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Caribbean Blue

microfilaria

Something was wrong. Jane could not put a finger on it, but she just felt different. She had woken at 4 AM, which was not unusual as she was often awake in the early morning. She was expected at the plant by 5:15; breakfast routinely included a cereal bar and a cup of coffee, which she most often enjoyed on the 20-minute commute to work. But this morning, it was different. When she pulled on her slippers, they felt snug. As she stood beside the bed, she felt unsteady. Her ankles hurt, her knees hurt, in fact her legs were throbbing. “That damn dog” she commented, suspecting that lady, her German shepherd had once again slept on her legs.

The dog routinely slept on the bed during thunderstorms, and would get as close as possible to Jane, often waking her up with trembling at every flash or peal of thunder. But there was no storm last night. When Jane whistled, lady razed her head from the rug next to the fireplace. Jane sat back on the bed, and ran her hand down her leg. Her ankle was barely discernible under the swelling. Stumbling, she made her way to the phone and, with her boss answered, announced that she would not be in that morning. Jane had worked at the fact right now for 16 years, and had never missed a day. Her boss, Mr. McKay, was concerned. Jane assured him it was probably nothing, but she would send him an email when she got back from the clinic. Mr. McKay heard a clunk on the line, and then the dog barking. After calling for Jane several times and hearing only silence, Mr. McKay called 9-1-1.

When she awoke in a hospital bed, Jane was momentarily confused. Her head hurt, and her legs were killing her. And she didn’t recognize the ceiling. The nurse was watching from the door, and came in. “How are you feeling?” She asked. Jane replied that she hurt all over. Then she asked how she got there. The nurse could only tell her that she came in by ambulance almost 2 hours ago, and since that time had been seen and admitted for observation. Jen was told that the test results have not come back yet, and until they did, she was stuck in the hospital bed.

It was no more than 10 minutes later that Dr. Rossignol came to the door. A polite man in his early 50s, Dr. Rossignol had been in the ER when Jane had been admitted. As a hospitalist, Dr. Rossignol often saw patients who had been admitted and who had not yet had a visit from their primary physician. He seems surprised when Jane explained that she did not have a primary physician, and that she was never sick, never injured, and had never been in the hospital until that day. In fact Jane explained she was even born at home. She never been to a hospital, and had never needed one. She asked Dr. Rossignol what was wrong with her, and seemed annoyed when he replied, “We don’t yet know. You were still unconscious when you were brought in, so this gives us an opportunity to try to find out what the last 24 hours were like for you.”

Jane explained that she had awoken a bit earlier than usual, but not that much earlier, because her dog had slept on her legs. Jane felt under the sheet, almost without thinking, and found her legs were now swollen all the way to the knee. “That doesn’t feel right,” she said. And for the first time that she could remember, she felt panic. “What’s wrong with my legs”, she asked. Dr. Rossignol explained that they had noticed the swelling in the ER, and that they were still waiting for blood tests to come back. It was for this reason that she had been admitted. Jane was asked what she did for work, if she was on any medications are the kind, if she took any over-the-counter treatments; she worked in a paper mail, operating one of the fork-trucks; she moved enormous paper rolls from where they were spooled onto cardboard tubes, to the shipping department. She did not take pills, not even aspirin. Dr. Rossignol, who had been writing this information down, smiled and got out of the chair. “I’m sure it’s nothing”, he said. “I’ll let you know as soon as we have any more information”. As he rounded the corner to the hallway, he scratched his head, and looked back at the doorway to Jane’s room. This didn’t make much sense to him. She seemed in very good shape physically, certainly this was not drug related, she didn’t report any injuries, at least nothing she felt was serious enough to mention. Dr. Rossignol knew there were several causes to fluid retention in the lower extremities, all of which were very serious. He would have to wait for the blood test to come back and start ruling them out one by one.

Some of the possibilities were removed because of Jane’s age, 66, and the fact that she was a widow, her husband having died 12 years previous. But, the total lack of a medical history was troubling, and was something that may be hard to negotiate.

Dr. Rossignol sat at the nurse’s station, and began to review his mind the possible causes for Jane’s condition. Acute kidney failure, cardiomyopathy, cirrhosis of the liver, hormone therapy, lymphedema, nephrotic syndrome, an overdose of NSAID pain relievers, pericarditis, prescription medications, thrombophlebitis, Venus insufficiency, pregnancy, gout; he wrote each one down and then to get to cross them off his list one by one.

Pregnancy seemed highly unlikely, due to age and living situation. Because Jane said that she didn’t even take aspirin, overdose of NSAID paper leave reliever seemed highly unlikely. If a person doesn’t even take aspirin, they’re not going to take prescription meds either, so he quickly ruled that out. Hormone therapy? He would ask, but he very much doubted it. Jane seemed to have a general dislike for medical professionals, and he was certain that extended to him. That left only a few, and they were all a bit more serious. Venus insufficiency, or kidney damage? Possibly blocked lymphatic system, or pericarditis? It was then that his pager went off, and he was given the test results.

The lab results were normal, a bit to normal. He asked the nurse if urine collection and test had been performed, and was told it came back normal. Gout was removed from the list. That left only two possibilities: pericarditis or some form of thrombophlebitis. He immediately ordered an anticoagulant.

After eight hours, Jane’s condition had not improved, and a new symptom had appeared: she had begun coughing up blood. Dr. Rossignol immediately stopped the anticoagulant treatment, and ordered Mephyton injection. After about an hour, the vitamin K seemed to work, and Jane’s condition stabilized. But Dr. Rossignol was no closer to finding an answer, and the swelling was increasing; now it was above the knee, and the lower part of the leg was grotesquely distended. Dr. Rossignol thought for a moment. This has got to be heart related, but what if it’s not? What’s then? He had run out of ideas. It was time to make a phone call.

