At the end of last year we admitted a patient (also call him Ivan) with HIV infection and fungal meningitis.  This latter condition is severe and difficult to treat.  We administered a powerful drip (rarely available in Malawi) and he initially recovered.  During the hospitalization, Ivan complained to me of another problem:  skin cancer located on the right leg.  This tumor is called Kaposi's sarcoma and is common in advanced AIDS.  In our setting, it is often fatal, but sometimes responds to HIV treatment, or to expensive chemotherapy.  Looking at the lesion, and thinking the malignancy not too advanced, I decided that we should focus on the meningitis and hope that his HIV treatment would strengthen the immune system.

Immune regeneration is exactly what happened, but with a paradoxical effect.  The newly emboldened T-cells vigorously attacked the tumor as well as the normal surrounding tissue.  Ivan was re-admitted due to fever and pain.  Now I looked at the leg in horror.  The cancer was dying and taking the rest of the lower leg along with it.  The extremity was throbbing, and the decaying tissue became a cauldron of infection.

The ominous development nudged my mind down a well-trodden path:  this patient was going to die.  The complexity and severity of his diseases were too much for our clinic:  extremely low immunity; an aggressive cancer; a life-threatening brain infection; seizures; and a dropping hemoglobin level.  To receive chemotherapy, Ivan required a blood transfusion.  But his blood type is rare and hard to find in Malawi.  We opted to infuse a closely related type and pray.

Weeks of dressing changes and futile chemotherapy were staring us in the face--or so I concluded.  Yet this man, having come to us for aid, continued to be our charge as he progressed down the forbidding road.  I recalled Ivan Ilych, and the relief which flowed from someone doing what little he could for an aching body.  So I determined to change his wound, cleaning and dressing it daily.  It was a dreadful task, one to be resented--like attempting to salvage a gangrenous extremity during the Civil War.  At one point I even suggested to Ivan that perhaps we should consider amputation. 

Something happened on the way to the literary illusion.  This Ivan's plot line would go in a different direction.

Almost to the day after the amputation discussion, the lesion slowly--but perceptibly--began to improve.  The drainage and discomfort lessened, the time it took to change the gauze shortened.  The patient's need for blood and antibiotics ceased.  Supported faithfully by his wife, Ivan received chemotherapy every two weeks.

Six months after his initial illness, he returned to work.  It was difficult to know if the cancer was still active.  The leg was scarred, still slightly swollen, and not pretty.  Side effects of the chemotherapy prompted a temporary break.  Then I worried about recurrence and spread of the Kaposi's sarcoma, so we risked another cycle of cancer therapy.

Ivan illustrates the challenge of applying mortality data derived from research (and from the experience of clinicians) to the individual.  My judgment was wrong.  No doubt I underestimated his will to endure, and the love of his family.  Ivan Ilych "had to live thus all alone on the brink of an abyss, with no one who understood or pitied him."  Our Ivan sat on the edge of the same endless chasm, but not alone.

Few centers in Malawi can administer powerful therapy for fungal meningitis or Kaposi's sarcoma, and even fewer would change the wound daily--reducing or waiving hospital charges along the way.  So perhaps in most places he would have died.  At our place, he has, for now, survived.