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The Swim Coach

Naegleria-Fowleri-precautions

The headaches had gotten worse since Sarah woke that morning. She stood, gazing into her bathroom mirror, slowly turned, and went back to bed. There was no way she was going to work today. Not the way she felt. She reached for her cell phone and called the waterfront director at the summer camp. He was clearly annoyed, but understood. She had felt ill on Friday but he convinced her she was needed. Now, 8 AM Monday morning, she felt worse. Much worse.

It has been a great summer so far. Sarah and her friend Emily had gotten jobs at the local girls camp. Sarah, who loved to swim was the waterfront Director, and Emily, who loved to draw and paint, worked with the art director. It was going to be a great summer. How could she be sick now? She had only been at work for two weeks? What else could go wrong. By 6 o’clock that night she would regret asking the question.

When her mother came in to check on her, she found Sarah in the bathroom. She had felt nauseous around 4:30 and even though she hadn’t eaten much all day, she was feeling very sick. Her mother made a call to the family doctor who suggested that it was most probably the flu. There were a few bugs going around, and the symptoms fit. By the next morning however, Sarah’s mother Barbara was less sure. Another call to the family doctor and another conversation with the nurse garnered a call back from the doctor who phoned in prescription for antibiotics, and Barbara drove to the local pharmacy to pick it up. Sarah took the first dose and went back to bed. It was now 11:30 AM on Tuesday morning.

When Barbara went to Sarah’s room to check on her, she found that Sarah had a fever. This must be the flu she thought to herself, and reminded Sarah to take the next dose of antibiotics. As Barbara turned to leave, something made her turn around and face her daughter. Something seemed…not quite right. While Barbara stood at the door, hand on the knob, ready to go out, she watch Sarah reach for the antibiotic container and the glass of water on the nightstand. She seemed out of it, confused. Barbara walked over and put the glass in Sarah’s hand, but she couldn’t seem to grasp it. The glass, water and all, fell to Sarah’s lap, soaking her sheet and pillow.

Barbara asked Sarah to set up in the chair for a minute and she would change the sheets. Sarah just looked at her mother, a blank expression, as if she didn’t quite understand. Barbara checked Sarah’s temperature, and found it was still elevated. She went downstairs to the phone, and another phone call to the doctor’s office ended with an agreement to take Sarah to the outpatient clinic. The nurse that Barbara spoke with at the clinic assured her that it was simply influenza. There have been a few strange going around, and Midsummer was prime flu season here in Texas. Barbara ran down through the symptoms: headache, fever, nausea, feeling tired. These were flu symptoms and Sarah simply had gotten a very bad strain. Plenty of fluids, bed rest, and aspirin or Tylenol for headache. If the symptoms had not gone away in four or five days, or if they get worse, Barbara was to call the clinic.

Tuesday afternoon, Barbara heard a scream and ran to Sarah’s bedroom. Sarah was standing in the bathroom, her hands on the wall. Barbara asked what was wrong, and her stomach dropped when she heard Sarah could not see. Barbara help Sarah get dressed, and immediately drove her to the clinic. She was done being patronized by nurses or anyone else. She needed some answers. Sarah needed some answers. When the nurse looked at Sarah, she was immediately concerned. This was certainly not the flu. Soon they were joined by a physician, Dr. Hernandez, who examined Sarah. He asked the nurse to order blood work. The look in the doctor’s eyes alarmed Barbara, and she pulled him aside to ask, “What is wrong with my daughter?” Her heart broke as he replied, “Right now I have no idea.” After checking Sarah’s vital signs, and getting a brief history, he went to the phone on the wall and made a call. A nurse came in and drew blood from Sarah.

The doctor hung up the phone, turned to Barbara, and said he had called an associate who worked at the medical center in Houston. She was epidemiologist and diagnostician, and was an expert at infectious disease. Her name was Dr. Gonzalez, and she was driving to the clinic immediately. In the meantime, they could do little but wait for her arrival, and try to make Sarah comfortable.

Stephanie Gonzales paged Dr. Hernandez from the lobby, and he went to meet her. They spoke briefly before going to the clinic, and Dr. Hernandez filled her in on the case so far. What was known was sadly not very much. The girl, Sarah, had been sick for approximately three days. At first it looked like the flu, but the latest symptom, a loss of sight, was very alarming. Dr. Hernandez was afraid it might be some strain of virus or maybe a bacteria and it might be contagious.

When Dr. Gonzales and Dr. Hernandez walked into the room, Sarah was lying on the bed, with visible discomfort. Dr. Gonzalez asked Sarah if she had any pain? Sarah replied that her head “throbbed” and she felt dizzy and very sick to her stomach. Dr. Gonzalez asked if she would prefer to have an extra pillow under her head, and Sarah said yes. When the nurse attempted to raise Sarah’s head, she screamed in pain. Dr. Gonzalez asked if her neck felt stiff or achy, and Sarah said it was very stiff. Dr. Hernandez turned to Dr. Gonzalez and the nurse, this was a new symptom, one that suggested a frightening turn. Meningitis.

