Outbreak by Robin Cook. Part one

“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 x 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 erradicated. 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.”

“How long has Dr. Richter been hospitalized?” asked Marissa.

“This is his fifth day. I think you should see the patients to have an idea of what we are dealing with.” Dr. Navarre stood up without waiting for Marissa’s response. She found she had to trot to keep up with him. They went through swinging doors and entered the hospital proper. Nervous as she was, Marissa could not help being impressed by the luxurious carpeting and almost hotellike decor.

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