Dear Editor
I KNOW I might have exceeded my allocated number of published letters for this year, but after Guyanese were informed of President Granger’s diagnosis, I have been inundated with calls and messages to provide a better understanding of what this means. I have taken a break off social media, so I’ll be grateful if you can indulge me by publishing this letter to better inform the concerned Guyanese populace.

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 cells. 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 e.g. Agent Orange) has also been associated with an increased risk of development of NHL.

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 decrease blood cells.

What is concerning for most NHL patients would be the fever, night sweats and weight loss. This is likely what your dear President was experiencing what he described as “symptoms.”
Please permit me to elaborate on what I meant by [the] terms indolent and aggressive. We can look at NHL like humans. We all have different personalities. Some of us are quiet (indolent) while others are quick to anger (aggressive).

The quiet person, if provoked, will simply walk away and smile. The aggressive, like myself, if provoked (say by being pinched on the arm) will drop a tonne of bricks on the person who pinched them; same with NHL. The indolent types will just sit there for years not causing any problems. The aggressive types are the most feared. They can kill you within weeks if not treated.

So what about prognosis (chances of survival or recovery)? Multiple studies have demonstrated that prognosis of NHL is far more dependent on [the] type of NHL; whether it is the aggressive type or the indolent type. Aggressive types fear worse. Other factors which are not so important include age (older, worse prognosis) presence of extranodal disease, performance status (how fit you are) and stage (how much it has spread)
Let me do some explaining. Extranodal disease simply means the NHL has affected areas other than the lymph nodes, eg bowel. What are lymph nodes? Can you remember as a child when you had cut on your foot. Remember that a painful lump developed in your groin that you called a “cornal.”

That was actually a swollen lymph node. Why did they swell? Let’s use an analogy. Let’s say Venezuela attacks Guyana in Mabaruma. The government of the day will get irate. Soldiers would be sent to defend Guyana’s sovereignty. The Generals will place the soldiers in strategic locations and send specialist groups of soldiers to fight the invading enemy. That’s exactly how our immune system works. It sends out white cells that accumulate in strategic locations.

For your foot, that strategic location is your groin. Hence, all your well trained immune soldiers accumulate there, causing your lymph nodes to swell, hence forming what is known in Guyana as a “cornal.” With NHL lots of these lymph nodes are swollen– Lymph nodes in the neck, armpit and groin. These lymphs are not swelling because of infection, but mainly because the white cells have gone rogue and just rapidly increasing in numbers, no longer listening to your immune system (the immune general), hence developing into NHL.

Questions may be asked as to whether Mr. Granger’s NHL was missed in Trinidad when his doctors assessed him in May. The answer I don’t know. What I do know is that when he went back to Trinidad a few Monday’s ago with symptoms, it is likely it was detected then. 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 test and blood cultures, using those blood culture bottles.

If that does not provide an answer, then 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 teach you to do. That’s why it should not be rushed.

Treatment of NHL is mostly with strong drugs called chemotherapy. What are chemotherapies? Let’s use this analogy. Remember the gulf war when President George Bush dropped cluster bombs on Iraq. Shock and awe was the name. Remember what happened? It did kill the Iraqi soldiers but also killed thousands of innocent civilians, simply because those types of bombs do not discriminate.

So chemotherapy is like that. It will kill the cancer but other active bystanders are sure to die. For example, it may kill your red blood cells, making you weak; it may kill you platelets that can make you bleed; it may kill your hair, making them “fall out”; it will kill your white cells, making you prone to infections; it will attack your bowels, giving you diarrhoea which further weakens the patient.

So why can’t you see your President today? Why can’t he travel? The 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 cells are low (anaemia). 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 (immunocompromise). They bad bugs are now aware of this. When your immune system was strong, they kept their distance. Nobody messes with America or Britain. Now the immune system is compromised, they attack (opportunistic infections).They will surely attack a weak Kuwait.

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’s 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. I hope this answers all your questions. For those who believe in God, pray that Mr Granger gets well soon. For those who do not believe in God, place your faith in his treating doctors.

Regards
Dr. Mark Devonish, MBBS MSc MRCP(UK) FRCP(Edin)
Consultant Acute Medicine, Nottingham University Hospital, UK