It was exactly one year ago to the day that Blaine Henry returned from Africa. Raised by working parents who believed that only through service to others a person could find himself, Blaine took this to heart. He had always tried to be a good person; throughout his high school years, he had been a volunteer at the local boys club. Therefore, it came as no surprise when he announced after his college graduation that he was volunteering in Africa.
Now, having served in Africa for three years, Blaine was back in his home state of Minnesota, contemplating his new job as assistant director of marketing for the state’s largest credit union. Armed with a degree in economics and a sense of purpose, he felt ready to settle down. His parents were overjoyed to have him home again, and as he blew out the 29 candles on his birthday cake, the time had come to open the next chapter of his life. Africa had been inspiring and amazing, but that was in the past and his future was waiting for him.
It was in Africa that he met Pamela, another organization volunteer. The only other American at the village school, she was from Southern California, and they had become fast friends. When the time came to return to the U.S., Pamela went home to San Francisco to see family and friends, yet after less than a month of twice-daily conversations by phone she bought a one-way ticket to Duluth. A June wedding was planned.
It was in the first week at his new job that Blaine began to notice a slight dizziness. Not wanting to alarm his fiancé or his parents, and having only recently returned from the heat of Africa to the Duluth winter, Blaine assumed he had simply caught a cold. Maybe he had not yet adjusted to the frigid winter. He had gotten used to the heat of Africa. He missed the heat. After finishing the workweek, and with a bottle of cold medicine, Blaine crawled into his old bed late Friday afternoon. By Sunday evening, his cold had not gotten any better. If anything, it had gotten worse. His parents and Pamela were worried. Blaine was hardly ever sick. In fact, aside from a slight reaction to the Malarone he had taken before leaving for Africa, he had rarely been ill. Blaine did his best to calm them. He had worked in Africa where people were sick with much more serious issues than a simple cold. He would be fine by morning.
Yet, when he awoke late on Monday afternoon, he learned from Pamela that his father had called his office to let them know he was sick. He was no better, and in fact, he felt worse. He agreed to let Pamela and his mother drive him to the local express care clinic, where the doctor on duty suggested that Blaine had the flu.
Both Blaine and Pamela had planned to get a flu shot after returning to the United States, Pamela had obtained one before leaving California, but Blaine had not found an opportunity to get the shot. He had a slight cough, although it was dry, and he was slightly congested. In addition, he had a mild fever. It was the flu season and the symptoms fit. Not wanting to take anymore of the physicians’ time, Blaine thanked him and got up to leave. Within five minutes, Pamela ran back in the clinic to tell the nurse that Blaine had been dizzy and collapsed.
The ER nurse rushed to where Blaine was sitting, leaning against the passenger door, and attempted to revive him. When he was brought in on a gurney, Blaine was admitted. By evening, Blaine developed chest pain and his fever was rising. Over the next few hours, his cough became productive, no longer dry and hacking, but now tinged with blood. This was not the flu. A chest x-ray was ordered, and Blaine’s lungs showed clouding. He had developed pneumonia. The physician quickly reviewed Blaine’s medical records, and noted his recent service in Africa. He had taken the required precautions, including antimalarial medications and routine examinations for schistosomiasis. Because of Blaine’s diligence of staying healthy, the physician considered both malaria and schistosomiasis, two all too common infections of Africa, ruled out.
Unfortunately, Blaine’s symptoms matched a number of possible viral infections and parasitic illnesses that he may have been exposed to in Africa. Only by ruling these out could the staff know what illness to treat. IV Fluids were started, and Blaine was put on high dose acetaminophen to try to lower his pain and fever. Dr. Pratt looked at the latest vitals, and ran down through the possibilities. They seemed endless. And ruling each likely disease out would take time. One look at Blaine’s present condition made him wonder if there was enough time.
By morning, Blaine’s condition had gotten worse. Much worse. He now complained of pain in his elbows and knees, and he described tightness in his chest “as if someone were sitting on it”. His O2, measured as DO or dissolved oxygen, was now at 84%, despite being given 100% oxygen. Whatever this was, an answer needed to be found sooner rather than later. It may also be infectious. The CDC would need to be notified if this could not be diagnosed soon. At the very least, he should notify the Epidemiologist, Dr. Sessay. Just in case, this was something infectious that needed to be reported.
Blaine was transferred to the intensive care unit in a pressurized room. Pressurize rooms are often suggested when symptoms point to an unknown infectious disease. The physician on duty in the I.C.U., Dr. Pratt, reviewed Blaine’s medical history and symptomology carefully. When he read that Blaine had recently returned from an extended stay in Africa, he immediately began to consider a new group of infectious diseases that fit the symptoms. Blaine might have been exposed to a host of infectious and parasitic diseases, and, until Dr. Pratt new the illness Blaine had, he could not assume it was not infectious.
Besides being an infectious disease epidemiologist, Dr. Sessay was a native of Sierra Leone, and had focused much of his writing and research on African infectious diseases. The immediate assumption by both Dr. Pratt and Dr. Sessay was dengue fever. Dengue fever is an infectious disease caused by the dengue virus. It is most often spread by mosquito bite. The symptoms of dengue fever include headache, muscle and joint pain, headache, and skin rash. In some cases, dengue fever worsens into dengue hemorrhagic fever resulting in profuse bleeding, low blood platelet levels, and hypotensive crisis. A quick review all of the most recent nurses notes revealed that Blaine’s blood pressure was slightly elevated and after gowning up, Dr. Pratt and Dr. Sessay could see no rash on Blaine’s skin. Chances were that this was not dengue fever. Cryptosporidiosis fit the symptoms somewhat better. Cryptosporidiosis is a common cause of waterborne disease in Africa, Asia, and even the United States. It is caused by a parasite that spreads when a source of drinking water is contaminated, usually with the feces of infected animals or humans. The disease becomes clinical in persons with impaired immune systems, and the primary symptoms include diarrhea, stomach cramps, an upset stomach, and slight fever. Dr. Pratt knew it was possible to be infected with cryptosporidiosis without exhibiting any symptoms.
