Robin Cook: Outbreak

The clinic was conveniently situated on a wide thoroughfare. There were few cars at that time of morning. Marissa pulled into a parking garage, took a ticket and found a spot near the entrance. The entire structure was modern, including the garage, the clinic, and what Marissa guessed was the hospital, which appeared to be seven stories tall. Getting out of the car, she stretched, then lifted out her briefcase. In it were her class notes from the epidemiology portion of the introductory course—as if that would be any help—a note pad, pencils, a small textbook on diagnostic virology, an extra lipstick and a pack of chewing gum. What a joke.

Once inside, Marissa noted the familiar hospital odor of disinfectant—a smell that somehow calmed her and made her feel instantly at home. There was an information booth, but it was empty. She asked a maintenance man mopping the floor how to get to the hospital wing, and he pointed to a red stripe on the floor. Marissa followed it to the emergency room. There was little activity there, with few patients in the waiting room and only two nurses behind the main desk. Marissa sought out the on-call doctor and explained who she was.

“Oh, great!” said the ER doctor enthusiastically. “Are we glad you’re here! Dr. Navarre has been waiting all night for you. Let me get him.”

Marissa absentmindedly played with some paper clips. When she looked up, she realized the two nurses were staring at her. She smiled and they smiled back.

“Can I get you some coffee?” asked the taller of the two.

“That would be nice,” said Marissa. In addition to her basic anxiety, she was feeling the effects of only two hours of fitful sleep on the flight from Atlanta.

Sipping the hot liquid, Marissa recalled the Berton Roueche medical detective stories in The New Yorker. She wished that she could be involved in a case like the one solved by John Snow, the father of modern epidemiology: A London cholera epidemic was aborted when Snow deductively isolated the problem to a particular London water pump. The real beauty of Snow’s work was that he did it before the germ theory of disease was accepted. Wouldn’t it be wonderful to be involved in such a clear-cut situation?

The door to the on-call room opened, and a handsome, black-haired man appeared. Blinking in the bright ER light, he came directly toward Marissa. The corners of his mouth pulled up in a big smile. “Dr. Blumenthal, we are so glad to see you. You have no idea.”

As they shook hands, Dr. Navarre gazed down at Marissa. Standing next to her, he was momentarily taken aback by her diminutive size and youthful appearance. To be polite, he inquired about her flight and asked if she was hungry.

“I think it would be best to get right down to business,” said Marissa.

Dr. Navarre readily agreed. As he led Marissa to the hospital conference room, he introduced himself as chief of the department of medicine. This news didn’t help Marissa’s confidence. She recognized that Dr. Navarre undoubtedly knew a hundred times more than she about infectious disease.

Motioning for Marissa to sit at the round conference table, Dr. Navarre picked up the phone and dialed. While the call was going through, he explained that Dr. Spenser Cox, the State Epidemiologist was extremely eager to talk to Marissa the moment she arrived.

Wonderful, thought Marissa, forcing a weak smile.

Dr. Cox sounded equally as happy as Dr. Navarre that Marissa was there. He explained to her that unfortunately he was currently embroiled in a problem in the San Francisco Bay area involving an outbreak of hepatitis B that they thought could be related to AIDS.

“I assume,” continued Dr. Cox, “that Dr. Navarre has told you that the problem at the Richter Clinic currently involves only seven patients.”

“He hasn’t told me anything yet,” said Marissa.

“I’m sure he is just about to,” said Dr. Cox. “Up here, we have almost five hundred cases of hepatitis B, so you can understand why I can’t come down there immediately.”

“Of course,” said Marissa.

“Good luck,” said Dr. Cox. “By the way, how long have you been with the CDC?”

“Not that long,” admitted Marissa.

There was a short pause. “Well, keep me informed,” said Dr. Cox.

Marissa handed the receiver back to Dr. Navarre, who hung up. “Let me bring you up to date,” he said, switching to a standard medical monotone as he pulled some three-by-five cards from his pocket. “We have seven cases of an undiagnosed, but obviously severe, febrile illness characterized by prostration and multi-system involvement. The first patient to be hospitalized happens to be one of the cofounders of the clinic, Dr. Richter himself. The next, a woman from the medical records department.” Dr. Navarre began placing his three-by-five cards on the table. Each one represented a patient. He organized them in the order in which the cases had presented themselves.

Discreetly snapping open her briefcase without allowing Dr. Navarre to see what it contained, Marissa extracted her note pad and a pencil. Her mind raced back to the courses she’d recently completed, remembering that she needed to break the information down into understandable categories. First the illness: Was it really something new? Did a problem really exist? That was the province of the simple 2 × 2 table and some rudimentary statistics. Marissa knew she had to characterize the illness even if she couldn’t make a specific diagnosis. The next step would be to determine host factors of the victims, such as age, sex, health, eating habits, hobbies, etc., then to determine time, place and circumstances in which each patient displayed initial symptoms, in order to learn what elements of commonality existed. Then there would be the question of transmission of the illness, which might lead to the infectious agent. Finally, the host or reservoir would have to be irradicated. It sounded so easy, but Marissa knew it would be a difficult problem, even for someone as experienced as Dubchek.

Marissa wiped her moist hand on her skirt, then picked up her pencil once more. “So,” she said, staring at the blank page. “Since no diagnosis has been made, what’s being considered?”

“Everything,” said Dr. Navarre.

“Influenza?” asked Marissa, hoping she wasn’t sounding overly simplistic.

“Not likely,” said Dr. Navarre. “The patients have respiratory symptoms but they do not predominate. Besides, serological testing has been negative for influenza virus in all seven patients. We don’t know what they have, but it is not influenza.”

“Any ideas?” asked Marissa.

“Mostly negatives,” said Dr. Navarre. “Everything we’ve tested has been negative: blood cultures, urine cultures, sputum cultures, stool cultures, even cerebrospinal fluid cultures. We thought about malaria and actually treated for it, though the blood smears were negative for the parasites. We even treated for typhoid, with either tetracycline or chloramphenicol, despite the negative cultures. But, just like with the antimalarials, there was no effect whatsoever. The patients are all going downhill no matter what we do.”

“You must have some kind of differential diagnosis,” said Marissa.

“Of course,” responded Dr. Navarre. “We’ve had a number of infectious disease consults. The consensus is that it is a viral problem, although leptospirosis is still a weak contender.” Dr. Navarre searched through his index cards, then held one up. “Ah, here are the current differential diagnoses: leptospirosis, as I mentioned; yellow fever; dengue; mononucleosis; or, just to cover the bases, some other enteroviral, arboviral or adenoviral infection. Needless to say, we’ve made about as much progress in the diagnostic realm as the therapeutic.”