© 1999 by European Society of Cardiology
Copyright © 1999, European Society of Cardiology
Crimson scalenes in Indigo Apple
As was his custom, Theodore Conrad was at the kitchen stove eagerly preparing his favorite sauce for rigatoni: cream with basil and anchovies; cloves of roasted garlic, sliced on the long axis; and melted gorgonzola. As he stirred this concoction, he savored the bouquet and palate of one of his favorite Chilean wines, a 1995 merlot from the Casa Lapostolle vineyard in the Rapel Valley. As she looked up from the newspaper she was reading, Elizabeth noted that ‘Mississippi will be hosting the Splendors of Versailles exhibit this year. This follows on its 1996 selection to host the Palaces of St. Petersburg display’.
"How was Mississippi, home to author and Nobel laureate William Faulkner, selected?" asked Theodore.
"It appears the French government wanted 1 million dollars to refurnish two rooms at the Chateau de Versailles. The state legislature, eager to boost Mississippi tourism, agreed to pay."
"I wonder if it will be the Chambre de la Reine, Salle du Sacre, Galerie des Batailles, or the opposing Salons de la Paix and de la Guerre," remarked a smiling Theodore. "In any event," he added, "let me tell you about a conundrum that took place in Mississippi not too long ago".
It was August 5, 1993, another hot and humid summer Sunday in Indigo Apple, Mississippi. Magnolias, azaleas and camellias had long since stopped blooming in this isolated rural community located in the southwestern portion of the state. There were no antebellums, or pre Civil War mansions, in this town of 2000. At the Holy Memorial Church, 100 of its inhabitants had assembled for today’s worship service. Even the oppressive heat did not dissuade these devout churchgoers from their appointed mission with another one of preacher Larson’s inspiring sermons. He often addressed civil rights. Today’s session was entitled Let There Be Love. It focused on the need for compassion and understanding of one’s fellow man. Hand-held fans were aflutter as parishioners made a futile attempt to stave off the heat while nodding their heads in agreement with Larson’s pronouncements.
Seated front and center in the pew to Larson’s right was Matsie Bart. As a member of city council, Matsie felt it her civic duty to ‘tend her flock, to keep the faith.’ As she scanned nearby parishioners to ascertain their response to Larson’s prevailing theme, she shouted "Amen." For emphasis she added, "Amen, brother," and nodded her head in approval of Larson’s plea for peace amongst all men.
Seated next to Matsie was Chester Hydrant, the city’s part-time sheriff. As was his custom on Sundays, Chester was dressed in his starched police uniform. Only his holster and imposing revolver were missing. Even on his best day, Chester gave one the impression of a serial killer. Chester was also employed at Murdock’s, the town’s major food market, where he was responsible for the meat section. Butchering came easily to him.
In the pew to Larson’s left, dressed in their Sunday finest, were Billy Bob and Sue Ellen Smith with their 4-year-old daughter, Clementine. Billy Bob was a mail carrier at the post office, Sue Ellen a homemaker.
Immediately behind the Smiths and squirming to prevent paresthesias of their maximi were Billy Joe and Peggy Sue McAllister with their son, Michael, who enjoyed leaning over the pew to tug on Clementine’s pigtails. Billy Joe worked over at the paper mill not far from Natchez, while Peggy Sue was a librarian at the town’s elementary school.
"We must rise up against prejudice and bigotry," urged Larson. "One cannot judge a book by its cover. The color of a man’s skin, his religious preference, or the accent of his speech does not belie his substance, his integrity, his value to society. We should not be so mindless as to suggest that it is only in this part of the country or in the western world that cultured and civilized men can be found. We must not forsake our fellow man."
"Amen, brother!" chanted Matsie Bart and Chester Hydrant in unison.
As the faithful filed out of church, they had the chance to compliment Larson on his passionate rendering and to make small talk. Milling together outside the church provided socialization, a chance to keep abreast of happenings in Indigo Apple.
Murdock’s provided another opportunity. Sue Ellen was shopping there late Monday morning. She wished to find a roast for tonight’s dinner. As she approached the meat section, she saw Chester. He had just finished cleaning the butcher’s area and was now placing servings of cut beef in the refrigerated display area. As he did so, he repeatedly wiped his dripping nose with the back of his hand. A full wipe, to be sure, extending from wrist to knuckles of his right and then left hands. She winced at the thought of his nasal droplets spraying the meat. And his hands, she noted. They were so grungy looking. When had he last washed? Sue Ellen decided the Smith’s would have pasta for dinner tonight. She would also politely inquire from the manager when Chester was off duty so that she might coordinate her shopping accordingly.
Dr. Robert Foster was busy at work in his office Tuesday morning providing primary care for the people of all ages living in Indigo Apple. Nurse Hernandez, recently hired, guided him between examining rooms and provided a brief summary of each patient’s history and current purpose of today’s visitation. As she handed him a thick chart, she pointed her head in the direction of examining room C. "It’s Matsie Bart’s annual checkup. You’ll recall this 62-year-old woman had a cholecystectomy last May for her gallstones, when it was discovered she was a typhoid carrier. You gave her a 6-week course of ampicillin and probenecid."
