by Barbara Ebel
Annabel nodded and swiped her hand across her cheek to remove the last tear.
“Okay. It’s a deal.”
CHAPTER 30
The lecture hall soon filled up. Few seats remained. Shania Enno followed the activities of the young man setting up the technology for her lecture with keen eyes. When he appeared to be finished, she leaned Alejandro against the podium and fiddled with the electronic pointer. The cover page of her lecture was prominently displayed on three substantial screens:
Our Infinitesimal yet Colossal Danger by Shania Enno, M.D.
Shania tested the microphone to make sure everyone heard her just fine. She nodded at the young man, who gave her a little salute with his right hand and walked to the back of the room where he switched his duty to the recording of her lecture.
Annabel crossed her legs, ready to be comfortable and as attentive as possible. Bob nestled further back into his chair.
“I bet she’s going to knock the lecture into orbit,” he whispered. “I can’t imagine being on stage with a pointer and a microphone at her age.”
“Why not? I’m going to try my best to be like her. And did you see? They have set up to tape her lecture. Maybe they’ll send her talk into NPT!” She giggled and focused forward.
Shania cleared her throat. “Good afternoon. Today is this week’s medicine department Grand Rounds. In case any of you are in the wrong lecture, you are welcome to stay.” She pranced the blue light of the pointer up on the title of her talk. “Our Infinitesimal yet Colossal Danger discussion today may take longer than an hour, but the department has cleared the time from clinical duties for all of you. So sit back, listen, and learn.
“As a foreword, this discussion must include my notes on global warming. The medical aspect of my lecture is not complete without the inclusion of that subject matter. We can’t talk about one without the other. However, here’s my caveat. On purpose, I am not going to call the weather phenomena ‘global warming.’ In my opinion, that term conjures up politics, political rhetoric, and a right and a left side of a political spectrum that usurps what scientists say after they research and investigate weather phenomena on our planet.
“Instead, I will only use the term ‘climate change.’ Whatever your political views are, go dump them outside. The necessary foundation of my medical and biological discussion today rests on climate change because, without it, the medical diseases I will speak of would not be rearing their ugly heads as much as they are.
“So you also understand where I’m coming from,” Dr. Enno said while she still stayed on the title slide of her lecture, “again, this talk is politically neutral. Although there must be climate change occurring for the infectious diseases I speak of today to propagate, I make no statement as to why the planet is warming. If human beings are responsible for it and whether or not they can do anything to change it, is not part of my discussion.”
She looked all around. Satisfied that she made her point, she nodded and moved ahead to the first slide.
“The ice sheets are melting. This here is a big chunk of Antarctica which broke off this year. The seas are warming from below the ice masses, which is causing, and will continue to cause, major collapses of mile-high ice. This is, and will be causing, rising seas.
“And on the opposite end of this pole, passages are being made by Mother Nature in the Arctic … allowing shipping vessels to travel in previously unnavigable seas; and in Greenland, two men recently spotted open land from a helicopter … surrounded by snow and ice. They landed and it is believed they stood on that soil for the first time as far back in history as can be imagined. These events are heretofore a thing of one’s imagination.
“Of course, man’s coastal areas are in ridiculous trouble. In a residential area of Miami, four years ago, residents kayaked during high tide through their neighborhood because of rising seas but, since then, they are not. Because 500 million dollars of taxpayers’ money was spent to beef up a barrier against the tidewater which kept creeping higher. Mind you, not due to storms, but due to rising seas. When will that stop? To pump in massive monies like that for the short fix of a few years? And granted, that is only one little area. Beach restoration and the funds needed are going on and being spent year after year along our sandy coastlines.”
Shania sighed with despair, which echoed through the microphone.
“I am pleased I am an old lady who will no longer be around to continue to witness the stupidity of government funding and the communities which demand shoring up of land that is inevitably doomed.”
She changed the slide to an expansive aerial view of the cold continent of Greenland with the section of earth she alluded to.
“Now bear with me. Although I am an old lady, don’t underestimate me. My roundabout way to get to the infectious diseases that came to light for Dr. Mejia and Dr. Schott’s team this month is not unwarranted. My wits are with me and I will paint the entire picture which precludes the story of the foxy diseases I will present. Yes, they are clever!
“I say ‘foxy,’ which means clever, and although I could possibly use fox in my discussion, I am going to instead bring in the white-footed mouse. Because … my main patient with today’s premier infectious disease presented with an unknown history to us of having been knee deep in their environment. So much so, that he was trying to cull their population from the grounds where he lives.
“Our patient is a thirty-five-year-old Ohio National Park Ranger,” she explained, “who helps maintain the inner workings and tours of a former presidential home as well as sees to the outside grounds and safety of the nearby woods and trails.
“Anyway, getting back to climate change and the white-footed mouse.” She popped up a picture of a horde of scurrying mice. Many medical students were previous biology majors, so she knew she had a captive audience interested in animals, their behavior, and their range.
