Over the next few years, many of us are going to encounter people with illnesses that don’t make sense. At first, these stories sound like medical curiosities — tragic, unusual, but distant. That illusion disappears the moment it happens to someone you love.
I want to be very clear at the outset: what follows is not a diagnosis. I have not examined this patient. I am working only from a publicly reported case in New Zealand that describes a previously fit man with hundreds of blood clots, failing organs, and no clear diagnosis. But medicine advances precisely by recognising patterns early, before they become textbook entries.
This case matters because when clinicians lose a unifying framework, care becomes fragmented, reactive, and often futile.
A Fit Man, a Slow Unravelling
The headlines focus on the initial presentation with collapse, vomiting blood, confusion, intensive care, ventilators, and now the possibility of needing a heart transplant. But that is not where this illness began.
Weeks earlier, there were quieter signals:
Progressive breathlessness
Difficulty climbing stairs
Episodes of coughing up blood
These are not benign symptoms. They are red flags. They tell us that the disease process was already well underway long before the dramatic hospital admission.
Yet modern medicine has a habit of anchoring to the moment of crisis. Everything before it becomes background noise.
That is a mistake.
The Clues Hidden in Plain Sight
As more details emerge, the picture becomes deeply unsettling:
Pulmonary emboli scattered throughout the lungs
Areas of dead lung tissue with cough
Multiple small strokes
Kidney failure
Progressive heart failure
This is not a single-organ problem. It is not even a single-system problem.
When clots appear in both the venous and arterial circulation, when organs fail in parallel rather than sequence, we are no longer dealing with chance. We are dealing with a systemic process which targets the blood vessels themselves.
And that changes everything.
Why the Obvious Explanations Fall Short
Influenza has been mentioned. Viral pneumonia has been suggested. These explanations are comforting because they are familiar.
But familiarity does not equal accuracy.
Influenza can cause severe illness, even myocarditis, but it does not usually produce:
Hundreds of clots throughout the body
Simultaneous arterial and venous thrombosis
Progressive multi-organ failure over weeks
Severe bleeding and clotting at the same time
When the scale and distribution of disease exceed what a diagnosis can plausibly explain, the diagnosis must be questioned.
Well, it's taken me about two years to complete this course, but have finally made it! … Really grateful to have had this opportunity, so will be looking at other courses. Thank you so much, Dr McMillan!
Francisca
COVID Changed the Rules — and We Are Still Pretending It Didn’t
One of the most dangerous misconceptions left over from the pandemic is that COVID is primarily a lung infection. This is too simplistic a concept.
COVID is, at its core, a vascular immune disease. It targets the lining of blood vessels. It disrupts interferon signalling. It primes the immune system to misfire — sometimes weeks after the virus itself has disappeared.
That timing matters.
A negative PCR weeks after mild symptoms does not rule COVID out. In many cases, it is exactly what we would expect. What follows is not viral damage. It is immune damage.
When the Storm Is No Longer in the Lungs
Early in the pandemic, severe COVID announced itself loudly: respiratory failure, oxygen deprivation, ICU beds filled overnight.
Now the storm is quieter — and more dangerous.
Instead of a lung storm, we see:
A vascular storm: widespread clotting
A heart storm: myocarditis and pump failure without blocked arteries
A brain storm: microstrokes, confusion
A kidney storm: inflammatory renal failure
A gut storm: bleeding, inflammation, barrier breakdown
When these occur together, medicine struggles, not because the disease is unknowable, but because our frameworks are outdated.
The Therapeutic Trap
This case exposes a cruel paradox:
The patient is full of clots, but cannot be anticoagulated because he is bleeding
Filters in the venous system and procedures buy time but do not treat the cause
Organ support replaces function but does not stop the process
At some point, clinicians are left arguing over which failing organ matters most — the heart or the lungs — while the immune system continues unchecked.
Replacing an organ does not solve an immune disease.
A Question We Are Afraid to Ask
If this is an immune-driven thrombo-inflammatory syndrome, then the uncomfortable question becomes unavoidable:
Should immune modulation be considered earlier — not as a last resort, but as a diagnostic trial?
I am not suggesting recklessness. Infection must be excluded. Sepsis must be ruled out. But when every investigation comes back inconclusive and deterioration continues, refusing to consider immune suppression is not caution, it is inertia.
What are we protecting patients from, exactly?
Why This Case Will Not Be the Last
COVID continues to circulate. Population immunity is complex, uneven, and in some cases dysregulated. The presentations are no longer dramatic infections — they are delayed, systemic, and confusing.
That makes them easy to miss.
We are entering an era where patients will present with overlapping syndromes that do not respect organ boundaries. If we insist on treating them as isolated failures, outcomes will continue to be poor.
A Call to Clinicians — and to Families
If there is one message I want to leave, it is this:
When a disease makes no sense, the problem is often not the patient — it is the framework.
Ask harder questions. Look earlier in the timeline. Think immunologically, not just anatomically. And if you are a family member watching this unfold, know that advocacy matters.
The earlier we recognise these patterns, the better chance we have of changing where they end.
We owe our patients — and ourselves — better than silence.
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