FLORIDA DOCTOR FOUND FIRST CLUE OF ANTHRAX
29 Nov 2002
Source: Atlanta Journal-Constitution, October 14, 2001.
Florida doctor found first clue of anthrax
By CHARLES SEABROOK, Atlanta Journal-Constitution Staff Writer
Atlantis, Fla. -- About 6:30 a.m. Oct. 2, Dr. Larry Bush, an infectious disease specialist at JFK Memorial Hospital in Atlantis, received a call saying his help was needed with a gravely ill patient who had just come into the emergency room.
The 63-year-old patient, Bob Stevens (case 5) of nearby Lantana, was confused, had a high fever and was vomiting. Doctors first thought Stevens had meningitis, but they were not sure. They were asking Bush to help them make a definitive diagnosis and recommend treatment.
A vial of spinal fluid was drawn from Stevens. When Bush saw the fluid, he found it "grossly cloudy" -- a sign of something other than meningitis.
"I realized then that we might have something very unusual here," he said.
It would be more unusual than anything he imagined. During the next 48 hours, Bush and his colleagues would doggedly pursue the source of Stevens' affliction.
The final diagnosis would be inhaled anthrax, a highly lethal but very rare malady that had not been seen in the United States since 1976. Only 18 known cases of the disease have been reported in the past 100 years.
The diagnosis would trigger the most intensive public health investigation ever carried out in Florida, one that would uncover two more cases (case 7, third not confirmed or suspected by CDC) of anthrax exposure. Disease detectives would work around the clock to find the source of the anthrax. At the same time, the FBI and other law enforcement officials would initiate their own investigation to determine if a crime had been committed or if the nation was seeing the first wave of a bioterrorism attack. All of that would be followed by the news Friday of a fourth anthrax case, this one at NBC News in New York where an assistant to anchorman Tom Brokaw (case 2) contracted the skin form of anthrax after opening an envelope containing a suspicious powder that was sent to her boss two weeks after the terrorist attacks.
Officials now say that if Bush and his colleagues had not been unduly diligent in pursuing the cause of Steven's illness, the anthrax outbreak that has riveted national attention during the past two weeks possibly would never have been detected. Doctors could have attributed Stevens' illness to some more common cause -- say, bacterial meningitis.
The morning of Oct. 2, anthrax was not on the radar screen of doctors treating Stevens, who was the director of photography for the supermarket tabloid the Sun in nearby Boca Raton.
Bush spoke with Stevens' wife, Maureen, who told him that they had spent the weekend in North Carolina visiting their daughter in the Charlotte area and hiking in some nearby outdoor tourist spots, including Chimney Rock.
On the ride back from North Carolina, Stevens complained of not feeling well. Right after they arrived at their home in Lantana, they went to sleep because of Stevens' ailment.
A few hours later, about 2 a.m. on Oct. 2, Stevens was acting strange -- he tried to dress to go to work and wandered confusedly about the house. He was running a high fever. His frightened wife got him into the car and quickly drove the short distance up Congress Avenue to JFK Memorial in Atlantis.
"Shortly after I got to the hospital, Mr. Stevens went into a coma, and I never got to speak to him," Bush said.
After interviewing Maureen Stevens, he turned his attention to the strange-looking spinal fluid. What he saw under the microscope puzzled him -- there were several "gram-positive" bacteria shaped like rods in the fluid. (Bacteria generally fall into two categories, gram-positive or gram-negative, depending on the color they turn after being stained with a special dye.)
From the shape, Bush realized quickly that the organisms probably were a species in the Bacillis genus, which includes more than 50 species of bacteria -- including Bacillis anthracis, or anthrax.
"When you see rod-shaped bacteria in the spinal fluid, you become particularly concerned," Bush said. "I was looking at these rod-shaped cells, trying by the process of elimination to determine what they could not be. I was thinking they could be listeria, but they didn't fit the pattern."
Then he realized that only a handful of rod-shaped bacteria fit the particular shape he was peering at under the microscope. That handful included anthrax.
It was then that he raised the nearly unthinkable possibility that anthrax might be at the root of Stevens' suffering. Bush was concerned, however, that by merely mentioning anthrax, he might cause undue alarm. "I didn't want the word anthrax to get out of this hospital until I was certain of what I had," he said.
Like the vast majority of medical people in the United States, the 49-year-old Bush had never seen a case of anthrax. He had learned about it as a student at the Medical College of Pennsylvania and later while working on an infectious disease fellowship at medical school.
Although concerned about creating a false panic over anthrax, Bush felt it his duty to call the hospital's pathologist, Dr. Norman Suddeth, and his medical partner Dr. Barry Abrams, and cautiously run his concern by them. They all agreed that some quick laboratory tests were needed.
They knew that anthrax has some distinguishing characteristics -- it is capable of moving spontaneously, it has a certain type of cap around its rod-shaped cell, it is sensitive to penicillin and it produces spores. The lab tests revealed that the orgamism in Stevens' spinal fluid fit the first three criteria.
And within five hours, the doctors had the bacterium growing in a culture dish. It produced spores.