Still, for Blaine to be this sick, the infection would have had caused diarrhea or painful intestinal cramps. Blaine had not experienced these, so cryptosporidiosis was ruled out. They were back to square one.
Leishmaniasis was next on the list of possibilities. Had Blaine remembered being bitten by flies? Yes, he was often bitten by flies and mosquitoes; it was part of the job. Because there are several types of Leishmaniasis, all found in parts of Africa, and because Blaine had been in the sub Sahara region for nearly 3 years, it was a distinct possibility. Of the several types of the disease, the symptoms vary. Because many cases of Leishmaniasis resolve with minimal treatment, fluids were continued and everyone expected Blaine to begin to recover. But by the third day, his symptoms had not improved, and his O2 SAT was 78%. Whatever this was, it was making Blaine very ill, and it was time for some outside of the box thinking.
Dr. Pratt was unwilling to start treatment with antibiotics until they knew exactly what disease Blaine had acquired. Starting antibiotics may prove to be the worst course of treatment. Until they know, fluids and oxygen were administered and Dr. Pratt hoped that he and Dr. Sessay could figure this out before Blaine became critical. Aside from this, patients with severe cases of Leishmaniasis exhibit skin sores. Blaine had none.
Dr. Sessay met with Blaine’s parents and fiancé. How long had he been in Africa? When did he return? Did he travel with anyone? Were they sick? The fact that Blaine had been back at home for several weeks before becoming ill led Dr. Sessay to believe this is not a disease he had acquired in Africa. Finding no helpful information, Dr. Sessay asked where Blaine had been living since his return. When Blaine had been in high school, he had converted part of the basement into a bedroom. He and his fiancé had been apartment hunting and until they found affordable place, they were staying in his old bedroom. Dr. Sessay asked if it would be possible to visit his bedroom, in hopes of discovering what it was that had made him so ill. As Blaine had reported that he and Pamela seldom separated in Africa, and as she had no symptoms, it must be something directly related to the environment. Something was making Blaine very ill.
Blaine’s father drove Dr. Sessay to their modest ranch home, and after removing his shoes, the epidemiologist followed Blaine’s father down the basement stairs to the room where he and his fiancé had been staying. Nothing seemed unusual. The room was dark, but it was comfortable. Blaine’s father asked why Pamela would not also be sick if it was something in their home. Dr. Sessay was about to conclude his visit when he asked how long Pamela had been staying here. “About two weeks.” How long had Blaine been staying in the room? “About six weeks” was the answer. Dr. Sessay asked Blaine’s father if he might have a flashlight, and one was quickly found. After searching through the bedroom and finding nothing, Dr. Sessay was nearly halfway up the basement stairs when he noticed what looked like a closet off to one side of Blaine’s bedroom. When asked what was stored in the closet, Blaine’s father told him it was a bathroom.
Dr. Sessay opened the door to the bathroom, and was immediately struck by a mildew smell. A quick scan of the ceiling indicated no exhaust fan, and one basement window opened to the outside. Dr. Sessay called Dr. Pratt who was in the hallway outside Blaine’s room. Had both Blaine and Pamela used the shower in the basement bathroom? The answer came back as yes. Dr. Sessay was puzzled. Exposure to the bedroom and the bathroom would have been similar after a few weeks, it did not make sense. Then Dr. Sessay had an idea. Did Blaine open the window when showering? He knew the answer before it came. “No. Blaine had not adapted to the winter in the upper Midwest, and was often cold.” Pamela had commented that he “would often take long hot showers, over an hour, just to warm up. He always kept the bathroom window closed.” Dr. Sessay asked for a stool or ladder, and climbing up to the sill of the basement window, he found a thick layer of mildew. Grabbing a test tube, Dr. Sessay scraped a small amount and the tube. What Dr. Pratt saw on the microscope slide looked like a flower, the common presentation of aspergillus.
On the drive back to the hospital, Dr. Pratt reported that Blaine’s condition was continuing to worsen. Dr. Sessay told Dr. Pratt he suspected allergic bronchiopulmonary aspergillosis, and that treatment with either amphotericin B or oral itraconazole in combination with steroids should be considered as soon as possible. Dr. Pratt concurred.
Because amphotericin B should never be used in non-acute cases of fungal infection, and even then, if the patient has a history of white blood cell transfusions, heart disease, liver disease, or kidney disease, its use is counter indicated. The safer route would be administration of oral itraconazole, however, given Blaine’s rapidly declining condition, it was considered a reasonable risk. Blaine was given both options, and after discussing treatment options with Pamela, Blaine chose amphotericin B and inhaled corticosteroids.
Within a few hours, Blaine’s dissolved oxygen level had increased to 90%, and his oxygen was cut to 50% before being removed the next morning. Blaine was transferred from the ICU to a medical bed, and was allowed to return home at the end of the week. Blaine was instructed to continue the steroid treatment and to follow up with Dr. Pratt after one week. He was also advised not to sleep or to shower in the basement room. Blaine and Pamela moved into an apartment two weeks after he was discharged, and after nearly 10 months, Blaine is starting to feel like his old self, despite his continued use of the steroids to treat his condition. He knows he may never be “cured” but at the very least, he knows how to avoid flare-ups.