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Could the disease be back?
The doctor’s voice over the phone was warm and reassuring. The patient, a 62-year-old man, had a chest CT earlier that day, and Dr. David Smith, his longtime P.C.P., was telling him that the radiologist saw a mass. It sounded bad, but it probably wasn’t cancer, Smith told him. “I didn’t want you to see the report and worry,” he added. The report said that the mass in his lungs looked like a neoplasm — the fancy word for tumor. But it went on to acknowledge that it could also just be left over from the really bad pneumonia the man had three months earlier.
And it had been a bad pneumonia. First he started coughing. Then he had trouble taking a deep breath. He burned with fever and had a stabbing pain in the upper right part of his back with every breath. He tried to tough it out with cough syrup and ibuprofen, but when it wasn’t getting better, his fiancée insisted that he call his doctor. The nurse who called him back sent him straight to Yale New Haven Hospital. A chest X-ray showed a large cloud of white and gray taking up most of the upper part of his right lung — pneumonia.
He was given antibiotics to treat a presumed bacterial infection, and by the next day he started to feel a little better. He was sent home to finish the five-day course. The fever went away, and then the back pain, but the cough lingered. Just taking a breath or talking could trigger a long bout of hacking so violent it left him breathless.
Chest X-rays repeated after one month and then two months looked better. The cloud shrank to a blob the size of a peanut. But when it was still there after three months, Smith ordered a chest CT. That was the report that Smith was calling his patient about. The patient listened quietly but was still worried. He already had cancer once, decades earlier, and the possibility that he could have it again scared him.
Samples to the C.D.C.
Smith knew his patient well and had already reached out to one of the lung-cancer experts at Yale New Haven Hospital to consult her on whether a biopsy was needed. She agreed with the radiologist: It was probably just left over from his pneumonia. Give it a couple of more months, she advised, and if the mass was still there, that’s when you’d do a biopsy.
A few weeks later, the cough finally went away, and the man felt quite well. Still, the possibility of lung cancer haunted him. He had never smoked, but he was a woodworker, a sculptor, and often eschewed the mask, even when exposed to airborne particles. As an artist, he sometimes felt that the mask was a barrier between him and his work.
When his doctor called after the second CT and told him that the mass in his chest had grown, the man felt a pang of real fear. The biopsy was uncomfortable but not painful. He lay on his back and a long needle was introduced between two ribs. Because of the medications he was given, he felt only an intense pressure. The results were a relief. It wasn’t cancer, they said. Instead, it looked like some kind of infection. A few of the samples showed strange-looking cellular organisms that no one seemed to be able to identify. The pathologist sent pictures of the tissue and the unrecognized organisms to the Centers for Disease Control and Prevention in search of a diagnosis.
Days later they sent back their answer. This was, they believed, a fungus called blastomyces. Had the patient been in the Ohio or Mississippi River Valleys recently? Or anywhere in the Midwest or South? Blasto, as it’s called familiarly, lives in the dirt there and few other places. If inhaled, it can cause a serious infection in the lungs called blastomycosis, which could be fatal if not treated. Smith immediately referred the patient to the infectious-disease team. The doctor on service that week was Dr. Marwan Mikheal Azar, who, as luck had it, was an expert in fungal diseases.
Azar had only recently finished his specialty training. He had done additional training in microbiology and examined the images that had been sent to the C.D.C. eagerly. After the first look, though, he wasn’t sure the C.D.C. had got it right. The fungi seen in the slides were too big to be blastomyces. Those were tiny organisms — less than one-tenth the diameter of a human hair. The organism shown in these pictures was big in comparison — maybe about the width of that human hair. Moreover, one of the cells had a recognizable pattern. It couldn’t be seen completely but looked like a sack filled with tiny beads.
That image suggested a very different fungus, one known as coccidioides. Like blastomyces, cocci (as it’s called) lives in dirt. But it is endemic to a region on the other side of the country — especially the Western desert of Arizona, California and Mexico. If inhaled, the organisms could end up in the lungs and cause a pneumonia called, variously, coccidioidomycosis or desert rheumatism or Valley fever. Each of the tiny beads Azar saw inside the organism was actually a baby fungus. When the beads grew large enough, the sack would rupture, releasing the offspring. Each bead would grow and develop tiny seeds of its own.
A Visit to a Dude Ranch
The patient was a slender, energetic man who looked younger than his 62 years, Azar noted when he met the man the following week. Informed by the results of the biopsy, the infectious-disease doctor asked the patient the same questions the C.D.C. raised about his recent travel. Had he been to the Midwest or the South in the past year or so? Maybe around the Mississippi or Ohio River Valleys?
He had, the patient replied, but not for decades. But, he added, he spent several days at a dude ranch in Arizona a few weeks before he got sick. The pneumonia had been awful, but he felt fine now. Azar felt a moment of satisfaction: He was in Arizona just before getting sick? This probably was coccidioidomycosis. And yet the C.D.C. thought it was blasto. Azar needed to be sure of what he was treating. Blastomycosis was a much more serious disease than coccidioidomycosis, requiring significantly longer treatment. He sent a sample of the tissue taken from the man’s lungs to the C.D.C. for genetic identification of the yeast. In the meantime, Azar started the man on an antifungal medication, itraconazole, that worked against both types of yeast.
It took weeks for the results to come back. But finally they had a definitive answer: It was cocci.
Relieved to be free of a possible cancer diagnosis, the patient jumped onto the internet to read up on Valley fever. It was all over Arizona. His sister-in-law reminded him later that there used to be a card about the disease in the rooms of the dude ranch they visited every year for the past 30-something years. He quickly found the Valley Fever Center for Excellence at the University of Arizona College of Medicine-Tucson, only a few miles from the dude ranch. It was set up to teach doctors and patients about the infection. Two-thirds of all patients with cocci got it right there in Arizona. These were the real experts in cocci, the patient told Azar. He should call them. Azar wasn’t sure what he could learn from these folks. But he did have some questions. So when the patient brought it up again, he called.
He had read the guidelines on the treatment of this disease — written, as it turned out, by the physician who led the Center for Excellence — and their recommendation was to stop treatment if the patient didn’t have symptoms. Could that be right? “I learned so much,” Azar acknowledged to the patient. Most important: The man didn’t need the medication. His body had already neutralized the bug.
It’s amazing, Azar told me, that something can be so ordinary in one part of the country and so rare every place else. If that patient had presented to the E.R. in Tucson, it’s more likely that they would have recognized what he had as Valley fever. If he had symptoms, they would have treated him; if he didn’t, they wouldn’t. But they certainly would not have ordered a biopsy. And they would have never thought for a moment that he had cancer.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write her at Lisa.Sandersmdnyt@gmail.com.