Two with Haff Disease equals a hole in our understanding

Last week a woman bought fish from a Brooklyn market and prepared it for herself and her mother.  The next day the younger woman, who ate more of the fish, vomited and experienced muscle pain severe enough that she made a visit to a nearby hospital. Laboratory tests showed muscle enzyme levels 300 times normal, evidence of rhabdomyolysis, the release of the muscle protein myoglobin into the bloodstream. She had none of the usual risk factors for rhabdomyolysis such as extreme muscle overuse, trauma, muscle compression or drugs. Within a few hours her mother presented to the same hospital with similar, but less severe symptoms. Both women were treated and are expected to make full recoveries. No additional cases have occurred.

First reported in 1924, Haff disease gets its name from the Koenigsberg Haff, a brackish inlet of the Baltic Sea where the syndrome was first described. The syndrome is characterized by the sudden onset of severe rhabdomyolysis with nausea, vomiting, chest pain, shortness of breath, and pain with light touch. In Europe Haff disease has been associated with consumption of burbot, eel, and pike. In the United States 23 cases have been reported since 1984 and have followed the consumption of Buffalo fish, crayfish, and salmon. Like paralytic shellfish and ciguatera poisoning, a heat-stabile toxin is suspected but has yet to be identified.

The Buffalo Fish (Ictiobus cyprinellus) is a fresh-water fish and was reported to have been eaten by the two NYC Haff disease cases. Samples of fish from the market have been sent for testing and a temporary embargo has been placed while a trace-back to the source is underway.

Crack the case- Salmonella Heidelberg and chicken livers

Last week the news covered a story of chicken livers contaminated with Salmonella Heidelberg. They were labeled as “ready-to-eat” but the livers had been braised such that from the outside they looked cooked but the insides were coolly raw. The outbreak had been going on in New York and New Jersey for two months and we were approaching fifty cases without a solid lead when two public health students, working as interns in our office, cracked the case. Interviewing cases is not a glamorous task, in fact it is downright monotonous. We employ a 17-page shotgun questionnaire to the approximate 1000 annual cases of Salmonella that occur in NYC annually in order to elicit suspect food items. To accomplish this task we have a team of MPH students dial the cases and beg their indulgence as we plunge into the twenty-minute interview. The students make the calls one aisle over from my cubicle, so I overhear them as they repeat the same questions to every case. Questions like “have you any eaten any stuffed, frozen chicken products, such as chicken Kiev or chicken Cordon Bleu?” So when two students, classmates and friends, shared the uncommon mention of chicken liver we had a new lead. Chicken and eggs are of course standard questions but we don’t usually ask about individual chicken parts, such as hearts and livers. The next day a third person mentioned chopped liver. We dispatched a food inspector to the store to retrieve the chicken livers. At the city’s Public Health Lab they were able to grow the same Salmonella species (serotype Heidelberg) from the cooked chicken livers. A week later the molecular results came back, a perfect match to the strain causing the outbreak. The chicken livers were recalled and outbreak was stopped.  Two new disease detectives earned their badges.

For more information:

http://www.nyc.gov/html/doh/html/pr2011/pr028-11.shtml

http://www.foodsafetynews.com/2011/11/cdc-157-salmonella-chicken-liver-cases-in-ny-nj/

http://www.cdc.gov/salmonella/heidelberg-chickenlivers/111011/index.html

OWS-using a hammer to put out a fire

This is a infectious disease blog, but I can't pass up an observation on current events.

The occupation of Wall Street got our attention, but now they are just pissing people off. They may have a few thousand protesters but there are 8.3 million people in NYC, and OWS is rapidly losing public support. When did this become a freedom of speech issue? A battle against the police? Every hour of police overtime is another city worker who will get laid off.  Is this the goal? To increase unemployment?  I thought greed was the enemy? Law enforcement should be an ally not an adversary. Does anyone believe that Bernie Madoff was the only crook on Wall Street? Don’t we want them investigating crooks instead of cleaning up the mess?

OWS get your heads out of the sixties. Regroup. Find a charismatic, well spoken, respected leader. Develop an agenda. Make a list of action items. Having people pull their money out of big banks in favor of credit unions was a good one. How about organizing a no stock trade week? Use the Internet, social media. Be creative. That will get Wall Street’s attention. They make money on every trade whether we do or not. Right now they are sitting up in their towers laughing at your foolishness. Hit them where it hurts, in their fat wallets. March to Washington to change legislation, but stay off the Brooklyn Bridge. Don’t litter.  Right now we the general public view OWS like a toddler throwing a tantrum. We hear you crying and see you misbehaving but we don’t know what you want. Use your big boy voice.

Inhalation Anthrax in NYC-Fall 2001 (Part 5 of 5)

Relieved, as we were, that no anthrax spores had been found in the NYC subways and that in the several weeks that had passed no new anthrax cases arose, it wasn’t the end to the spore story. The fifth and final death, the last of the 2001 mail murders, was perhaps the most perplexing. It occurred in a most unlikely setting: Oxford, a small rural town in southwestern Connecticut. With a population of just under 10,000 Oxford is far from major highways and cities. It boasts two banks, a beautiful public golf course and an annual crime rate of zero.