"Good afternoon, Matsie," Dr. Foster said as he entered the room. "How are you today?" He found her seated on the examining table, hands crossed on her lap.
"Well, I’m fine," she said. Then lowering her voice she added, "but I’m concerned about all the new people that are moving into Indigo Apple. Many speak with an accent. Your new nurse, for example".
"Pardon me?" said a startled Foster. "You mean if someone doesn’t speak with a southern drawl, you don’t trust them?"
"You know what I mean," Matsie added, accentuating her remark with the wink of an eye. "They’re different, and there’s always the risk they’ll bring in some disease from Mexico." Foster was stunned. He was torn between speaking his mind to this typhoid carrier or being polite. He deferred making comment and opted to remain civil with a city elder. He provided the necessary health care.
It was Friday morning, August 10. Billy Bob had already left for work at the post office when Sue Ellen noticed he had not packed his lunch. Perhaps he planned to eat out today, she thought. If not, he’d have the chance to chow down tonight at Brady’s, a local restaurant. Brady’s featured family dining every Friday evening and the Smith’s and McAllister’s were regulars. Sue Ellen and Peggy Sue enjoyed coming together to chitchat while their husbands recounted sporting events.
Peggy Sue was at school on Friday preparing for the upcoming fall session. She had lost track of time. When she looked at her watch, she noted it was 4:46 pm. Time to leave. She still had to pick up Michael at the sitter’s, freshen up, and be down at Brady’s by 6:00 pm. Billy Joe would drive there directly from work. As she was rushing to leave school, she paused for a cool drink of water at the fountain. After a brief gulp, she stopped. Strange, she thought, the water tastes odd. Must be from inadequate use of the fountain over the summer.
The usual crowd had gathered at Brady’s, with all tables accounted for. There was laughter in the air. Seated at their usual table for two were Matsie and Chester. Matsie was sipping her glass of white wine, while Chester gulped swigs from his long-necked bottle of beer. Each were pontificating with Billy Bob and Billy Joe seated at a nearby large table. Arriving almost together were Sue Ellen and Peggy Sue with children in tow. Relieved to extricate themselves from this socially polite interaction, Billy Bob and Billy Joe sprang to their feet to provide for the children.
"Did you have lunch today, honey?" asked Sue Ellen.
’No, I was so busy sorting and delivering mail. There was a mass mailing from a company marketing its new and improved detergent. Around 2:00 pm I did find a few minutes to get several doughnuts over at the bakery. You know, the ones I like so much. The Bavarian Cremes. I sure am thirsty and hungry.’ Plates heaped high with steaming hot food were soon placed on all tables, together with pitchers of iced tea and lemonade. Billy Bob quickly quenched his thirst with a tall glass of iced tea and ravenously attacked the meal of roast beef with gravy, mashed potatoes and string beans. Assuaged, he rejoined his family and friends in social interchange.
Fifteen minutes later Billy Bob began to feel nauseous and sensed the oncoming rush of reverse peristalsis. He sprang to his feet and ran off to the restroom, where he vomited. Abdominal pains followed. "I must have eaten too fast," he thought. When he returned to the table he again was seized with nausea and could not control himself. He vomited on the floor. Embarrassed, he apologized and suggested it was "something I ate earlier today." Soon thereafter, Sue Ellen, Peggy Sue and Billy Joe were retching. Michael and Clementine followed in like manner. All complained of abdominal pains.
"It must be the food!" yelled Chester. "That damn cook, the immigrant Manuel Hernandez. He probably contaminated the food and now our community and its children are sick."
"Amen, brother!" shouted Matsie. "It must be his fault. He’s the husband of Foster’s new nurse from Mexico."
"I got a mind to take Manuel out back. There’s a big old oak tree there and we know what to do with him, don’t we?" shouted Chester, his neck crimson with rage. "He probably brought food poisoning to Indigo Apple. He could be a typhoid carrier." Matsie’s face and neck turned bright red with her private thoughts.
The manager pleaded for calm as several other people took ill. He immediately called Dr. Foster to relate the problem. Foster asked that all people at the restaurant report to the ER immediately. He would meet them there. By 9:00 pm the small hospital’s parking lot and its even smaller ER was packed with people. Fourteen people had taken ill. All complained of vomiting and abdominal pain. Some had diarrhea. It began within 15–45 minutes of their meal at Brady’s. Peak incidence was at 8:15 pm. Matsie and Chester, who had been spared, paced the ER, ranting and raving about food poisoning and not trusting ‘furriners.’ Foster and the nursing staff could not be distracted. They had to start IV fluids and dispense antiemetics.
"Well what is it, doctor?" questioned an angry Matsie as she confronted him between responsibilities. What caused this outbreak? It was food poisoning, right?"
"It’s that Manuel Hernandez, right?" shouted Chester. "I’ll call the lieutenant governor and have him deported."
"Well, it could be food poisoning," Foster stated, "but it doesn’t quite add up. It could as easily be something else. I need some time to sort things out." He would not allow himself to be deterred by these small minds.
"You doctors are all alike," grumbled Matsie.
