by Barbara Ebel
The procedure went quickly, especially due to Michael’s age. His back lacked aged changes which make spinal needles more difficult to slip between vertebrae. A geared-up nurse helped Michael stay in a curled position as the precious cerebrospinal fluid dripped into Danny’s vials.
Danny placed all the vials into the tray with enough for Joelle, the hospital, and the CDC. He asked staff to ready Michael for a trip to the MRI machine, delivered some samples to the lab and hurried across the campus to Joelle’s.
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Joelle got back to her lab after visiting Radiology with Danny and Tim and persisted with her agar plates and methods. At her cluttered desk, she made notes in her leather notebook after peering through the microscope on the counter for some time. She noted the date, time, specimen number, patient, and other details and then leaned back in her rolling chair.
Although Joelle felt exhilarated with the hunt for their demonic organism, she’d been burning extra hours with the chase and needed catch-up sleep. She’d never been one to run on adrenaline for too long. She found it difficult enough getting through surgery rotations and emergency room electives while in medical school.
She closed her eyes for a moment to the silence of the lab while her thoughts deviated to her Mother. If only she were still here. They had been on a course to have an even thicker mother-daughter bond. How proud she would have been with Joelle’s accomplishments and how happy Joelle would have been assisting her mother in her old age. If she could figure out the cause of the meningoencephalitis outbreak soon, perhaps it will save someone else’s mother, and not have a result like her own.
Joelle opened her eyes, yawned and returned to the black counter. She peeked again under the scope. This time she confirmed it to herself – a clearing, or thin tracks in the agar, the non-nutrient plates having been coated with E. coli. Her pulse picked up as she checked on the direct fluorescent antibody stain nearby. Then her heart galloped like a horse.
She felt as if she’d been working toward this moment essentially all her life as she stared at the histopathology of amebic meningoencephalitis due to Naegleria fowleri, or something close to it.
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When Danny stepped into the lab and Joelle turned his way, she looked luminescent as she had just realized the diagnosis. A wide smile erupted on Danny’s face as he placed down the CSF samples and Joelle energized her forearms.
“Ha,” Joelle said, “who goes first?”
Danny resonated a laugh, “ladies first.”
“I’ve got it, Danny! It’s an amoeba. Naegleria fowleri or a like-imposter. Look at this direct fluorescent antibody stain.”
“Joelle, great work. We had every faith in you. Show me now.”
She pointed at the microscope to show him the green shine, like some small sea life shimmering in the dark ocean night.
“I can’t tell you how important a find this is,” she said as he looked. “Most of these rare cases are discovered post mortem.”
Danny shuddered at the thought. “You’ll have to refresh that life cycle for me. And more importantly, where we go from here with all our patients?”
“Yes, and you’ve discovered something as well?” Her earrings sparkled when they caught the overhead light and she held her breath in anticipation.
“I think the first patient is the young teen who had the acute subdural hematoma. His surgery was last week, Monday, same day as Troy Neal. Harold went to see him the next day. The OR staff on duty for his surgery all became infected and his floor duty nurse, Peggy, as well. I’ve brought you CSF samples because I just tapped him.” The words rushed out of Danny like from a water faucet. He moved the nearby stool and sat down as Joelle perched on her own.
Danny had Joelle’s full attention. They faced each other, knee to knee. “You mentioned him before,” Joelle said, “and we eliminated him due to his proven subdural, surgery, and confirmation. His accident happened on the boat, but did the family give you any more history?”
Danny didn’t remember Michael saying that much. The parents had taken turns. Joelle interrupted his thoughts. “Do you know if he went swimming?”
“That’s it. The mother, I think, was annoyed because he’d been doing something she wasn’t fond of. His brother and friend were with him, perhaps he was showing off. The motor was turned off, the kids were swimming, and Michael kept climbing up an island cliff and jumping off. The mother said it was at least a twenty-foot drop. Then they climbed back on board, the speeder came by, and Michael took a tumble.”
