“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.”
CHAPTER 49
The Nashua Street Jail was a big brick building housing more than seven hundred pretrial detainees, Jordan among them. Jordan maintained a calm, measured demeanor as he spoke to Julie on the other side of the glass partition. He massaged his fingers repeatedly, while swiveling on his metal stool, but these were the only outward signs of his nervousness. The wound to his temple had been sutured, and the area protected by a bandage.
Julie’s heart ached for him. Seeing him here, dressed in prison orange, fueled her resolve to get him out. As Jordan had predicted, the presiding judge denied bail at Jordan’s arraignment. They had led Jordan out of the courtroom in handcuffs with his mother and sisters crying, and Julie looking on dolefully.
Julie had not yet been linked to the murdered security guard. She planned to keep it that way until the time was right for her to come forward.
Jordan had been confined to a cell for two days, but reassured Julie he was doing just fine. The guards were treating him well. He was familiar with the routine and joked about how it was like riding a bicycle.
“Word I heard is the guy who tried to kill us was an ex-cop turned PI named Lincoln Cole,” Jordan said.
“I heard the same on the news,” Julie said.
“What you didn’t hear is that Dominick ID’d Cole as the guy who paid him to scare you.”
“Scare me? We both know that wasn’t the plan.”
“He still isn’t owning up to what he was really going to do.”
“You believe him about Cole?”
“Sure as heck, yes I do.”
Julie concurred.
“Who hired Cole to be a guard?” Jordan asked.
“That’s what we’re trying to find out,” Julie said. “I’m waiting for a call from Allyson. When I get it, I’m going to see Detectives Spence and Capshaw. Then I’m taking down whoever murdered Sam. That’s a promise.”