Woody Hard Leg

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Katrin Sadigh, MD

Color ascends her plump form in layers—from the wide double skirt up to the chemise beneath the long sleeve blouse beneath the heavy rain jacket, up to the hat which she took off before sitting down in the chair. Despite the layers, she cannot hide her legs, the swollen, thickened skin, what we soon learn to be described clinically as “woody hard.” The shape of her sandals is imprinted on the tops of her feet. She tries to tuck her feet under the hem of the billowing skirts, but my eyes have already spotted the growth on her left lower leg. From the boggy epidermis, it rises first as skin-colored specks with sheen, resembling dewdrops. As it proliferates, drops coalesce into plaques, and later into nodules, organizing in rows like a garden. With time, the larger nodules ulcerate and the skin breaks open like a cauliflower, even accumulating pigments of color along the edges. In shades of yellow and orange, her leg is adorned in the way of a fallen log, deep in a forest, supplying nutrients to a colony of mushroom.

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Sarah King (left), UVM Larner College of Medicine Class of 2017, working with a medical team at Parirenyatwa Hospital, Harare, Zimbabwe

Her name is Glory. She was diagnosed with HIV years ago, but had defaulted on antiretroviral therapy. She does not offer an explanation, but does share that funds were not a part of it. Later, the resident tells us that the answer is in the bracelets stacked up her wrists. A true believer, she had cast hope anchored in money onto the Church, and had forgone life-saving therapy for years until the swelling of her legs advanced to her hips, and the pain kept her up at night. Now, at the age of 47 and a CD4 count of 65, she has acquired human herpesvirus 8 (HHV-8), the virus at the heart of Kaposi Sarcoma (KS), a vascular tumor that like any other cancer can start small and spread big. As a new diagnosis, and naive to chemotherapy, she qualified for a study that consists of a bronchoscopy during which fluid from deep within the lung is collected and tested for evidence of more extensive disease.

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Dr. Sadigh working with a medical team at Parirenyatwa Hospital, Harare, Zimbabwe

Two months later, she has returned to KS clinic for follow up. The resident finds her chart, and leafs through the multiple sheets until he finds the report. He stares at it while inconspicuously shaking his head. “TB.” This changes everything. The patient will need to start anti-TB medications immediately. Treatment of her cancer, as well as of advanced HIV, will have to wait. He explains all of this in a quiet voice to the patient. Each nod of the head is accompanied by “Yes, doctor.” While the breakdown of actions to follow, “first we need a viral load, then report to the pharmacy, next…” is clear and well understood, it fails to deliver the real message. She gathers the ends of her skirts in one hand and her large shoulder bag in the other, pushing off the chair with the less diseased right leg with a heaviness that remains long after the door closes behind her.

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