Infectious Disease

Dust to Dust

Original Title: C-70650; Box 8.4

It was wonderful to finally meet Caitlyn. It seemed rather odd that, just a few months ago, he didn’t even know he had a granddaughter. Caitlyn’s mother, Alice, had not spoken to her father in over10 years. Looking back, Walter could not even remember what the argument had been about. It was during Alice’s mother’s hospitalization that trouble had begun, and Alice, an only child, disagreed with her father’s choice of cancer treatment. Alice was always an independent person, and when she had moved to Utah after college, she had maintained a close relationship with her mother. Walter had not approved of her lifestyle, and the two had a difficult relationship. When Alice’s mother passed, Alice blamed her father. She had done the research on a macrobiotic diet, she had read up on herbal remedies and natural treatments for cancer, and had begged her father to consider these as an alternative to the chemotherapy her mother was about to start. These arguments further stressed an already strained relationship to the breaking point.

When Walter’s wife passed, Alice believed it was because he had refused to listen to anyone else but his wife’s doctors, and for many years she blamed him for her death. She had called him an intellectual coward and had accused him of letting the established medical system do his thinking. For many years he thought she might be right. After all, what did he know about medicine, much less something like cancer?

Over the years Walter had been able to keep track of Alice through his sister, Geneva. Growing up, Alice was always close to Geneva for some reasons. Geneva had never married, and she and Alice were only seven years apart in age. Geneva had been a surprise, born after Walter’s parents were in their late 50’s. She had always been the peacemaker, reaching out to family and friends. Alice had maintained contact with Geneva, and when she and Walter had lunch or talked, she would fill him in on any news about Alice. But she never mentioned Caitlyn. Walter assumed she had been asked not to discuss the topic, and Geneva, always trying to keep the lines of communications open, had agreed. He would tell his sister he felt betrayed, but what good would that do? Besides, he knew now.

Walter was not sure what had changed Alice’s mind. Perhaps having a family of her own, and all the uncertainty that comes with it. He was very surprised when she called; he didn’t recognize her voice, and it took him a moment when she said, “It’s Alice.” They had spoken several times over the next few weeks, and she asked her father to come for a visit. Walter recalled how nervous he was just phoning the airline. The flight from Austin to Stockton was both too long and too short.

Walter, who had thought of little else since planning the visit, was uncertain as to what he would say. Should he give her a hug? Should he wait to see what she said or did? He was at a loss. He was never at a loss to know what to do or say. When he retired from his position as a pharmaceutical sales manager, the company CFO had said that Walter’s success has been in his “knowing exactly what to say regardless of the situation.” It seemed odd that now, he would find himself at a loss for words.

He almost didn’t recognize her when got to the lobby of the airport. He saw a woman who looked a bit like his wife, and yet not at all what he expected. She has certainly changed. Standing beside her was a tall man in glasses, and a little girl who held his hand tightly. “Dad?” Alice had asked after he nodded, she remarked he had changed. He was thinner, grayer, but seemed healthier.

Since his wife’s death, Walter had tried to stay busy. He had joined a health club and bicycled daily. He still lived in the same house, had the same furniture, and ate at the same restaurants. He was almost afraid to change too much as if he was unfaithful to the life they had. After giving her father a hug and introducing her husband Chuck, she looked down at the little girl and said, “This is Caitlyn. Your granddaughter.” The little girl smiled up at him, and Walter’s eyes immediately welled with tears. “I am very happy to meet you,” he said. Caitlyn reached up, and scooping her in his arms; Walter hugged her.

The following week seemed a blur. Both Alice and Chuck worked at the local college, and as it was midsummer, both were on break. Both Alice and Chuck were active. They ran daily, and Caitlyn enjoyed riding along beside them on her bike. They had planned a family camping trip into the wilderness, but when Alice and Walter had reconnected, she thought to cancel the trip. Walter insisted they not change their plans, and he thought it would be great fun.

Walter had never been to the San Joaquin Valley and thought the landscape haunting and beautiful. When they arrived at the hike-in area of the camping areas, Walter looked around in amazement. Austin, where Walter had been born and raised, was mostly flat. Very busy for a small city, there were a many great things to do there, especially dining out and music concerts. But Walter had never had time for camping when Alice was growing up. He was far too busy earning a living. As he followed along, holding Caitlyn’s hand, he thought about all he had missed when Alice was a child.

Almost before he realized, Walter was at the airport going home. It had been a wonderful, and emotional week, and already Alice and Chuck were planning on going to Austin in August before classes started. It was a few days after he had unpacked at home that the pain had started. At first, it was mild, uncomfortable, but manageable. But within a few weeks, it had become sharp and stabbing. He assumed he had pulled a muscle hiking, most likely when he climbed an old pine to get a picture of the family and their campsite for Caitlyn’s scrapbook. He called his doctor’s office and got an appointment for the next day.

When the doctor had asked about chills, sweats, coughing, Walter told him he had not experienced any of those. “The trouble is I have this sharp pain in my shoulder blade,” he told the doctor. “How active would you say you are,” asked the doctor. Walter remarked that he went to the fitness club daily and rode his bike 20 to 30 miles each afternoon. The doctor asked Walter to stand, and putting a stethoscope to his chest, asked him to take some slow, deep breaths. The doctor noticed decreased breath sounds in the right lung. Asked if this deep breathing caused pain, Water remarked that it did not. Walter was sent home with a prescription for a mild muscle relaxer and advised to “take it easy for the next week.”

The muscle relaxants did not ease the pain, but Walter thought to follow the doctor’s advice, so he took it easy for the next week. But after nearly nine days, the pain had simply become sharper. And this morning he had awoken with a terrible headache. As he stumbled to the bathroom, he opened the medicine cabinet and caught sight of redness in his ear. Dabbing with his finger, he realized it was wet. He pulled back his finger tinged with blood.