“What heavily influences a species’ life cycle? Climate! Over time, the weather dictates the environmental conditions which affect an organism’s reproduction, behavior, phenology, physiological tolerance, and its sensitivity to habitat quality and food supply.
“And above all … its absolute survival. Because of recent climate change, fluctuations in the weather are faster and of greater amplitude than ever, ever before in the entire past. This affects the distribution patterns and niches of a species.
“Scientists have empirical evidence which is mounting by the day that the earth’s species are responding to climate warming and the temperatures have already had a dramatic effect on the flora and fauna of geographical regions in the 20th century.
“What’s going on is that the stability of a species’ niche is being challenged. Its tolerance and adaptability is being pushed to its outer limits. They shift themselves poleward or upward in their geographic elevation. At the same time, this climate change increases the ability for invasive species to establish themselves in new areas.
“A stark example of a species shifting poleward in its distribution is the successful Eastern North American native rodent, the white-footed mouse. Scientists have calculated his increased and expanded rate of migration on the Upper Peninsula of Michigan for the last forty years. Records also document his northward trek in southern Quebec. The numbers are quite appalling.
“The white-footed mouse usually lives a couple of years, but in northern climates it lives a bit less - one or two years. They eat insects and seeds and, in particular, gather and store seeds and nuts in the fall. They often live in the walls of apartments and homes where they store their food and build their nests and are also the most abundant small rodent in mixed forests in the eastern United States. And, last year the northeast had a record abundance of acorns, which fueled them into a booming population explosion!
“On the other hand, their usefulness is that they eat fungi and spread the spores on the ground in their droppings. This allows local trees to gain nutrients through their roots. They also do eat harmful insect pests and
do not engage in harmful activities towards farmers’ crops.
“So what’s the big deal and why do I bring up these mice? The significance is that their northern migration is a public health concern!
“And everything is interconnected, isn’t it?”
She gave them a moment to think about that and began again and said in a louder voice and with more passion:
“The prolific, northern migrating white-footed mouse is known to be the main host for Ixodes scapularis, the black-legged tick at the larval stage. And each summer, fall, and spring, the tick population increases because of milder winters and the growing mice and deer populations. Dozens of ticks can attach to a single rodent!”
Dr. Enno skipped ahead to her first photograph of the life cycle of her publicized tick. Of the larva, nymph, and adult male and female tick, the larval stage was the beginning of the cycle and the tiniest specimen on her slide of the entire life cycle.
It gave Annabel the creeps to see the slide with the little vampire, especially the premature size of the larva; she glanced at Bob and shook her head while Bob shuddered.
“The thirty-five-year-old male national park ranger who presented to our medical team first presented to the ER staff with flu-like symptoms. He was sent home with instructions to get rest and to treat his cold symptoms. He came back approximately one week later with worsening symptoms - a fever, headache, vomiting, and central symptoms such as slight memory problems.
“As far as preliminary testing suggestive of an encephalitis, an EEG and an MRI were useful, but a brain CT fell short of being helpful. And to the gloom and frustration of our team, and to the jeopardy of our patient, he soon lapsed into a coma and was in the ICU on life support.
“As most of you can appreciate, the possibilities, the cause of his situation and diagnosis, were prolific. And time was of utmost importance to discover and treat his disease. Would this man succumb to his death, stay unconscious for the foreseeable future, and/or could we start him on an antibiotic and reverse his path of ruination?
“As Mr. X’s day by day hospital course unfolded, the internal medicine team worked their magic to keep him alive with respiratory support, intravenous fluids, and drips to decrease intracranial pressure while I chipped away at unearthing and discarding possible diagnoses. But here is where I tell you physicians and students-in-training that the history of your patients is of paramount importance.
“From our patient’s coworker - a woman who lived in one of the cabins of the national park like our patient - we later learned two important aspects of Mr. X’s lifestyle.
“First, as part of his park responsibilities, he was practicing extermination techniques on the white-footed mouse living in the park and their cabins - the very rodent so incriminated in carrying the dreaded ticks, which cause severe illness in humans.
“And secondarily, our patient is a deer hunter. According to the time frame of a recent bow and arrow expedition he had taken, and the fact that he spent the latter part of an entire day hauling in a buck, and skinning and processing it, his body could have become the habitat for one tick or multiple ticks from his activities with either the mice or the deer. In addition, even from the dogs the rangers take care of on their property.
“We know for a fact from his coworker ranger friend, that on the day of his last deer hunting expedition, he pried ticks off of his body. No one likes to do that and people unaccustomed with these critters sometimes don’t even know what they are. However, I am sure our patient knew what he was dealing with, and most likely took certain preventative measures, which were not one-hundred percent effective. We will talk about that and I’ll give you my two-cents about alarming your patients to the vastly increased threat to them regarding ticks.
“So, back to the possible diagnosis. Much to our disappointment, and along the course of our patient’s workup, bacterial infectious diseases were eliminated as the culprit. He failed courses of antibiotics and continued to lie in his stuporous state.