In the office of diagnostic medicine, medical epidemiologist Dr. Leopold Perkins desk phone rang. At first, Dr. Perkins thought he would let the answering service pick up, as he had being about to meet his wife Sandra for lunch. Almost as a second thought, he checked on his heel, picked up the phone, and said “Perkins.” After a brief conversation, Dr. Perkins found himself on the phone with Sandra and apologizing for missing lunch. He entered the elevator on the east wing, and pushed the button for the third floor. When he got to the nurses station, Dr. Rossignol was waiting for him. Dr. Perkins began by asking for history, and requested that no detail, regardless of how seemingly unimportant, be left out.

Dr. Rossignol explained the situation of Jane’s admission, and attached that haven’t run bus far. Everything seemed remarkably normal. “Is she conscious?” Perkins asked. Talk to Roger and all commented that she was only 20 minutes before. Together, they walked to Jane’s room. “Who are you?” Jane asked, and then smiling said “the coroner?” Talk to Russ dollars playing that Dr. Perkins was a clinical epidemiologist in the diagnostic and infectious disease office and that he wanted to be certain that all the bases were covered so that Jane would have the best care possible. Jane replied “yeah? Like when you gave me that that medication and I almost coughed my lungs out?” Dr. Rossignol, looking sheepishly, apologized again and suggested that this time they would be more careful and that Dr. Perkins presents might help them cover more bases.

Dr. Rossignol sat in the chair opposite Dr. Perkins, and was somewhat puzzled at some of the questions that Dr. Perkins asked. Had she had her childhood vaccinations? To which Jane reply she had. Had she ever traveled to Asia or Africa? Jane reply she had not. And then had only taken one vacation in her entire life. She traveled five years ago with her sister Dorothy and her church group to the Caribbean. It was so wonderful and rewarding that she had stayed a few months after Dorothy had returned. Jane figured she had never had a vacation, and she was performing very important work. Mr. McKay, her manager, encouraged her to spend the time away He said she needed it. When she mentioned this, Dr. Perkins began to nod his head slowly. He looked at Dr. Rossignol, and said I may have some ideas.

Dr. Rossignol sat alongside Dr. Perkins at the nurse’s station, and said, “tell me what you’re thinking.” Dr. Perkins replied, “It all fits.” What fits?” asked Dr. Rossignol, now growing impatient. “From what you told me, our patient came in with swelling that she had attributed to pressure from her dog sleeping on her legs correct? So it’s safe to assume that the swelling came on quickly?” Dr. Rossignol thought for a moment and said, “Yes, it would appear so.” Dr. Perkins said slowly, looking off into space “If it had been a cardiovascular issue, or renal insufficiency, or any routine infection, it should have come on more gradually, but that’s not the situation.” “Agreed,” replied Dr. Rossignol, “so what could it be? “Do you think she has caught something?” Dr. Rossignol inquired. “I think perhaps something is caught her” Dr. Perkins replied with a half smile on his face. Dr. Perkins was a man who enjoyed a good mystery, particularly a medical mystery, which is why he went into epidemiology after a successful career as a child psychologist. Leaning back in his chair, staring at the ceiling, Dr. Rossignol could see he was deep in thought.

Suddenly, Dr. Perkins was out of his chair and quickly walked down the hallway to Jane’s room. Entering, he saw Jane was nearly asleep, and apologize for waking her asking if you could answer one question for him. “When you were in the Caribbean? I mean, what time of the year was it?” “We were there from the first of September until the end of November, why?” Jane responded. Dr. Perkins thanked her for the information, and then at a trot, returned to the nurse’s station and Dr. Rossignol. “I think I have it figured out” he replied. I had a pretty good idea, but when our patient told me that she was in the Caribbean during the rainy season, well, that cinched it for me. “Cinched what?” Dr. Rossi not asked, visibly annoyed. I think that, given the symptoms, history, and the situation, we have a case of Lymphatic filariasis.”

Dr. Rossignol thought for a moment, “I’m not familiar with this condition.” “There is no reason why you would be” Dr. Perkins said, “there has never been a case of it in the United States. In fact, it is largely relegated to Southeast Asia and Africa, but there have been a number of cases in the Caribbean. It is a tiny thread like worm that takes up residence in the human lymph system. Mosquitoes spread the parasite; she was in the Caribbean for an extended period of time when the mosquitoes are most active. The worms pass from the mosquito through the skin, and travel to the lymphatic system. If I am correct, and there is no guarantee I am, I will have to make a call to the CDC, and you will need to order the medication.”

A blood sample was taken, and microscopy identified microfilariae. Dr. Perkins suggested that Jane be prescribed diethylcarbamazine to kill the larval worms, and Dr. Rossignol requested the CDC provide the medication. While most persons infected with this parasite do not experience lymphedema, Jane’s age, diet, and exposure, elevated her risk.

About Lymphatic filariasis.

Most infected people are asymptomatic and will never develop clinical symptoms, despite the fact that the parasite damages the lymph system. A small percentage of persons will develop lymphedema. Improper functioning of the lymph system that results in fluid collection and swelling causes this. This mostly affects the legs, but can also occur in the arms, breasts, and genitalia. Most people develop these clinical manifestations years after being infected. In Africa, Lymphatic filariasis is better known as Elephantiasis; it affects well over 100 million people in 73 countries throughout the tropics and sub-tropics of Asia, Africa, the Western Pacific, and parts of the Caribbean and South America.

 

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