Joelle placed her hands together in a prayer-like fashion and touched her nose and mouth for a moment. “You’ve got it Danny. I wish if he had done that, he’d worn nose plugs, and what kid is going to do that? Plunging into the lake like that, from that distance, pushed the fresh water up his nostrils. This amoeba travels from the nose to the brain. It weasels its way into the central nervous system through olfactory mucosa, right through the cribriform plate of the nasal tissues.”
Joelle saddened with the horror of it. “Danny, the olfactory bulbs necrose with this monster as it scurries along nerve fibers straight up into the brain where it literally consumes brain cells. With its unique morphology, it attaches to them and sucks out their contents.”
Danny now recalled it, but had never seen a case, nor heard of one personally. He fidgeted on the stool, the beginning life cycle difficult to imagine.
“Danny,” Joelle continued, “acquiring this amoeba almost always results in death.”
Joelle hated to go on with the stunning statistic. “Survival of patients is less than one percent. But I’m not finished.” She swallowed hard. “That’s the basics, although I haven’t told you the three stages of its life cycle. We have a modified version of what has been previously reported. Maybe a mutation of some sort. It has evidently also affected salivary glands, making them over productive and probably creating another means of contamination. The change has made it even more worrisome.”
“Why?” Danny asked.
“There’s no real success with the suggested antibiotic regimen used for this organism - which we have to put our patients on right away anyway. But now with this alteration, we don’t stand a prayer’s chance in hell.”
Danny slumped. “So these hijackers are going to eat human brains – one cell at a time.”
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Finally breaking away from the lab, Danny suggested they grab a late lunch. They walked to Coffee ‘N More right between the hospital and lab and they bought chicken croissant sandwiches and drinks. Slipping into a corner booth, Danny began eating immediately. He was overly hungry, which made the soft, fresh sandwich taste even better.
Between bites, Danny told Joelle the last part of Michael’s story. “There’s another thing,” he said. “It sounded like Michael’s parents were infected, too. They may be in a hospital in Kentucky. Perhaps it’s who Ralph went to see. I’ll call him when I’m done.”
“That’ll be in another thirty seconds based on how you’re wolfing down your lunch.”
Danny’s beam spread across his face after a wholesome laugh. “I should’ve eaten hours ago, but duty called.”
“If you’re correct, that’s additional terrible news about his parents,” Joelle said. She washed down half her sandwich with iced tea.
Danny ate a few chips on the side and then scrolled for Ralph’s number. Joelle nodded as he placed the call. Within a few seconds, Ralph got on with a reserved “hello.”
“I was going to call one of you in a little while,” Ralph said. “It’s been busy here and our outbreak has indeed spread.”
“It’s Michael Johnson’s parents, isn’t it?” Danny asked.
After a surprised pause, Ralph answered. “How did you know?”
“Joelle and I figured out the initial source, Michael Johnson. He’s the fourteen year old who had an acute subdural hematoma but also kept jumping off a high cliff into lake water prior to the acci
dent. Joelle has determined the killer organism to be Naegleria fowleri. However, a killer has turned into a super killer based on Joelle’s interpretation that this amoeba has mutated.”
“Hello, Danny,” Ralph said. “I leave you two alone and you work together like biscuits ‘n gravy.”
Even under the sad commentary of information, Danny had to laugh while shaking his head at Joelle.
“But they aren’t the only ones,” Ralph said. “There’s another patient up here and two more in hospitals in Tennessee and Georgia. By phone I’ve traced the patients to having visited family or friends at your all’s facility. I plan on leaving here soon after some correlating. You need to have the CEO call another press conference and I’ll be back as soon as possible.”
“I’ll schedule for early tomorrow morning,” Danny said. “In the meantime, Joelle and I will change the present treatment and start what she thinks are the best drugs.”
“Does she think it’s Chlorpromazine?”
After Joelle concurred, Ralph added, “I’ll relay this information to the other hospital physicians. Say a southern prayer we contain this demon.”