Meanwhile, a quick but thorough search of the medical literature showed that Stevens' symptoms were classic signs of inhaled anthrax -- a flu-like ailment rapidly progressing to high fever and coma, swollen lymph nodes and expanded blood vessels.
It was now the afternoon of Wednesday, Oct. 3. Bush and his colleagues were still not certain Stevens' illness was anthrax. But they had seen enough for Bush to alert his friend Dr. Jean Malecki, director of the Palm Beach County Health Department.
"Jean was very, very concerned," Bush said. "And, though I didn't want to think it, the thought of bioterrorism did cross my mind."
The doctors then sent the samples of the bacteria via Federal Express to a state laboratory in Jacksonville, where an even more specific test was available for anthrax. A microbiologist there ran the test twice. He told Bush that one result definitely indicated anthrax, but the other was equivocal.
"I asked him, based on those results, would he be comfortable in saying officially that we had anthrax," Bush said. "He said, 'No,' but he said he would run the test again."
By this time, Malecki had alerted the U.S. Centers for Disease Control and Prevention in Atlanta, which dispatched a special courier to Jacksonville to pick up samples of the bacteria.
The next morning, Thursday, Oct. 4, the CDC and the Jacksonville lab separately reached the same conclusion: Bob Stevens was infected with inhaled anthrax.
Immediately, Malecki and the Florida Department of Health -- and the FBI and Florida law enforcment officials -- began an official investigation.
At 4 p.m. the next day -- Friday, Oct. 4 -- Stevens died, the first fatality of inhaled anthrax in the United States in 25 years.
That same day, the CDC dispatched a dozen of its renowned disease fighters to the West Palm Beach area via chartered plane. Stevens' home on quiet Massachusetts Avenue in Lantana, a neighborhood of modest bungalows where basketball courts stand on the edge of driveways, was cordoned off by yellow tape as investigators descended on the house to take hundreds of samples of soil, household items and anything else that might harbor anthrax.
Because the incubation period for anthrax is as long as 60 days, the investigators believed that Stevens was infected in Florida instead of North Carolina where he had just visited.
His family was put on antibiotic treatment to prevent anthrax, and neighbors watched nervously as officials came down their street, scooping up soil samples from their yards.
A particular concern was that Stevems' neighborhood is only a mile from the Lantana airport, where two of the terrorists involved in the Sept. 11 attacks took flight lessons. Also nearby were several landing strips where the attackers had inquired about renting cropdusters.
Health and law enforcement officials also went to the Boca Raton headquaters of American Media, where Stevens worked, to gather hundreds of samples to be tested for anthrax. American Media publishes the Sun as well as other leading tabloids, including the Tattler and, the Globe and the Star.
Also that Friday, Ernesto Blanco (case 7), a 73-year-old mailroom clerk in the American Media building, was admitted to Cedars Medical Center in Miami, suffering from a respiratory ailment and other problems. He lived in Miami and commuted to Boca Raton by train.
The next day he casually mentioned to a hospital employee that he worked in the same building as Stevens. Quickly, doctors ordered that a nasal swab be taken from Blanco. The sample was sent to CDC's lab.
Late on Sunday morning, the CDC had some more alarming news for Malecki -- the sample from Blanco's nose contained anthrax spores. There was no indication that Blanco was infected by anthrax, but the finding left little doubt that the American Media building was infested with the spores. Indeed, anthrax spores also were found on the office computer keyboard used by Stevens.
"We were very surprised and very concerned by this information," Malecki said.
It also raised the specter of a bioterrorism.
Now, Malecki had an urgent decision to make, one that would set off a flurry of media activity and command the attention of a jittery nation.
At 5 p.m., based on further evidence from the CDC, Malecki shut down the America Media building. The company's officials pledged full cooperation.
The FBI, with the help of Boca Raton police, evacuated employees -- including American Media owner David Pecker -- and began an around-the-clock guard.
Sunday night and early Monday morning, company supervisors and health department officials began calling American Media's 300 employees, telling them not to go to work. Instead, they were told to show up for testing at the county health department's annex in Delray Beach. Some were called as late as 2:30 a.m. Monday.
The CDC arranged to fly in antibiotics to give to the workers.
At 8 a.m. Monday, officials announced in a press conference that the hurried-up testing would be expanded to include anyone who had visited or worked in the building since Aug. 1.
By 10 a.m., a long line of worried people had formed at the Delray Beach clinic to undergo a nasal swab and receive a supply of the antibiotic Cipro to ward off anthrax. AMI employees also were asked to fill out a detailed questionnaire by the FBI.
Altogether, about 1,000 people were tested, some after waiting hours under a blazing sun.
On Wednesday came the next bombshell -- another American Media employee, Stephanie Dailey of Boynton Beach, had tested positive for anthrax exposure. Like Blanco, she was not infected, because the bacteria did not penetrate into her lungs.
Bush is now an interested observer. He says the experience in Florida has heightened anthrax awareness among doctors and medical centers around the country, and lives may be saved as a result.
He said: "It shows the need for vigilance and not be too hasty in ruling out something that may be rare."