Widodo, having finally smothered the last flicker of his temper, rang Zein without hesitation.
Zein had only just completed the Isha prayer when his mobile trembled on the table beside him.
"Mr Widodo is calling..." He murmured, and pressed the answer button at once.
"Good evening, Mr Widodo!" Zein said.
"Good evening, Doctor..." Widodo replied, his voice edged with a quiet, unmistakable panic.
Zein caught it at once, "What's happened, Mr Widodo?! You sound distinctly unsettled!"
Widodo released a weary breath before recounting the outcome of the hospital meeting concerning a patient named Sulastri.
"So, Doctor… I've only just concluded a meeting with the medical team in the main hall. We were reviewing the case of a rather extraordinary patient named Sulastri, fifty years of age. She's presenting symptoms that… frankly, fall beyond the bounds of ordinary medical reasoning!"
Still dressed in his flowing gamis, Zein lowered himself onto the sofa, listening with the patience of someone accustomed to peculiarities.
"The patient develops red speckles across her skin each morning, and they remain until late afternoon! Yet once night descends, precisely after sunset, those speckles turn pitch black! This cycle repeats itself without fail! Every day! For a full fortnight!"
Zein's brows drew together, "Red speckles turning black solely at night?!"
"Precisely! And it's entirely unrelated to lighting or ambient temperature, we've verified that thoroughly! Even when placed in an isolation room with strict controls over light and climate, the transformation persisted! It's as if her body responds to time itself, not to external conditions!"
"And what did the team conclude?!" replied Zein.
"That's exactly the difficulty, Doctor! No one can decipher it! Some recommended dermatopathology to rule out lupus or vasculitis! Others suspected a rare fungal or parasitic organism responsive to circadian rhythm!"
"Then came suggestions for day-night biopsies, fungal cultures, tests for photosensitive compounds, even measurements of melatonin and cortisol!" Widodo explained.
"And the results?!" Zein asked sharply.
Widodo's voice faltered, thinned into helplessness, "All negative, Doctor! Every single one of them!"
Zein's brow tightened, a small furrow settling between his eyes, while Widodo pressed on, his voice sinking into a weary hush.
"Skin biopsy revealed only a mild, rather unremarkable inflammation! Fungal and parasitic cultures were entirely negative!"
"The autoimmune tests, ANA and dsDNA, lingered at the very edge of normal! And the hormonal assessments showed no meaningful fluctuations!"
"There isn't a single result that gives us a firm direction, let alone a diagnosis!"
"Does the patient have any history of trauma or long standing illness?" Zein asked.
"Mrs Sulastri was once a nurse! Retired five years ago! Her medical history is plain as daylight! No chronic conditions, no long-term medication, no record of any psychological disturbance!"
Zein fell into a contemplative silence, as though tracing invisible patterns in the air while trying to imagine the machinery within Sulastri's body misfiring in the dark.
Widodo exhaled sharply before continuing, his frustration crackling through the line.
"What troubles me even more is the chaos of theories. One doctor insists it's some form of extreme psychosomatic reaction, another is eager to dabble in alternative treatment, and someone even suggested installing a twenty four hour infra red camera just to prove the colour changes aren't an optical trick!"
Zein didn't answer at once. His gaze drifted to the chandelier above him, its glass catching the soft light, before he spoke in a low, steady voice.
"I'll come to the hospital tomorrow morning! Send all the medical data and the laboratory results to my email tonight! I want to study them before dawn!"
Widodo sounded marginally relieved, though the strain in his voice had not entirely lifted.
"Thank you, Doctor. I'm sorry for disturbing your evening…"
"It's quite all right, sir! This concerns a human life! I'll help as best I can!"
Once the call ended, Zein set his phone upon the table and rose to his feet.
His eyes were no longer as calm as they usually were.
He turned towards the window, gazing out at the dense, brooding night that pressed against the glass like a living thing.
"Speckles that change with time… Is this a rare illness, or something entirely new?" He whispered, the words scarcely more than a breath.
Several minutes later, a soft chime cut through the stillness.
[PING!]
An email had arrived, sent from [email protected].
Remaining by the window for a heartbeat longer, Zein returned to his chair and opened the message.
His eyes travelled over the densely packed, meticulously arranged information.
With every line he read, the crease on his forehead deepened, as though each sentence carried a weight the night itself could not contain.