Meningitis is an inflammation of the protective membranes covering the brain and spinal cord, known collectively as the meninges. Meningitis can because by caused by infection from viruses, bacteria, or other microorganisms, and even some drugs. It was a very serious condition because meningitis causes pressure on the brain and if left untreated can be deadly. Dr. Gonzalez asked Barbara if anything had changed in Sarah’s life recently. Have they moved, eaten any new foods, traveled? Barbara answered no. Their lives if anything had been more stable over the past few years. Sarah had always been very healthy. In fact, she played sports on her high school team; field hockey and most recently the swim team. Had the teams of been traveling recently? Say the last week? Barbara told Dr. Gonzalez that the teams did not practice over the summer, and Sarah had not gone anyplace knew.

Dr. Gonzalez asked if labs have been taken, and nodded when Dr. Hernandez told her they had. Now, they had to wait. Meningitis can have many causes, but after drugs and medications were illuminated as possibilities, the list was still long. Viral or bacterial meningitis could be treated with varying medications, but viruses and bacteria are very different. Antibiotics would do nothing for virus, and antivirals would do nothing for bacteria. They had to be certain. Standard treatment for bacterial meningitis was ampicillin or cefotaxime. Viral meningitis was more puzzling, and the prime candidates are include mumps, herpes virus, Epstein-Barr virus, varicella-zoster, measles, influenza, and in very rare cases, LCMV (lymphocytic choriomeningitis virus). Had Sarah received all her vaccines? Bob responded that yes, she had, and all were up-to-date. This ruled out several prime candidates for meningitis, but the list was still extensive.

Barbara asked if this could just be a very bad flu? To which Dr. Gonzalez said it was possible, but she felt it highly unlikely. Dr. Hernandez agreed. By this time they had been in the clinic for nearly 4 hours, and Sarah’s condition was rapidly declining. A morphine drip had been started tow hours ago to help ease her head pain, but now it was hardly making a difference. The nurse took Sarah’s temperature again and found it dropped to 101.5. Certainly, this must be a good sign. Dr. Gonzalez disagreed. It is a sign, but not a good one. She turned to Barbara and asked if Sarah did any hiking, or backpacking or camping? The answer came back as no. Since Sarah begun her summer job, she had little time for much else.

Almost as an aside, Dr. Gonzalez asked Barbara what Sarah’s job was. Barbara explained Sarah’s job was working at a girl’s summer camp on a nearby lake as a waterfront assistant. She helped teach the girls swimming, diving, and even waterskiing. Dr. Gonzalez was unfamiliar with the area, and asked where the lake was and what the water temperature might usually be. Both Dr. Gonzalez and Dr. Hernandez’ eyes widened as Barbara explained the water was very warm, and many parts of it were thermal. The lake was very popular for campers because of the warm water. Dr. Hernandez immediately reached for the phone and called the lab. Within a few minutes, a technician arrived with a small container and handed it to Dr. Hernandez. Sarah was asked to lie on her side and pulled her knees to her chest. This proved very difficult, as her neck and head were extremely painful.

Dr. Hernandez peeled back the wrapper containing what seemed to be an enormous needle, and after dabbing some brown solution on Sarah’s lower back, proceeded to do a lumbar puncture. The fluid quickly ran out of the nozzle, indicating high cerebrospinal fluid pressure. The nurse handed Dr. Hernandez a small container, and Dr. Hernandez withdrew the needle, asking Sarah to lie still for a while. He left the room with Dr. Gonzalez and they headed to the lab. They seemed in such a hurry that Barbara was visibly alarmed, asking where they had gone. The nurse did her best to comfort and calm Barbara, but it was clearly not working. “Do they know what’s wrong with Sarah?” She asked the nurse.

In the lab, Dr. Hernandez added a drop to the slide and pressed down a cover before inserting it under the microscope. Dr. Gonzalez new the answer before Dr. Hernandez head looked into the eyepiece. The symptoms with clear enough; all that was missing was how Sarah had become infected. The last piece of the puzzle was the summer job. Sarah had been infected with , an amoeba that lives in fresh, warm water. Dr. Hernandez turned to Dr. Gonzalez telling her what the microscope had revealed. If Sarah was to survive, treatment must be started immediately.

A nurse came to Sarah’s room and treatment with Amphotericin B was begun. About 10 minutes later, the nurse returned with Rifampicin and Sulfisoxazole. Dr. Gonzalez placed a call to the CDC, and a courier was dispatched with Miltefosine, a drug used to treat leishmaniasis. Sarah was moved to the pediatric ICU unit of the hospital, and treatment was continued. The CDC was notified as to the location of the lake that Sarah was thought to have contracted the infection. All that’s Barbara could do now was wait.

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