Could it Be "Lime's"? Lyme Disease & Some Thoughts on Diagnosis

One of the benefits (or drawbacks) of practicing medicine in Western Pennsylvania is that we're in the middle of an area in which Lyme Disease is highly prevalent. This prevalence has caused the general public to be very aware of Lyme Disease (or, as they call it, "Lime's Disease"--a phrase that instantly makes me cringe both for the mispronunciation and for the abyss I am about to descend). Such an awareness, in many ways, has mixed results. On the one hand, an informed patient is unequivocally better than one who is not: it can make diagnosis and treatment much easier as well as help with public health messaging regarding  precautions needed to take to avoid ticks. However, the general public is often unable to sift through all the misinformation about Lyme that exists and understand when it is truly a possibility and when it is arbitrary to suggest its involvement in an illness (let alone responsible for "chronic" symptoms).  I recently was asked to test for Lyme disease in a person with stroke symptoms.

Because Lyme disease has various stages and varied symptoms, many people have heard anecdotes about someone they know with mysterious symptoms that were eventually found to be due to Lyme disease. However, what must be kept in mind is that though there are rare cases of many conditions that have been shown to be the result of Lyme disease, they are a rarity and testing for Lyme disease in the absence of a real suspicion of a role for Lyme can lead one down the wrong path. It must be remembered that at least 10% of people with positive Lyme results have had asymptomatic infections and a positive antibody test will be meaningless if just tested as part of a "shotgun" approach to diagnosis.  

Chances are that any given person's stroke is caused, not by Lyme, but by atherosclerosis--indeed a major study on this topic said Lyme testing added "little value". The same is true is for the myriad other conditions that often get blamed on Lyme. This is not to say that Lyme isn't capable of being behind someone's nebulous symptoms, just that many people (physicians included) seize on Lyme when they're looking for a quick and easy answer.

Return to Sender: The Biosafety of Unknowingly Shipping Live Anthrax

The NY Post front page during the 2001 anthrax attacks

A couple of things to note regarding the mistaken shipment of live anthrax spores from Dugway Proving Grounds in Utah:

• The biggest concern, to me, is that there was a failure to know what was being shipped. Live anthrax spores can be shipped, but must be done in a proper fashion to prevent package damage as well as to assure that those who receive it are prepared (e.g. vaccinated, appropriate lab setting)
• Why did irradiation fail in this setting?

I don't believe anyone will be sickened by this lapse (those exposed who were not vaccinated are received post-exposure prophylaxis) but it is concerning chiefly because there clearly is a biosafety problem that remains at the nation's labs and each lapse, when it is splashed across the front pages, alarms the public who understandably may begin to question what is very vital research.  

Meticulous biosafety at government labs tasked with doing such important research is essential given that the FBI's (somewhat disputed) conclusions regarding the source of the anthrax employed during the Amerithrax attacks (see an interesting new twist on this here). 

Lassa Fever Slithers Through Ebola Monitors

By now, most people know of the imported, and ultimately fatal, Lassa Fever case in New Jersey in a traveler from Liberia. This isn't a cause for panic and we've dealt with Lassa importations several times before and though there are many overlapping symptoms between Ebola and Lassa, Lassa is unequivocally more benign.

To me the most fascinating aspect of this case is how this man's travel history was not fully known to treating clinicians in the state in which Kaci Hickox was unjustifiably quarantined during the height of the Ebola hysteria. There's a great New York Times piece on this part of the story. A few important timeline highlights:

• The man arrived at JFK airport on May 17 from Liberia via Morocco (presumably passing exit screening in Liberia)
• He deplaned and was not febrile during his entry screen at JFK
• His case was passed off to local health officials in New Jersey for active monitoring
• The man developed fever and sore throat prompting a visit to an emergency department where he was treated and released on May 18. 
• He was unable to be contacted by health department officials on May 18
• He was reached on May 20 and May 21 and was apparently without fever
• He represented with worsened symptoms on May 22 and was admitted
• He died on May 25

There are important implications that arise from the New York Times piece that include:

• Did the health department in New Jersey know of the patient's visit to the hospital on May 18 at any time prior to his readmission?
• How are hospitals to know and have situational awareness of who is under active monitoring if the patient doesn't volunteer that information? 
• All public health response systems require cooperation from the public for optimal function

These events should prompt a re-examing of the current system and emphasize the importance of emphasizing a travel history be taken in all patients with infectious syndromes whether they may have come from Lassa-laden West Africa or Legionnaire's Disease laden Pittsburgh. 