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Wednesday morning before 8 a.m. every doctor involved, plus Robert Madden, showed up again in the hospital’s conference room on the top floor. No one skipped the continental breakfast. Danny told Timothy to go ahead and sit and brought him coffee and a plate of fruit and hard boiled eggs, went back for his own, took a napkin and glanced at the reddened and scabbed flesh on his left palm.
“What did you do to your hand?” Joelle asked as she lined up behind him. “You didn’t do that in surgery, did you?”
Danny smiled her way. “Ha, no, I’m a more careful neurosurgeon than I am with yard work. I almost sawed off my hand. That would have put me out of commission for good.”
Joelle shook her head. “Guys and their toys. You’re lucky. I hope your hands are insured!”
“That’s the problem being in a surgical specialty. Your livelihood is a lot more vulnerable than being in primary care.”
“I suppose my specialty is pretty safe, except for being more susceptible to deadly viruses.”
“You would have been fascinated with this one. Within the last twelve months, I operated on a patient’s brain that had a hydatid cyst. Echinococcus granulosas from a dog’s tapeworm.”
Joelle’s eyes grew wide as she stood there with an empty plate. “No way. I’d expect something like that from South America, but Nashville?”
“South of the border is where he picked it up.”
“You must have stopped breathing to remove it. That cyst could have ruptured, releasing thousands of parasitic particles into his brain.”
“I didn’t breathe and I didn’t blink.”
“Jeez, Danny, remind me to go under your OR knife but not use your landscaping services.”
Robert Madden said a quick “good morning y’all” to everyone and Danny quickly took his choice of a bagel and a large black coffee.
“As you all know,” Robert said, “we’ve made huge progress in the last twenty-four hours in getting to the bottom of this outbreak. However, that was another twenty-four hours that this organism had continued to spread. Ralph from the CDC is back from his quick jaunt to Bowling Green. Our press conference is in thirty minutes downstairs and this is to correlate our information and make sure we’re all on the same page. I think Joelle would like to say a quick word or two first.”
Joelle placed her coffee cup farther away and stood up. “Dr. Tilson confirmed yesterday by MRI that the young man, Michael Jackson, was the original source of this outbreak and as some of you know, we’ve discovered the organism causing this meningoencephalitis. We might as well refer to it as PAM which stands for primary amoebic meningoencepahlitis. The amoeba is Naegleria fowleri or a similar derivative.”
“Joelle,” Peter said, “yesterday Dr. Tilson explained to me how this organism invades a human brain. But being a hospitalist, I don’t really know about its life cycle. Can you enlighten me?”
“Would love to,” Joelle said. She put her hand forward and gestured with three fingers. “It exists in three forms – a cyst, trophozoite, and flagellate stage. Cysts exist in the most unfavorable conditions such as extreme cold. The flagellate form is simply a trophozoite which gets transformed quickly due to changes in its ionic environment, like sticking it in distilled water, a different ionic concentration.”
Danny noted Joelle had only sipped her coffee, but her description took on speed.
“It’s the trophozoite which is the reproductive form, proliferating by binary fission. Their pseudophila allow them to travel and change directions, feeding on bacteria in nature, but eating or phagocytizing red and white blood cells in humans and destroying tissue.”
Joelle’s voice grew grim as she looked at each individual in the room. Timothy’s hand trembled on his cane and Danny grimaced visualizing the capabilities of the amoeba. “The shocking thing for humans is they eat our brains piecemeal by a unique adaptation extending straight out from its cell - a sucking apparatus.”
Peter had put his fork down. “Aren’t I glad I asked?”
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After more discussion and certainty that all the involved patients were quarantined and under proper infectious disease protocols, they swiftly left for the press conference on the first floor. What awaited them had no resemblance to the last reporters’ gathering.
