WAIKOLOA, HAWAII — An infamous, deadly disease that killed a large portion of the population of Europe in medieval times can still make rare and disruptive appearances in the modern emergency department.
Speaking at a symposium on emergency medicine sponsored by Stanford University, Dr. Diku P. Mandavia recalled the case of a 30-year-old woman admitted to a special part of the emergency department where very ill patients were placed.
“She's intubated,” he recalled. “She's on three pressor agents. She's in frank sepsis. She's in shock. They're throwing the kitchen sink at her, as far as antibiotics—she's got four or five antibiotics. They still can't sort out what to do. Her chest and urine are clear. All the other suspects are clear.”
The woman had been in the emergency department for 10 hours before she came to his attention, explained Dr. Mandavia, attending staff physician at Cedars-Sinai Medical Center, Los Angeles. When he asked for the cause of the sepsis, a resident said that a deep abscess in the right axilla was suspected. The abscess had not yet been drained because of concerns about how deep it was, and that draining might cause injury.
Dr. Mandavia called for an axillary ultrasound to be done, after which he had the abscess drained and cultured.
“A lot of pus emerged,” he remembered. “After draining, the patient went to bed in the ICU. This all happened by 3 p.m., Wednesday afternoon. At about 10:30 p.m. on Friday night, I get a phone call at home, and it's from a faculty [member] who never calls me.”
The caller asked if he recalled the case of the septic woman whose abscess was drained; Dr Mandavia said he did.
“She said, 'Guess what? You've been exposed to the plague!'” he recalled.
“You may know nothing about the plague,” he said to his audience. “I knew nothing myself.” Dr. Mandavia started looking for information about it on the Internet, but “there's not a lot out there,” he commented. “It's not an everyday diagnosis.”
Dr. Mandavia called a couple of infectious disease experts who also didn't know much about it. Meanwhile, the hospital was in turmoil; the Centers for Disease Control and Prevention was involved, “and I'm an indexed case now,” he said.
Meanwhile, Dr. Mandavia learned a crucial piece of information: There's a critical difference between the bubonic plague and the highly contagious disease it can convert to, called the pneumonic plague.
“Thank God she had the bubonic plague because if she had had the pneumonic plague, I would have been dead in 24 hours,” Dr. Mandavia explained. “Everyone in the room would have been dead in 24 hours.”
How did the patient get the bubonic plague? “This was a patient who had very, very poor hygiene in the house, and there were dead rodents and fleas,” he explained.