Case 344: Amerithrax

**SPEAKER_1** (0:13)
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Retirement didn't suit 63-year-old photojournalist Robert Stevens. He lasted just six months before Boredom drove him back to his beloved former job as a photo editor at the Sun-Tabloid newspaper. By October 2001, Robert was settling back into the routine at the paper's editorial headquarters in Boca Raton, Florida, when he was struck down by a persistent illness. Suffering from fever, chills, nausea, vomiting, and intense muscle aches, Robert assumed he had come down with a particularly severe strain of the flu. But as his condition rapidly worsened, he was taken to hospital. By then, he had become incoherent and delirious, and a seizure soon left him in a coma. Doctors carried out urgent tests, including an examination of Robert's spinal fluid. The normally clear liquid had turned cloudy with white blood cells, a sign that his body was fighting a serious infection. Under a microscope, the cores appeared as clusters of rod-shaped bacteria, almost worm-like in form. Their presence left medical staff stunned.
Anthrax is an infectious disease caused by bacteria typically found in the blood of grazing animals. When infected animals die and decompose, the bacteria are released as toxic spores that are invisible to the naked eye and can contaminate soil, plants and water. Outside a host, these spores are metabolically inactive, essentially dormant, which makes them extraordinarily resilient. They can withstand extreme environmental conditions and remain viable for decades. But once inside a warm, nutrient-rich environment such as the human body, they activate into germinating bacteria and begin to multiply. Although anthrax was not something the average person encountered in everyday life, Robert Stevens had clearly been exposed to it somewhere. As an avid outdoorsman, the possibilities seemed endless. He had recently fished by a lake, pulled weeds in his vegetable garden, cycled through a park with a friend, taken his granddaughter to the beach, and eaten steak at a restaurant. The weekend before he was hospitalized, Robert traveled to North Carolina with his wife and daughter. During a hike through Chimney Rock State Park, he took a detour that led him to a waterfall. Leaning over the clear, cool water, he cupped his hands and drank two mouthfuls. As doctors deliberated the source of Robert's infection, news of the highly unusual case reached the press. Experts were quick to reassure the public that the situation was under control. The threat was considered low because anthrax is not contagious and Robert's illness appeared to be an isolated incident. One of Robert's doctors said, There is no reason to believe at this juncture that this is anything other than a manifestation of a rare and obviously very serious illness that has found its way into the life of one individual.
But one epidemiologist wasn't so sure. His job was to analyse patterns, trends and data related to disease, using them to assess risk and anticipate what might come next. Naturally occurring anthrax had become exceedingly rare in developed countries after the widespread introduction of vaccines for both animals and humans half a century earlier. Historically, the highest risk regions in the United States were rural areas with large livestock populations and extensive grazing land, not densely populated coastal cities. Florida was not considered an endemic region, and nearly three decades had passed since the state's last known case. In recent years, anthrax infections were typically linked to industrial settings involving contaminated imported animal products such as wool, hides, hair or meat, not mountain streams, vegetable gardens or steak dinners. Most concerning of all, an x-ray revealed that Robert Stevens had swollen lymph nodes between his lungs and spine, a hallmark sign of inhalation anthrax. Inside the lungs are macrophages, specialized white blood cells that act as the body's first responders by patrolling the airways and destroying foreign particles and bacteria. When anthrax spores are inhaled, macrophages engulf them as they would any other pathogen. But unlike most microbes, anthrax spores can survive inside these cells. As part of their normal immune function, the macrophages travel to nearby lymph nodes, inadvertently carrying the spores with them. There, the spores germinate into active bacteria that enter the bloodstream and spread throughout the body. Their growth is rapid. What begins as a small number of bacteria can multiply into trillions within days. Early symptoms often resemble a mild respiratory illness, one of the disease's greatest clinical challenges, as it can easily go undetected. Meanwhile, the bacteria release toxins that damage tissue and disrupt vital bodily functions, attacking the body on multiple fronts and overwhelming its natural defences. If the exposure dose is low and antibiotics are administered promptly, patients can recover. But if the dose is high and treatment is delayed, the disease can progress with terrifying speed. By the late stages, anthrax bacteria can account for roughly 30% of the patient's blood weight. Nausea becomes violent, bloody vomiting. Swollen joints make even the slightest movement excruciating. The face becomes so inflamed it is almost unrecognisable. Bloody fluids squeeze the space between the brain and skull causing immense pain and delirium. The lungs, kidneys, and eventually heart begin to fail. Even with medical intervention it is almost impossible to treat inhalation anthrax once it reaches this stage. Such was the case for Robert Stevens. He was diagnosed with inhalation anthrax on Thursday October 4, 2001 He died the next day.