150831 August 31, 2015

Legionnaire's Disease

and Other Outbreaks/Epidemics

Part 1

by John Drummond, MD

LHS '65

        The recent outbreak of Legionnaire's Disease in New York City prompted memories of various new infectious diseases that were unheard of when we were growing up.  My medical education evolved into the Internal Medicine subspecialty of Infectious Disease gradually:  four years of Pre-Med at Auburn, which was essentially a major in Chemistry and a minor in Physics, four years of med school at UAB, three years of Internal Medicine internship/residency at Grady Memorial Hospital, Emory and the Atlanta V.A., two years of Infectious Disease fellowship and a year on the Emory faculty as Chief Resident in Medicine at Grady.  A total of 14 consecutive years between LHS graduation in 1965 and opening a medical practice at Piedmont Hospital in Atlanta on August 1, 1979.  Traditionally, the better training programs paid the lowest salaries.  As an intern at Grady/Emory/Atlanta V.A. the salary was $9,120 for the year.  Since every 4th day medical interns on the inpatient services pulled a 36-hour shift,  appropriately referred to as "Long Call", one of my fellow interns calculated that we were making about $1.65/hour. 

         The academic year begins on July 1.  My first assignment was in the Medical Emergency Clinic, working the 12-hour night shift,  7PM-7AM;  from 11PM to 7AM there were only two interns and a junior resident.  The other intern was not an internal medicine guy, but in a "rotating ophthalmology" program, which meant he only spent four months out of twelve on the medical service.  Worse, he had come from McGill University in Canada, and had never before seen a gunshot wound or even a stabbing, which were part of the daily routine in Birmingham; so he was not much help, but I had to feel sorry for the poor guy.  About 2AM July 3rd, a young man about 20 years old burst through the ER door snarling and clawing, having convinced himself that he was a Werewolf (to his credit, there actually was a Full Moon that night).  It took six of us, including a couple of beefy security guards, to hold him down on a gurney so a nurse could pop him in the butt with a shot of Thorazine for his acute psychotic break.  Within minutes, he was not only calm, but asleep and almost purring like a kitten; but to be safe, we left him handcuffed to the gurney just in case the Thorazine wore off too soon.  The horrified Canadian intern just about passed out when he realized:  "OMG, I have another 362 days of this (stuff)!.  I don't think I'm gonna make it"  (he did). 

        I could tell enough Grady stories to fill a few chapters in Tommy's next book, but this story is really about outbreaks and epidemics of mysterious new diseases caused by microbes.  At The American Legion Convention in Philadelphia during August 1976, several attendees developed a strange type of pneumonia, in not just one lung but both, that did not respond to conventional antibiotics and therefore led to a high mortality (death) rate.   Usually we prove an infection is present by growing the bug in a culture, but all culture specimens, including lung tissue and blood, failed to reveal an infectious agent.  What the heck was going on?  Conspiracy theories abounded, including one that proposed the veterans were being poisoned by some late-onset anti-Vietnam War terrorist group;  but that did not explain why some citizens of Philly who merely walked down that front sidewalk, never actually entering the convention hotel, also developed pneumonia and died.  Typically pneumonia is a winter-time disease, often following a case of the flu; we in the Infectious Disease community often refer to winter as "Pneumonia Season."  But this was a summertime pneumonia, without any prodromal illness.  Of course the CDC was called in to investigate, sending officers of the EIS (Epidemic Intelligence Service) to interview victims and perform epidemiologic studies, trying desperately to cull together enough facts to figure out the cause, and following that, the cure.

        As an aside, if during the Vietnam years a young male doctor was lucky enough to be selected to join  the CDC for two years in the EIS, he was commissioned as the equivalent of a lieutenant in the Army, but spent the two years in The U.S. Public Health Service stateside instead of toting a rifle in the jungles of Southeast Asia.  Upon completion of the two-year commitment, he was said to have earned his "Yellow Beret."

        After several months of intense study, a microbiologist at the CDC was finally able to grow a tiny bacteria from lung tissue taken from patients with Legionnaire's pneumonia.  His last name was McCabe, and the bug officially entered the microbiology nomenclature as "Legionella mccabeii."   It was found to be sensitive to an old dinosaur of an antibiotic, Erythromycin, so we finally had a bullet for this lung infection.  It thrives in a moist environment, including soil.  The bug had collected in the condensed water under the Philadelphia hotel's air-conditioning unit, located on the hotel's roof.  So that people entering and leaving, or strolling down the sidewalk in front of the hotel, were walking through an invisible fog of airborne bacteria, inhaling the bug which led to an often-fatal pneumonia.  A similar scenario of contaminated air-conditioning units on the roof was again determined to have caused the recent New York City outbreak.

(CONTINUED NEXT WEEK)