“At the core of helpfulness in a situation like this is a patient’s own immune system. As we are at a loss with discovery, his or her own body is at war with whatever is slinking around in their bloodstream. An immune response is generated against the foreign substance … cells such as those from the thymus, spleen, lymph nodes, and lymphocytes become warriors against the invasive intruder and, most importantly, antibodies are formed. These high molecular weight proteins, normally produced by B cells, act specifically against the antigen and can be detected by laboratory tests of blood or spinal fluid.
“Thank goodness for the specificity and know-how which emerges from our CDC. They are at the forefront of new, emerging diseases, and have the wherewithal to develop diagnostic tests and deliver diagnostic conclusions where possible. After sending off our patient’s laboratory samples, we were told of Mr. X’s rare tick-borne disease.
“A positive POW virus IgM test result was confirmed.
“A virus! Powassan virus.”
She nodded her head to several residents who had befuddled expressions on their faces.
“That’s correct. Powassan virus. You’ve never heard of it. Our patient is the seventy-sixth patient diagnosed with the disease in the last ten years, but the incidence has heightened in the last two years. The numbers are clustered and are ramping up just like we discussed the ramping up the geographical northward expansion and numbers of the white-footed mouse. Don’t forget we had that population boom.”
Dr. Enno reached for the plastic cup of water on the podium and took a sip.
“Many states north and northwest of us have recorded cases, but we now have the distinction of being the first reportable case in Ohio.
“So what is the cure for this potentially catastrophic or fatal disease, which causes inflammation of the brain and/or lining of the brain? What is the treatment for this disease, which can cause mental confusion, seizures, memory loss, and long-term neurologic problems?
“There is no known pharmaceutical drug in our armamentarium to cure or treat Powassan virus!”
A hand shot up from a senior medical student in the front of the room. “Penicillin or doxycycline doesn’t work?”
“No. No such luck since Powassan is a virus, not a bacterium.”
Another arm rose for a question. “The specific tick you mentioned before – Ixodes something – has it been conclusively linked to this particular disease?”
“Ixodes scapularis maintains a life cycle with the white-footed mouse. The answer to your question is ‘yes.’ There are also two types of Powassan or POW viruses. Type 2, also termed Deer Tick virus, is the one associated with Ixodes scapularis. This tick often bites humans. It’s also the primary vector of other human diseases such as Lyme disease.”
Dr. Enno took another sip and sat down on the wooden chair on the stage. She spoke clearly into the microphone.
“Speaking of Lyme disease, however, there’s a big difference between the possibility of acquiring that disease or Powassan. If you find a tick adhered to your body and remove it within the first day or two, you can escape acquiring the spiral-shaped Lyme bacterium because it takes them forty-eight hours to transmit. And we know how awful Lyme disease is.
“However, Powassan goes through the tick’s body into its saliva and into the patient’s bloodstream within a few minutes of a bite. So even though the virus is only present in about four percent of Ixodes scapularis ticks, lower than the 30 to 40 percent presence of Lyme disease bacterium in Ixodes scapularis, if the right tick bores its little head into you, you’re sunk.”
Shania leaned forward.
“These blacklegged deer ticks have a super taste for human flesh and since there is no treatment for POW virus, half of all patients who contract it will suffer permanent brain damage and ten percent will die.”
CHAPTER 31
Dr. Enno stood, gripped Alejandro, and paced across the stage from right to left. Annabel dug into her pocket and pulled out her chocolate-covered blueberries. Sh
e sucked on one while she passed a few to Bob.
“Thanks,” he said and smiled.
“I’m so glad you came.”
“I am too. A test and a lecture in one day. I’m tired already, but she’s worth it. She’s so thorough and she hasn’t even brought up my case yet.”
“Did she ask you if she could use your name?” Annabel whispered.
He nodded. “I have no problem with her doing that. Many of the medicine people here are aware that I’m off the wards because of some kind of illness. At least there won’t be a doubt as to my credibility.”
Shania stopped behind the podium after the bit of activity she had afforded herself. She cleared her throat and chuckled. “Making sure my bones don’t freeze up.
“After Powassan virus quickly reached our patient’s brain and held his body hostage, the team kept him alive, we received his diagnosis, and I communicated back and forth with the CDC and local health officials. And above all, we maintained our hope and vigilance for his recovery.
“We are thrilled to report that today our patient not only opened his eyes and is lucid, but his very own medical student extubated him and he will be on his way to recovery. Hopefully, he’ll be out of the unit soon, transferred to a regular room, and engaged with a small dose of physical therapy to gain his strength back.
“Now, many of you are familiar with the tickborne diseases from the newspapers or television or the occasional case we see in our teaching environment. They are more commonly the illnesses caused by infected ticks carrying wretched bacteria such as Rocky Mountain Spotted fever or Lyme disease. But lo and behold, our own medical student, Bob Palmer, had grander plans than acquiring those. He has been recuperating from what’s called Ehrlichiosis.”