When Walter arrived at the express care department, he was feeling tired, and his head still ached despite using a pain reliever. The clinic nurse took his vitals, and he waited for the nurse practitioner to come in. She looked in his ears and found dried blood. She looked in his ears and found his eardrums were intact. She asked if he had suffered any trauma lately? Car accident, or a bad fall? When he answered no, she then looked up his nose, although Walter was uncertain why. She listened to his lungs and heart, and hearing something odd. She percussed the area around his upper right side, both front and back. After taking more information, she left the room. As Walter sat on the examining table, she wondered if he might have caught a cold on the camping rip, or maybe on the plane? He had always been told that airplanes were filled with viruses.

She came back in with a pad and began writing. She told Walter that he most probably had a mild lung infection, and handed him a prescription. It read “Augmentin. “Follow the directions, and you should start to feel better in a day or two. If you do not feel better, or if the symptoms worsen, call your regular doctor or return to the clinic,” she said as she left the room. The nurse came back in with instructions, and he was walked to the door.

That night, the headache was worse, and when he coughed, his nose began to trickle blood. He called his doctor, and left a message. Dr. Smith called early the next morning, and Walter went in. He told Dr. Smith about his visit to the clinic. He said he meant just to call him over the next day or so to set an appointment, but panicked. Henry Smith, MD had been Walter’s physician, as well as his wife and daughter for many years. He also knew that Walter did not like coming to his office, except perhaps before he retired. But that was business.

Dr. Smith performed many of the same tests as the clinic and agreed that an antibiotic was the best course of action. He checked Walter’s blood pressure expecting it to be high, which might explain the nosebleed but found it low instead. Walter still complained of a headache, and Dr. Smith suggested an over the counter saline sinus spray, as the bleeding could be irritation from dry air. He also gave Walter a prescription for a pain reliever, and Walter was told if his symptoms did not improve by the next day, or if they became worse, he should call immediately.

Walter was never one to sit around, and as his nosebleeds had stopped, and his headache was better, he decided to go back to the fitness club. He had missed enough time. After less than ten minutes on the stationary bike, Walter could not catch his breath. It felt like someone was sitting on his chest. Even after he stopped, he just could not seem to get a good breath. Walking to the change room, he became dizzy. The next thing he remembered, he was on the floor looking up and a young woman, who was asking him questions. She told him an ambulance was on its way and to try not to move.

Walter was taken to the medical center, and Dr. Smith was called. Again the long list of questions, medications, changes in diet or exercise, etc. When Dr. Smith arrived, Walter was still in the exam room. The doctor spoke with the physician in the emergency department and then came into see Walter. Walter’s breathing had become more difficult, and now it was painful to breathe deeply.

The emergency room doctor listened to Walter’s lungs and called down to imaging department. Before Walter knew it, he was on a gurney being wheeled into the elevator, then down one floor and into the imaging department. He was helped onto a cold, hard table. Chest imaging showed a cloud area in his right lung midway, and he was then taken back to the ED. “Had he been tested for Tuberculosis? Had he had a test for HIV?” he was asked. “Yes” was his response. As pharmaceutical salesmen, they often visited offices and clinics where patients were present. It was standard policy to be tested. Soon a young lady appeared and his blood was drawn.

When the tests came back, Walter had been sitting in the waiting room. He told them he felt a bit better, and could he go home? The nurse told him that they would prefer he did not leave until they had a better understanding of what was going on. An hour later, Walter was being wheeled to a procedure room where he underwent Thoracentesis. The amount of liquid the doctor removed from his pleural cavity was small, but a sample was sent for testing.

The next morning, after he had finished his breakfast, he had a visit by two men he had never met. One was the hospitalist who had been treating Walter since being moved from the ED; the other was a clinical epidemiologist. They were there to try to explain what had happened to him. The hospitalist told Walter that the inflammation in his right lung had appeared as a cloudy image in the X-ray he had taken when he had arrived at the ED. When he underwent the extraction of liquid from his lung, the test had revealed no tuberculosis, but it did reveal a fungus known as Conidia that is often found in desert areas. The epidemiologist then told Walter that the condition, known as coccidioidomycosis, was rare in Texas. He then asked Walter if he had traveled recently, to which Walter explained he had visited his family in California and had been camping in the desert.

Walter was placed on the antifungal medication Itraconazole and told the possible side effects from taking the drug. He was to check in with his doctor after three days and to report any dizziness or lightheadedness. Walter was told that the eradication of the fungus might take six months or longer. As Walter was obviously not pregnant and did not report any kidney or liver diseases or heart conditions, he was advised what symptoms to be alert for and was discharged after 36 hours.

Walter observed his doctor’s’ orders and returned to his fitness regime after four weeks. After his nine-month checkup, he was found to be virtually free of the infection, and medication was discontinued.

Today, nearly four years after treatment, Walter remains close to his family and visits California often. But now they enjoy the aquariums and museums, and Walter leaves the camping to the younger generations.

 

 

From the CDC

Coccidioidomycosis is an infection caused by the fungus Coccidioides. The fungus is known to live in the soil in the southwestern United States and parts of Mexico and Central and South America. The fungus was also recently found in south-central Washington. People can get Valley fever by breathing in the microscopic fungal spores from the air, although most people who breathe in the spores don’t get sick. Usually, people who get sick with Valley fever will get better on their own within a few weeks to a few months, however, some people will need antifungal medication. Certain groups of people are at higher risk for becoming severely ill. It’s difficult to prevent exposure to Coccidioides in areas where it’s common in the environment, but people who are at higher risk for severe infection should try to avoid breathing in large amounts of dust if they’re in these areas.

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