Impression (DI Gardener 4)

“Help yourself.” Fitz continued with his explanation. “It’s a genetic disorder. The body starts to absorb excessive amounts of iron from the diet, which is then deposited in various organs. Mainly the liver, but the pancreas usually gets a high dose, as well as the heart, endocrine glands, and joints.

“The liver generally only stores a small amount of iron, which is an essential source for new red blood cells. Imperative for overall good health. When large amounts of iron are stored in the liver, the result is an enlarged or damaged liver. Deposits of iron can occur in other organs and joints, causing serious tissue damage.”

“You said, ‘first thought’,” Gardener pointed out. “Are you concerned it might be something else?”

“The other possibility is non-alcoholic steatohepatitis. It’s known as the silent liver disease. It resembles alcoholic liver disease, but occurs in people who drink little or no alcohol. The major feature in NASH is fat in the liver, along with inflammation and damage. Most people with NASH feel fine. Don’t even know they have a liver problem. Nevertheless, it can be severe and can lead to cirrhosis, in which the liver is permanently damaged and scarred and no longer able to work properly. The only means of proving a diagnosis of NASH and separating it from simple fatty liver is a biopsy.”

“Presumably, if there are few or no symptoms, it could take a while to show.”

“It can take years, even decades,” said Fitz. “The process can stop and, in some cases, reverse on its own without specific therapy. Or it gets worse, causing scarring. Or fibrosis can accumulate in the liver. As fibrosis worsens, cirrhosis develo

ps; the liver becomes seriously scarred, very hard, and unable to function normally. Not every person with NASH develops cirrhosis, but once serious scarring or cirrhosis is present, few treatments can halt the progression.”

“You don’t sound too comfortable with that one either,” said Gardener.

“No, not really,” replied Fitz. “Under normal circumstances, a person with cirrhosis experiences fluid retention, muscle wasting, bleeding from the intestines, and liver failure. She doesn’t have any of that. It’s possible that she may have one of the hepatitis strains such as A, B, or C, although NASH is more common. Many patients with NASH have elevated blood lipids, such as cholesterol and triglycerides, and many have diabetes or prediabetes.”

“Did she have diabetes?” Gardener asked, remembering the syringe, hoping to hit on something he could investigate.

“No, but not every patient with diabetes has NASH. They have normal blood cholesterol and lipids. NASH can occur without any apparent risk factor, even in children.

“We’re not quite sure what causes NASH, but there are several possible candidates. Insulin resistance, for one, but she wasn’t diabetic, so it wouldn’t be that. Release of toxic inflammatory proteins by fat cells, known as cytokines, is another.”

“Not likely to be that either,” said Reilly. “She was thinner than a whippet.”

“Which is why I’ve sent for an antibody screen. The third option is oxidative stress, the deterioration of cells inside the liver.”

“What about treatment?”

“Currently, there is none. But we can’t be certain what it is yet. However, there are some very good clinics, especially the private one on Bond Street.”

“I doubt she could afford a private clinic,” said Gardener.

“Even if she was a patient, she might not have been paying,” offered Reilly, making notes. “If she wasn’t, and it is hepatitis, and she was a prostitute, it’s possible she’s passed it on to a boat load of other people.”

“Almost certainly, if she wasn’t using protection.”

Gardener thought of the condom packets found in her house, but it was still worth following up.

“We have to give it a try,” Gardener said to Reilly. “She may have been getting treatment somewhere.”

“In which case she would have medical records,” offered Reilly. “That could really help, if we can find them.”

“Anything else?”

“Nothing more I can tell you about her. It’s the man you found slumped in the doorway at five o’clock this morning that presents a bigger mystery.”

Chapter Twenty-four

Gardener’s stomach lurched. Perhaps he should have another coffee.

He returned to his seat. “Go on, then, let’s have it.”

“His heart was in a state of fatty degeneration, and the liver was also diseased through increased fat. He definitely had NASH. The gall bladder was full of small calculi. The contents of his stomach contained about two fluid ounces of digested food. The only thing I recognized was fat and starch.”

“That’s Chinese out of the window for me,” said Reilly.

Fitz consulted his notes. “He was approximately fifty years of age. Most of the major organs were intact, but as I’ve said, he had NASH, so he wasn’t without his problems.”