly, skipping the chief, resident, and fellow, was a head-on challenge to the hospital's hierarchy. But it didn't matter. Before my eyes was a patient who needed to be saved, and in my head was a way to save that patient.

I found the name of the Rheumatology on-duty professor.

[Clinical Assistant Professor of Rheumatology, Choi Youngjun]

Inhale, okay. I considered going to the chief, but stopped because they seemed busy anyway. With a trembling hand, I pressed the call button. My heart felt like it was going to jump out of my mouth.

"…Hello."

A voice laced with fatigue. I opened my mouth, acting as calmly as possible.

"Hello, Professor. I am truly sorry for the late hour. I am Han Hyeonjae, a 1st-year in Emergency Medicine."

"Emergency Medicine? What's the matter?"

The voice over the handset was mixed with wonder and a bit of annoyance.

"Um…. There is currently a patient with a high fever of unknown origin in the Emergency Room. They underwent various tests at other hospitals but couldn't find the cause… and from what I see…."

I took another deep breath. The bridge to go back had already burned down.

"I am contacting you because Vexas Syndrome is suspected."

Silence. This time, a heavy silence flowed, incomparable to the time with Nam Seunghyun.

"……What? VEXAS? Did you contact the Internal Medicine on-duty doctor?"

The voice was trembling.

"Ah, yes…. Well… Teacher Nam Seunghyun did tell me to rule out the basic things first, but the patient's findings match so perfectly. I think you might need to come down yourself, Professor…. Before that, are there any test orders I should place first?"

"I'll go down to the ER. Wait for me, Dr. Han."

'Crazy bastard. A real crazy bastard.'

What on earth did I just do? A mere 1st-year ER newbie bypassed a sky-like 3rd-year and called a professor directly. The moment Professor Choi Youngjun dismisses my words as bullshit, I will be branded as a mindless, crazy bastard in this field and be finished.

I looked around. I could feel the nurses glancing at me. Various emotions were mixed in their gazes.

That bastard has some serious guts.

He's going to get chewed out like a dog soon, how exciting.

Gazes like that.

5 minutes passed. 10 minutes passed. That time felt like 10 years. I anxiously stared at the end of the hallway, just fiddling with the innocent patient's chart. Cold sweat flowed down my spine. As expected, did he just ignore it, thinking it was the delusion of a 1st-year?

It was right when all sorts of worst-case scenarios were tearing through my mind. The automatic door at the entrance of the Emergency Room slid open, and a man walked in. A man who looked to be in his late 30s to early 40s. He was a young professor who exuded an aura that said to anyone, I am a different person from slaves like you.

Clinical Assistant Professor of Rheumatology, Choi Youngjun.

Professor Choi Youngjun scanned the surroundings once, then walked straight toward me. My heart sank.

"Dr. Han Hyeonjae?"

"Yes! Professor! I am Han Hyeonjae!"

I stood up abruptly and bowed 90 degrees. Professor Choi Youngjun barely accepted my greeting and snatched the chart held in my hand. From the records of the previous hospital to the records I had scribbled down a moment ago.

"The patient?"

"They are over there."

Professor Choi approached the patient without a word. Putting on gloves, he began to personally examine the patient's condition. He flipped the patient's eyelids to check the conjunctiva and meticulously touched the pinna to check for cartilage swelling and tenderness.

Would my diagnosis be right? No, in the first place, it wasn't even my diagnosis. It was just a comment from a dead medic whose face I didn't even know. What if all of this is wrong?

After examining the patient for quite a long time, Professor Choi straightened up.

"Hm…."

"Dr. Han. VEXAS, this is a disease that has only been properly defined for a few years. It seems you have a lot of interest in the latest updates?"

In an instant, my mind went blank. Interest? Fuck, I don't give a shit. Latest updates my ass, I can barely remember what I ate yesterday. But how could I say that all of this was thanks to a crazy gallery that appeared in my head? My mouth, perfectly socialized through a year of training, instinctively spat out the correct answer.

"Yes! That is correct! Professor! I usually have a lot of interest in rheumatic diseases, so I look up relevant papers whenever I have time! I naturally believe that we must always acquire new knowledge!"

Flattery and lies flowed out so smoothly that it gave me goosebumps.

Hearing my answer, Professor Choi Youngjun smirked with a short laugh. Was it a sneer at a ridiculous guy, or encouragement for a commendable guy?

"Yes, that mindset is good."

The gazes staring at me had also changed. Before I knew it, Professor Choi was placing hospitalization orders and various tests. A 1st-year resident, and an Emergency Medicine resident at that, accurately pointed out a rare disease in Rheumatology and even called a professor to secure a hospitalization. An incident that itself would remain a legend of the Emergency Room.

Having finished all instructions, Professor Choi Youngjun adjusted his gown and turned back to look at me.

"You said you're Dr. Han Hyeonjae."

"Yes, Professor."

"First of all, good job. A definitive diagnosis will be difficult with clinical symptoms alone… but it does align. If it wasn't for Dr. Han, this patient would have just drifted from hospital to hospital without knowing the cause, and their condition would have only worsened. For now, in my view, the clinical symptoms align with Vexas. Let's hospitalize him."

With those final words, Professor Choi left the Emergency Room coolly, just as he had suddenly arrived. I stared blankly at the end of the hallway. As the tension in my whole body released, my legs shook. A feeling of something hot filling up inside my empty chest.

[Dead Medic Gallery]

Now, it's time to contemplate how to properly utilize these crazy bastards.