In a more stigmatizing and prejudicial time, bells were unfortunately tied around lepers to warn others of their approach. Such an approach was and is unnecessary for a better alarm bell is simply taking the travel history. 

Medicine Before the Vaccine: A Review of Polio Wars

In an era before vaccination against polio--which has chased the paralytic form of the disease  from all but 2 countries--care for those afflicted with the dread disease was paramount. That care was severely hampered by a lack of understanding of all the facets of polio including that it is a gastrointestinal virus which causes paralysis only in rare cases. At that time bed rest, splints, and orthopedic surgical procedures were part of the routine care administered to a patient. 

To a person reading this in 2015, bed rest should sound like a foreign concept as anyone suffering with a paralytic condition caused by, for example, a stroke is basically overwrought with visits from physical medicine and rehabilitation physicians (physiatrists), physical therapists, and occupational therapists who work diligently with the patient in the hope of regaining function as well as learning to accommodate any permanent dysfunction.

It is hard to imagine it otherwise, but it was.

In Polio Wars: Sister Kenny and the Golden Age of American Medicine Yale University historian Naomi Rogers provides an exquisitely detailed and scholarly account of how an Australian bush nurse took America, in the decade before the Salk vaccine, by storm and crusaded to change how polio was treated and conceptualized in the face of fierce opposition by the medical establishment. At one time, she was the most admired woman in America and the subject of a Hollywood biopic. 

Reading the book one is immersed in the world of American medicine in the 1940s and 1950s where physicians held a special status that, I believe, has eroded into the Burger King Have-It-Your-Way style of medicine of today. Physicians forcefully debated, physicians voraciously read, and physicians meticulously thought. While life in such rarified air might be refreshing to read about for physicians, especially when they are today deluged by complaints from patients doggedly pursued by administrators who care little for whether a medical decision was correct or not, the downside was a recalcitrance by some to pursue therapeutic leads if their pedigree was lacking. Such was partially the situation with Elizabeth Kenny and her efforts to improve the care of polio patients. 

While Kenny, who may have lacked a full understanding of the pathophysiology of polio, clearly seems to have embellished and exaggerated the results of her work, which was centered on early mobilization, treatment of muscle spasm, and retraining of muscles (some of which had been advocated pre-Kenny) her intransigence was admirable and her battles with the well-connected and powerful instructive as well as instrumental to the professionalization of the field of physical therapy and highlighted the important role of physical medicine and rehabilitation physicians.

New Rabies Strain Still Can't Create Zombies

A sadly common question I get asked too frequently is "What virus can turn someone into a zombie?" The answer is that no virus can turn one into a zombie anymore than it can turn one into unicorn. However, if I were to name a disease that causes a person to behave in a manner that might be zombie-like, I would say it is the illness caused by the bat-borne rabies virus. For a great historical treatment of the mystique surrounding the illness see Rabid: A Cultural History of the World's Most Diabolical Virus.  

Rabies is a disease that evokes, to those who are familiar with it, fear and was an infection that the great Louis Pasteur trained his genius mind on to formulate a vaccine: the subject of my favorite children's book. In the US, just two human cases occurred in 2010 and most animal cases are in wildlife, though it is important to remember that cats are one of the more common domestic species to contract rabies (see this video of a zombie-like rabid cat). Once infection has set in, only 5 people are known to have survived despite the Herculean Milwaukee Protocol that has been developed in recent years. Rabies in humans, because of its severity and transmission characteristics (blood/body fluid) in humans it is rarely transmitted human-to-human, though organ transplantation is one potential route. 

So with the news of a new rabies strain being found in New Mexico is there a possibility that this could be akin the rage virus of 28 Days Later fame? 

Not a chance.

New lineages of viruses evolve naturally and rarely confer wholly new transmission characteristics. What is likely is that since the ultimate reservoir for rabies are the exceedingly prolific bat species, we know only a small fraction about all the strains of rabies that circulate amongst them. This poor rabid fox likely came into contact with a bat and acquired the new strain providing an opportunity to study the virus.

Sorry to disappoint but no zombie apocalypse in the offing...yet.