TESTING MAY NOT DETECT ANTHRAX
17 Jun 2003
Source: Baltimore Sun, January 9, 2002.
Testing may not detect anthrax
Doctors blame spores for postal inspector's mysterious illness; No other 'valid explanation'
By Scott Shane, Sun Staff
A 37-year-old Maryland postal inspector who handled anthrax-contaminated air filters at Washington's Brentwood mail-sorting center in October has been severely ill ever since with symptoms resembling those of inhalation anthrax, including fever and chest pain.
But because medical tests have never detected anthrax bacteria or antibodies in his blood, the federal Centers for Disease Control and Prevention has declined to classify his illness as anthrax.
Nevertheless, the doctors who have cared for him at Sinai Hospital in Baltimore for more than two months say in a medical journal article to be published today that they believe anthrax spores he inhaled 12 weeks ago are to blame for his illness.
The mysterious case of William R. Paliscak Jr. raises the troubling possibility that officials may not have fully recognized the extent of the wave of anthrax cases linked to letters sent last fall by an unidentified bioterrorist.
Officially, the CDC has recorded 18 confirmed anthrax cases: Seven people have suffered skin infections, and 11 people were stricken with the far more serious inhaled form - five of whom died.
Two postal workers who died, as well as two others who have recovered, contracted inhalation anthrax after working in the same area of the Brentwood facility where Paliscak removed the air filters. All five men were near a sorting machine through which an infected letter passed on its way to the office of Senate Majority Leader Tom Daschle.
Paliscak's illness may show that for reasons medical experts do not understand, some people infected with inhalation anthrax do not test positive for the disease. That could mean other cases of flu-like symptoms among postal workers and others exposed to anthrax spores were caused by the disease but never identified as such because blood tests for the bacteria were negative.
"We strongly believe that there is a relation between the patient's exposure to anthrax and the symptoms displayed," Paliscak's doctors write in The Journal of the American Osteopathic Association. The article's lead author is Dr. Tyler C. Cymet, an osteopathic physician who heads family medicine at Sinai. (Osteopathic doctors are fully licensed physicians who have additional training in a theory of medicine that suggests how injuries or illnesses in one part of the body can affect other parts.)
While calling Paliscak's case "a suspected case of anthrax where a diagnosis is not definite," Cymet and his co-authors, Drs. Gary J. Kerkvliet, Judy H. Tan and Jeremy D. Gradon, write in the JAOA that his symptoms "do not have any other valid explanation - despite extensive inpatient work-up."
Cymet said he and his colleagues decided to publish the article to see whether other doctors have encountered similar cases. "Our agenda is to find out if there's anyone out there with similar symptoms," he said.
Neither the article nor the doctors used Paliscak's name, but other sources and family members confirmed that he was the patient.
If the cause of Paliscak's illness has not been settled, its severity is not in doubt. He has spent most of his time since late October as a patient at Sinai and has not recovered sufficiently to return to work.
His doctors believe that he may finally be getting better. He was discharged from Sinai on Friday and is recuperating at his home in Edgewater, near Annapolis. Yesterday, he was still on intravenous antibiotics and was too weak to speak to a reporter, his family said.
"It's been beyond an ordeal," said his wife, Allison, who works as director of medical records at Sinai. "The good part is, unlike a lot of other people, he's still alive."
Kathy Harben, a CDC spokeswoman, said she could not comment on any particular case of suspected anthrax. But she noted that the CDC's strict case definition requires either a positive culture for anthrax bacteria or - because early antibiotic treatment can kill all bacteria while leaving deadly anthrax toxin - at least two other laboratory tests indicating anthrax infection.
"Public health officials, including those at CDC, have been learning as the investigation has gone on," Harben said. "We have investigated a lot of exposures at Brentwood. ... We're open to any new information. Based on this report [in the JAOA] I'm sure people will be looking at this case."
Paliscak's usual assignment with the Postal Inspection Service, the law enforcement arm of the Postal Service, was to investigate crimes committed by postal employees, said spokesman Dan Mihalko. Paliscak was based at Brentwood, a huge sorting center in Northeast Washington.
Mihalko called Paliscak "a very hard worker and a real good postal inspector" and expressed sympathy for his illness. But he said that in the absence of the CDC confirming his case as anthrax, the Postal Inspection Service cannot do so.
"There's no attempt to hide this," he said.
One person familiar with the case said that the absence of an official anthrax finding has kept the lengthy illness from being designated as work-related. As a result, Paliscak has had to use sick leave, which will run out if he does not return to work soon.
After the anthrax-laced letter addressed to Daschle was opened Oct. 15, postal officials began to try to track its path through the machinery. Because of his familiarity with the layout of machines at Brentwood, Paliscak was one of a team of postal inspectors and contractors who worked in the area over the next few days, Mihalko said.
Based on medical advice from the CDC, the workers wore gloves and paper face masks to protect themselves.
"With the information we had from medical experts at the time, we were comfortable telling people to wear gloves and a mask," Mihalko said. "Since then we've obviously learned a lot more" about the danger posed by lingering spores.
At least one air filter removed by Paliscak and others was subsequently found to be contaminated with anthrax, Mihalko said. In addition, the JAOA article says, Paliscak examined a machine later found to be contaminated.
Three days after his exposure, Paliscak, like other Brentwood workers, was given a 10-day supply of ciprofloxacin, or Cipro, an antibiotic widely used to prevent or treat anthrax infection. He took the pills for one day but then missed two doses, the article says.
By then he had a headache and a cough, soon accompanied by a fever, chills, aches and malaise, the article states. When incapacitating chest pain developed, he was admitted to Sinai, where a chest X-ray suggested the possibility of a widened mediastinum, part of the chest cavity, which is one of the definitive clues in diagnosing anthrax.
In addition, tests showed a very low level of oxygen in the blood, a condition commonly produced by lung infections.
When his condition improved, he was discharged. But the symptoms soon returned and grew worse, and he had to be readmitted to the hospital.
Medical knowledge of inhalation anthrax and its treatment has been limited until the current cases because the disease is very rare in the United States. But doctors say antibiotic treatment can wipe out the bacteria, leading to negative blood tests.
In one case of a microbiologist accidentally exposed to anthrax in 1951 while working on biological weapons at Fort Detrick, an Army medical report states that the bacteria were not found in his blood or other tissues, although anthrax-like bacteria were discovered in brain tissue in an autopsy.