"Yeah, a user unfriendly lot. Where are they when you need ’em?" added Chester.
Eight hours later, the worst was over. An exhausted Foster was preparing to discharge all those who had taken ill. "To remain hydrated, use only bottled water, juice and soft drinks," he instructed, then emphasized, "and no ice cubes." He then visited with the restaurant manager and Manuel.
"Doctor, I’m sorry for all this trouble," said the manager. "I’ve never been sick a day in my life, and the same is true for my wife," added a despondent Manuel. "My family back in Mexico have never been sick, either."
"I know how you both feel. Let’s review the events for today," said a sympathetic Foster. "We need to get to the bottom of this."
"Well," the manager began, "it was our usual and very popular Friday evening family dinner. We began preparations around 1:00 pm this afternoon. Manuel cooked the food. I primed the pumps for soda, lemonade, tea and ice. We both made sure there was a sufficient amount of glassware, silverware, dinner plates and paper napkins."
"I am always very careful with handling the food," added Manuel. "No sneezing, coughing or wiping a running nose. I always wear a hair net and wash my hands often, and always after using the washroom."
"Did either of you take ill? No. Did you eat the food you prepared?" asked Dr. Foster. Both nodded that they had. "Did either of you drink beverages you served?" Negative. They’d each had a draft beer around 5:00 pm, before the festivities began. Dr. Foster informed them that several other people did not take ill at the restaurant. "Si, yo comprendo," said an exasperated Manuel. "Sheriff Hydrant and Ms. Bart. The sheriff is a very angry man."
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"What did the sheriff and Ms. Bart have to eat and drink?" asked Dr. Foster. They’d eaten the same as everyone else. Ms. Bart had a glass of wine and the sheriff bottled beer. This was the last clue Foster had been searching for. Those who’d had water-based beverages, with or without ice, had taken ill. It had to be the water supply.
With but a few hours’ rest, Foster was on the telephone early Saturday morning. He spoke with the public water works department of Indigo Apple. The engineer who answered the phone indicated that similar reports of an acute illness had been coming in since late Friday afternoon among residents on a street on the north side of town, close to one of the water treatment plants. One of those who took ill was a town Alderman. He had suspected the tap water supply and even saved a sample. The engineer indicated he would immediately check the water treatment plant. There he discovered a 4% fluoride solution was being siphoned from the fluoride saturator tank into the ground reservoir. "It must have been the recently hired water system operator, Herschel Luer," the engineer reported. "Herschel’s had no formal training and lacks the basic understanding of the water treatment plant’s operation and how it empties into the stored reservoir."
Overfluoridation of the water system was therefore suspected. A water main flushing program was immediately begun that afternoon, purging water throughout Indigo Apple.
Sunday, August 12. The Office of Epidemiology of the Bureau of Preventive Health, Mississippi State Department of Health, was notified. The extent of the illness and its suspected causality were addressed in studies that began Monday morning.
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Site (restaurant) and community-based investigations would indicate that 34 persons ranging in age from 4 to 71 years who had consumed water-based and/or iced drinks at the restaurant had taken ill with nausea and vomiting between 6 and 9 pm on Friday, August 10. Between August 10 and 13, 20 of 60 odd households reported such an illness. Blood and urine samples demonstrated markedly elevated levels of fluoride, as did water samples obtained from the restaurant and the Alderman’s residence. The problem cleared after water system purging. It was felt the water treatment plant mishap had led to a bolus of fluoride gaining access to the town’s water supply. The heavy use of water at the restaurant on Friday made it most susceptible to high levels of this water-borne toxicant.
Hydrofluoric acid forms in the stomach after ingesting fluoride. This causes prompt nausea and vomiting without fever. Onset and the lack of constitutional symptoms distinguished this illness from bacterial infections such as Staphylococcus, Salmonella and Clostridia, which are known to cause gastroenteritis. Nausea may accompany ingestion of 5–9 mg of elemental fluoride. Water and ice samples at the restaurant and residence contained 48–200 mg/l and would have required that a person who drank as little as one-tenth to three-quarters (25 ml or 188 ml) of a glass of contaminated water would receive this requisite dose of fluoride.
On August 17, Foster reexamined those who had taken ill. He found complete recovery in all. He also visited with Chester Hydrant and then Matsie Bart. "I believe you owe Manuel Hernandez an apology. Should this not be possible, I and many other citizens of Indigo Apple will strongly recommend to city council that your employment be terminated. Let there be love in our hearts and a compassion for our fellow man. Crimson scalenes are not welcome in Indigo Apple."
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Other outbreaks of acute fluoride poisoning have been reported. Two involved elementary schools, where mishaps with their on-site fluoridator were responsible.
Between 1977 and 1985 endemic fluorosis occurred in the Ethiopian Rift Valley. Dental fluorosis was observed in many children residing in its villages and towns; a third had severe dental mottling. Skeletal fluorosis appeared in adults and was related to the fluoride concentration of drinking water in their community and duration of exposure (>10 yrs). Amongst those with crippling skeletal fluorosis, cerebral radiculo-myelopathy was the commonest neurologic complication.
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