*****
PATIENT MEDICAL DATA
Identity:
Name: Sulastri
Age: 50
Sex: Female
Occupation: Retired Nurse
Status: Inpatient, Isolation Ward 3B
Chief Complaint:
Red spots on the skin that turn black after sunset, occurring daily for the past two weeks.
Medical History:
No history of hypertension, diabetes, or autoimmune disease. Not on any regular medication. No known allergies or previous physical trauma.
Physical Examination:
General condition: good
Blood pressure: 118/76 mmHg
Pulse: 82 bpm
Temperature: 36.8°C
Skin lesions appear as erythematous macules during the day, turning dark in the evening without vesicles or tenderness. Distribution is symmetrical.
Laboratory Results
Full Blood Count:
Hb: 13.2 g/dL
Leucocytes: 6,400/µL
Platelets: 280,000/µL
ESR: 15 mm/hour
CRP: 0.6 mg/L
Organ Function and Metabolic Panel:
AST/ALT: Normal
Urea/Creatinine: Normal
Electrolytes: Normal
Fasting Glucose: 92 mg/dL
Autoimmune Panel:
ANA: Borderline (+1:40)
dsDNA: Negative
Rheumatoid Factor: Negative
Total IgE: 76 IU/mL
Hormonal and Circadian Rhythm Tests:
Morning melatonin: 8 pg/mL
Night-time melatonin: 152 pg/mL
Morning cortisol: 15.3 µg/dL
Night-time cortisol: 4.1 µg/dL
Dermatological and Microbiological Assessment:
Fungal and bacterial cultures: Negative
Skin parasites: Negative
Daytime biopsy: Mild dermatitis
Night-time biopsy: Increased melanin without abnormal cells
Photoreactivity Tests:
Photopatch test: Negative
UV reaction: Not abnormal
Infrared camera: Shows colour change beginning at 06:32 p.m., reaching peak blackening at 08:15 p.m.
Medical Team's Conclusion:
No organic cause identified.
Differential Diagnosis:
Rhythmic hyperpigmentation response Photosensitive dermatosis with chronobiological pattern, Psychodermatosis
Atypical biological disorder
*****
Zein stroked his chin slowly, "Everything's normal… yet the symptoms defy all reason!"
His eyes flicked back to the section describing the nocturnal surge in melanin.
"Melanin rising sharply without any UV exposure, and only at night?" He murmured.
Then his gaze halted at a single line at the bottom: "Time lapse video of the speckle changes attached."
His hand moved swiftly to open the video.
In the accelerated footage, he watched the woman's skin, once merely reddened, gradually darken, as if her body were responding to the passage of time itself, a creature attuned to the night.
Zein exhaled slowly, closing his phone with care. He rose and made his way to the bookcase in the corner of the room.
His fingers traced the spines of the neatly arranged volumes, seeking a thread of understanding.
In his mind, he searched for the key terms, pigmentation, circadian rhythm, and the fluctuating transformations of the skin.
After several minutes, he extracted an old, dark blue bound tome entitled Cutaneous Manifestations of Systemic Diseases, 4th Edition by Fitzpatrick & Kang.
He turned to the index, his eyes scanning for the term 'Circadian'.
Several pages had been previously marked, and Zein opened one section titled:
"Chronobiology and Skin Disorders: Melanin Regulation and Hormonal Influence"
It detailed that human skin contains melatonin receptors and a peripheral biological clock separate from the brain's central rhythm.
Hormones such as melatonin and cortisol, which follow a day-night cycle, modulate melanocyte activity, the cells responsible for pigmentation.
Certain rare conditions, such as porphyria cutanea tarda, exhibit photosensitive skin abnormalities, with colour changes or speckling dependent upon UV exposure.
Zein marked the page and then drew another reference volume. Melanin: The Biological Role and Circadian Influence.
Its author, Dr Jean Luc Marceau, a molecular biologist from France, explored in depth how fluctuations in melanin levels and tyrosinase enzyme production can be governed by the body's circadian clock, particularly in instances of post-inflammatory hyperpigmentation or reactive melanosis.
Zein murmured softly, "If this isn't an autoimmune disorder or an infection, could it be a disruption of melanin gene expression, triggered by daily temporal cycles?!"
His fingers lingered over a particular paragraph :
"There are rare case studies suggesting aberrant melanin activity synchronized with circadian oscillations, potentially related to malfunction in peripheral skin clocks or abnormal melatonin receptor expression."
Zein's eyes narrowed, his voice low as he murmured, "Perhaps this is a molecular anomaly of the skin's circadian clock, something never before recorded in clinical literature!"