Retired legal secretary Ms. Ottilie Lundgren was a homebody. At 94-years old her mind was still sharp but she preferred the comforts and familiarity of her routine.  She didn’t drive or prepare her own meals and other than her family and a few trick or treaters her only visitor in the preceding months was her local pastor. On November 14^th she began to feel ill with fever and fatigue. When shortness of breath began two days later she was taken to a local area hospital and admitted. She had been a smoker and was known to have lung disease as a result. Pneumonia in nonagenarians is not uncommon. The next day four samples of her blood were growing bacteria, the gram-positive rod variety, and after only 14 hours. Bacillus anthracis was confirmed and a match to the other 21 cases. She died on November 21^st.

State and local health department staff along with CDC, EPA and law enforcement descended on the small town. They interviewed family, neighbors, postal workers and too samples. As we had done for Kathy Nguyen, they reconstructed her movements in the last two months. They turned out to be few. She went to church weekly, occasionally to a local favorite restaurant, a hair salon and doctor visits. Tests for anthrax spores at her home were negative, just like Kathy Nguyen. We met with Jim Hadler and his team to compare notes: both women lived alone and wore hats, other than this we could find no similarity other than their choice of perfume. The bottle tested negative.

We had checked USPS records to see if any letters that had passed though the contaminated postal sorting were routed to Kathy Nguyen. None were and her local Bronx post office tested negative for spores. Public health officials in Connecticut did the same, and likewise found nothing. They tested 29 pieces of mail found in her home, again nothing. They again tried testing the postal distribution center in Wallingford, again negative.

Four miles away, in the neighboring town of Seymour, Connecticut, a family was following the story with much trepidation. Then came a knock at their door. The visitors were from the State Health Department, CDC and the FBI.  A letter, sorted in Trenton on October 9^th just fifteen seconds after the contaminated letter to Senator Leahy and on the same machine had been sent to their address. The epidemiologist asked if by chance did they still had the letter and envelope? They did. The outside surface turned out to be positive for anthrax spores while the inside was not. With this information epidemiologists returned twice more to the Wallingford Postal Center and swabbed and vacuumed again.  This time four of the sorting machines returned hot with spores.

Mrs. Lundgren opened her own mail. Junk mail she tore in half before tossing into the trash.  CDC postulated that letters that had passed through the contaminated postal sorting machines in Trenton after the Leahy and Daschle letters had subsequently contaminated other sorting machines in other towns, including Wallingford. A letter, perhaps a bill or greeting card, passing though a secondarily contaminated sorting machine had picked up enough spores to infect Mrs. Lundgren. So, what did this mean about the minimal dose of spores necessary to cause infection previously believed to be in the thousands? The range of incubation period for inhalation anthrax was believed to be as long as sixty days, but if only a few spores were necessary could this be even longer? Were there still others incubating a deadly disease? How could we identify people at risk? Anyone over sixty-one? Was the mail safe? Only time would tell.

Inhalation Anthrax in NYC-Fall 2001 (Part 4)

No one wanted to say it out loud. The implications were too frightening. We were pretty confident that there wasn’t a release of anthrax spores other than when media staff opened the envelopes, but that alone wasn’t going to dissolve the city’s anxiety. As the November days passed and we had no explanation for the Kathy Nguyen inhalation case we faced the inevitable. We had to eliminate one very public place as the source, we had to test the NYC subway system.

None of us believed that the NYC subway was presenting a risk to anyone. If there had been a release underground we would’ve been dealing with many inhalation cases, not one. We had a pretty good idea though that spores could be tracked from their original location and the technology to find them was sophisticated. Staff from ABC, NBC, CBS or the NY Post could’ve tracked spores on the soles of their shoes anywhere. Despite our confidence that there weren’t legions of straphangers out there incubating inhalation anthrax we worried about positive results, even a single spore. We certainly couldn’t close the subways but it would be tough public message to craft. There are anthrax spores in the NYC Subway system, but it is safe to ride. I envisioned a TV crew taping Dan Rather and the Mayor sharing a pole on a downtown 6 train to make the point.

NYPD did the sampling with CDC and us directing them. Six train lines were tested at ten stations, over 200 samples. None were positive. While we breathed a collective sigh of relief, one final, tragic case was incubating the disease. A case as mysterious as Kathy Nguyen’s but one that would finally yield some answers.

Inhalation Anthrax in NYC-Fall 2001 (Part 3)

If you pay for a monthly Metrocard with a debit or credit card it creates a record of the location of each swipe. Along with interviews of Ms. Nguyen’s close associates, her phone records, and credit cards bills we were able to reconstruct the last two weeks of her life to try and discern how she became exposed to anthrax spores. Our concern was palpable; were other New Yorkers incubating the disease or being exposed?

Her favorite stores and the businesses along her commute route for which a charge or receipt was found were visited.  Armed with a photo epidemiologists questioned merchants. Few recognized her and no illnesses consistent with anthrax were uncovered. Ms. Nguyen was a religious woman and her co-workers had provided a list of churches she might have visited.  The pastors were cordial, however, nothing turned up.

Everywhere we knew a letter had landed we found spores. Aside from Ms. Nguyen we could place each case in the vicinity of spores.  It was some relief that in the week after her death no new cases had arisen, but what was different about Ms. Nguyen? The strain of anthrax was the same. Her work place, home and mail were all clean. So, what was the exposure? There was one place left in NYC we hadn’t yet looked.