Robert Madden led the group. While Danny, Joelle, Ralph, Timothy, Pamela, and Peter pushed past the hordes of press and camera crews which flowed into the back of the auditorium, flashes went off and cameras started rolling. Robert already had a question hurled his way, but put his hand up signaling the crowd to wait until they formally got started.
Robert turned in the front of the crowd. He was sharply outfitted in a suit and tie. Along with his salt and pepper gray, he made a distinguished figure. “Ladies and gentlemen, we have major developments in this outbreak. I am immediately introducing Ralph Halbrow with the CDC.”
Ralph went to the podium past Robert. His hectic trip to Nashville and Kentucky, and the pressure of the disease, had caused puffiness under his eyes. “Before taking questions, we have discovered the organism wreaking havoc in not only this hospital but now in three states. We have also discovered where this organism came from.” Ralph went on to give explicit details and then introduced the other doctors and their specialties before opening up the floor for discussion.
A reporter nudged forward as soon as Ralph stopped. “Why are you finding new cases when the hospital insists that precautions are being taken for its spread?”
“People have obviously been around these patients before their diagnosis was made and they were put on infectious disease protocol. And we aren’t sure exactly the point in time when a person becomes infectious to others. But we have our suspicions.” Ralph took one thumb and stuck it under his burgundy suspender as he gave it another thought. “Also, you must realize the hospital has intermittently been on diversion, causing cases that would have been admitted here to land somewhere else. And in the case of Michael Johnson, the first case, his parents unknowingly came down with it from their son while they were away on a trip.”
A man with a CNN camera person beside him spoke next. “So this can become an epidemic? And are you saying there is no treatment to eliminate this amoeba?”
“Sir, this is an epidemic.” Cameras clicked in a mad rush and some reporters let out a gasp. “We do have a suggested treatment,” Ralph added, “but it doesn’t seem to work. The CDC and infectious disease here are going to immediately look into finding the cure.”
“Why do you think treatment doesn’t work?” the same reporter asked.
“Naegleria fowleri may have had a slight mutation. Our outbreak involves the patients having a timely heavy production of saliva. The organism is having an impact on the salivary glands, which are close to the nasal anatomy involved.”
Ralph signaled to a reporter in the back with his hand raised the whole time. “Mr. Halbrow, we understand you were in Bowling Green yesterday. Who pinned down these results?”
“Dr. Joelle Lewis and Dr. Danny Tilson.”
“Couldn’t the CDC have come up with this information sooner?”
“The CDC in Georgia has had the necessary samples as well. These specialists right here in your home town are close to the history, allowing them to piece together the puzzle sooner. I assure you, Dr. Tilson and Dr. Lewis are two of the sharpest knives in the drawer.”
Chapter 13
It had been years since Sara taught first year high school biology. She’d quit teaching when the girls were small and Danny toiled in training. After the divorce settled and she evaluated her life over the summer, she decided to get credentialed again and apply for a job. In only a few years, Annabel and Nancy could possibly be leaving for college. She’d have made the right decision to go back to her own career and not suffer the pangs of an empty nest.
She sent in three applications to regional high schools and lucked out with the best possible result. The school where Melissa had gone, and Annabel and Nancy attended, asked for an interview. In addition, that was where Sara had previously worked. Within two weeks the principal called, offering her a freshman teaching spot.
Sara brushed up on high school biology as well as state mandates on curriculums and preparing for the first day of school. She recognized her other good fortune as well. Annabel was entering her senior year and Nancy her sophomore year, so she wouldn’t have a potential conflict of interest with one of them in her class. They could also travel back and forth to school together when possible.
She figured it all added up - lately life without Danny was a win-win situation. Joining the work force again, keeping in good shape, and having two remarkably good teenagers boosted her self-confidence, which had taken a hit during the last months of her marriage. Looking in the mirror, she liked what she saw. Only two years younger than Danny, she wore forty-four years well. Her peppered true blonde hair stopped midway along her cheeks and her skin drank moisturizer with sun protection first thing in the morning, giving her complexion a boost.
