How Florida doctors diagnosed anthrax
Early Oct. 2, Robert Stevens was still a man with meningitis. He was awake when his wife led him into Lantana's JFK Medical Center's emergency room but deteriorating fast. Within five hours, he would be in a coma. Within four days, he would be dead.
Much sooner, a team of doctors began to consider the possibility the fast-moving germ consuming Stevens' body was something they had studied only in textbooks. Between moments of quiet horror and analytical amazement, they actually let themselves say the word aloud.
Anthrax.
They said it only once, afraid to spark a panic.
Last week, the leading players on Stevens' team of doctors — Dr. Larry Bush and Dr. Barry Abrams, infectious-disease specialists, and Dr. Randall Wolff, director of JFK Medical Center's emergency department — discussed the case, the bellwether for the nation's anthrax crisis.
It started when Stevens, 63, an outdoorsman and longtime photo editor at The Sun weekly tabloid, staggered through the doors of the Lantana hospital's ER at 2:15 a.m. Oct. 2, a Tuesday. He had returned from a four-day hiking trip cut short by sudden illness. He had been vomiting on the ride back from North Carolina, his wife said.
The emergency-room doctor scribbled a diagnosis common to fever and disorientation — bacterial meningitis — and put Stevens on antibiotics.
Nearly five hours later, Wolff walked into the ER to start his shift. He found Stevens convulsing just before he slipped into a coma. Wolff performed a spinal tap, looking for hints of meningitis. A sample of the fluid was cloudy when it should have been clear. Stevens' illness was indeed meningitis and caused by a bacterium.
Aggressive organism
But what kind of organism could be so aggressive?
A glance under the microscope of the spinal fluid gave the doctors pause.
The Gram stain, a dye used to identify various germs, revealed what looked like blue boxcars, rectangular and highly unusual.
Under a microscope, bacteria are usually red and rectangular, red and round or blue and round — but rarely blue and rectangular. It most likely meant one thing: bacillus, a family of bacteria that includes anthrax and about 50 other possibilities — all rare, but none as serious as anthrax.
"That was the start of some sort of sign that something wasn't right," Wolff said.
It was about 7:30 a.m.
Bush, at home in Wellington, Fla., was notified of Stevens' deteriorating health. By 8:15 a.m., he had examined the slide and was worried.
He turned to a microbiology technologist and voiced his fears for the first time: "This could be anthrax."
No case of respiratory anthrax had been seen in the United States since 1978.
But anthrax has been associated with bioterrorism. And since Sept. 11, reports were rife of suspected terrorists having lived in Palm Beach County, taking flying lessons and inquiring about crop-dusting planes.
"I thought, 'Anthrax, Lantana, terrorism; wow, that's weird,' " Bush said.
At 8:30 a.m., Bush and Wolff talked by phone with a microbiologist in Atlanta. Wolff remembers someone saying the "A-word" — once. Then they referred to the fearsome germ as "it."
"We were hesitant to mention the word because of all the implications," Wolff said. "I mentioned at the time that, considering the World Trade Center bombing, this bacillus is more likely to be anthrax than two weeks ago."
By 10:30 a.m., Bush called the hospital's regional lab in Fort Lauderdale, where the specimen had been sent, and spoke to microbiology director Anne Beall. Bush told Beall to "work toward or away from" anthrax without actually saying the word.
Searching for specific traits
The microbiologists studied the specimen for traits specific to anthrax: an inability to move, a protective capsule, a distinctive look when formed in a colony and an inability to break up blood cells.
Bush then called Dianne Aleman, chief nursing officer at JFK, and forced himself to say the word aloud for the second time.
"I think there's a potential case of anthrax in the ER," he said, asking her to expedite the critically ill Stevens' transfer to the intensive-care unit and to quell any rumors.
At 3 p.m., Beall called with the lab results. The bacterium did not move, it did not break up blood cells. It looked as if it could have been anthrax in a colony, but it wasn't clearly encapsulated.
That narrowed the possibilities from 50 to a half dozen, a number of them resistant to penicillin.
Doctors knew the bacillus in Stevens' spinal fluid was sensitive to penicillin. So is anthrax.
The field "was getting smaller and smaller," Bush said. "Other bacilli had been ruled out, but anthrax was still in the running."
It was enough for Bush to call Palm Beach County Health Director Jean Malecki. Stevens' specimen was sent to the state lab in Jacksonville for more testing.
Meanwhile, the doctors began to realize they were dealing with the first known case of respiratory anthrax not contracted from infected livestock or in a lab.
Bush thought about the hospital's location, across the street from the Lantana airport, where the suspected terrorists flew small planes.
"We were left with the final puzzle piece: If he had it, why?" wondered Abrams. "If you're going to say it's terrorism, why are there no other cases?"
In time, there would be. In time, they'd know.
At 4:30 p.m. Wednesday, Bush talked to the state lab and learned one of two tests was inconclusive. As the lab repeated the test, Abrams got a call from the Centers for Disease Control and Prevention (CDC).
"They were obviously cautiously suspicious," Abrams said, "but they weren't saying the A-word."
That hesitance ended by 8:20 a.m. Thursday, a day before Stevens died. A sophisticated nucleic-acid test confirmed the germ invading Stevens' body was anthrax.
Two hours later, the FBI and the state epidemiologist converged on JFK Medical Center.
An alert went out to all hospitals in South Florida to look for unexplained respiratory disease. Doctors at Cedars Medical Center in Miami zeroed in on Ernesto Blanco, a co-worker of Stevens', who had been diagnosed with pneumonia three days earlier.
Four days later, on Oct. 8, doctors confirmed an anthrax spore had been found in Blanco's nose. It would take another week before officials would confirm Blanco's respiratory illness was caused by anthrax.
Within days the germ had spread from Florida and New York to Washington, D.C., and beyond.