© 1999 by European Society of Cardiology
Copyright © 1999, European Society of Cardiology
Wasting away. What a waste. Part 2
* Tel.: +1-573-882-8580; fax: +1-573-884-4691 weberkt{at}health.missouri.edu
Wednesday, July 3, 1996. On his ride over to Lloyd Benton's office early Wednesday morning, C.O. recapitulated information he had obtained Tuesday evening about the mysterious illness in Hawk Point (see Cardiovasc Res 1999;44:1–4). Five people had died, four during the first week of June. Four were adults, one a child, and four were residents, one a visitor to the area. At the same time, there was a gastrointestinal disorder that featured diarrhea without constitutional symptoms. One of the two men who died was a trucker visiting friends. The other was Doc Murphy, the town's practitioner for more than 30 years. Murphy's death occurred on June 22, when his car ran off the road. He had become confused after fishing in the Mark Twain National Wildlife Refuge. One woman who succumbed died in her sleep. She was being treated for heart failure when she developed diarrhea. C.O. knew little about the trucker, the other woman, and the child who died. Was this one or more illnesses? Did it have a common cause? A common source? Were homicides involved?
‘It's good to meet you, Chief Benton. I've heard a great many nice things about you from Cy Litwak, who sends his regards,’ said C.O. as he greeted the police chief of Quincy, Illinois.
‘Thank you for coming down from Chicago. We can use your help in solving our problem,’ replied a grim Benton, whose remarks were accentuated with a firm handshake. He offered C.O. a chair as he sat behind his modest desk and began to review the situation. C.O. took notes as the Chief went along, noting questions.
‘Let me share with you what I learned last night,’ said C.O. as he highlighted conversations with Al Synovitis and Mike Hunt at Mystic's Lounge.
‘This is important information,’ smiled Benton. ‘It sets the stage for our investigation.’
C.O. continued, ‘May I suggest we invite practitioner Dr. Brian Parsons, your town's veterinarian and pharmacist, and operator of the town's water facility in for interviews this morning?’
‘That would be Drs. Sam Adams, David McGraw and Mr. Frank Watkins,’ noted Benton.
‘I also prepared a list of questions which I hoped your office staff might raise with involved families during telephone interviews today, and if necessary, tomorrow,’ requested C.O. ‘They include: symptoms and duration of illness; pet ownership, in particular exposure to sick pets and/or farm animals; swimming in surface water such as swimming pools, lakes and rivers; sources of drinking water, types of liquids ingested and tap water equivalents such as powdered drinks like instant tea, lemonade, and reconstituted frozen juices; vacations out of and visitors into the area and the coincidence of illness; and children enrolled in day care centers and schools. And we'll need a map of Hancock County, complete with streets, highways, recreational water sites and the Refuge. We'll use it to address distribution of illness.’
‘Sounds great! You've been doin’ your homework, C.O. I'll have Betty set up the interviews right away and then have Betty and Marvin conduct the telephone calls. I really appreciate your help,’ said a grateful Benton. ‘We may get to the bottom of this after all and find out if foul play was involved.’
The rest of the morning was spent conducting on-site interviews at police headquarters. The first interview was with Dr. Parsons.
‘Thank you for joining us in this investigation. I know how busy you must be,’ noted C.O.
‘Pleased to help,’ responded Parsons. ‘I want to be of assistance. This mystery has me perplexed, and an outside opinion is most welcome.’
‘Well, let's address events beginning with Memorial Day, May 28,’ noted C.O.
‘That date does appear to coincide with the onset of diarrheal illness. It involved adults and children, but I had no way of knowing how many were affected. I had the week off, took my family to Chicago. Doc Murphy covered our practice. Our office received a limited number of phone calls about the problem. Fewer came by for evaluation and treatment. Those who did obviously were more severe cases, but even so, they appeared to have had a self-limited course, since few returned for further assessment. I brought along a list of persons Doc Murphy had seen and I knew had acute gastrointestinal illness since May 28, including their addresses and telephone numbers.’
‘What about those who died?’ asked C.O.
‘I first heard about Gertrude Synovitis’ diarrhea only days after her death, and only because her brother, Al, called me when he returned from Iowa. My office was alerted that Gertrude had died in her sleep on June 2, when she didn't answer the door to her neighbor for their daily morning chat. I knew she had heart failure and was on a loop diuretic, digoxin, and beta blocker. I presumed her death was related to her heart failure. An arrhythmia of some sort. Once Al called and told me about her diarrhea, I presumed hypokalemia could have been contributory. Another woman who died in early June had recently received a kidney transplant in St. Louis this past April. Had to be hospitalized for a marked diarrhea which appeared on May 30. And then there was Jake Barnes, a trucker from Indiana, who visited friends here over Memorial Day. He, too, had to be admitted for profound diarrhea. Told me he had been diagnosed with AIDS 6 months ago. Lost each of ’em to shock and electrolyte imbalance. I ran standard tests in each case. Ova and parasites. Bacterial pathogens. All were negative. Couldn't figure it out.’
‘How about sick children?’ continued C.O.
‘I did hospitalize a 7-year-old hemophiliac, initially as a precautionary measure. He'd broken his arm while playing at the lake on Memorial Day. Days later he developed severe diarrhea and died. I didn't know about all the kids with diarrhea at the day care center until Mike Hunt called me about his daughter, Katie. Once alerted, I became suspicious of a contaminant in the school's water supply. Called Frank Watkins, in charge of the town's water system, for any clues. He hadn't found any problems with the treated water that he analyzes every other day.’
‘And what about Doc Murphy and his automobile accident?’ asked an inquisitive C.O. ‘Any reason to suspect he committed suicide?’
‘None whatsoever. His accident occurred on June 22,’ responded Parsons. ‘In the days prior to his death, though, he seemed troubled, but didn't share his thoughts with me. I presumed he was suspicious of something that occurred while I was away in Chicago. But he was not one to draw conclusions until he had assembled all the facts. Doc Murphy was a dedicated and compassionate physician. He'd do anything for his patients. After Doc's death, I met his longtime friend, Joe Skinner. Joe told me Doc had acted strange and seemed confused after they went fishing over at Gregor's Creek.’
‘Did you notice anything strange at Doc's autopsy?’ asked C.O.
‘Only that he had sores on both legs, and of course there was the head trauma that I presumed caused his death. No evidence of significant coronary artery disease or acute coronary thrombosis.’
‘This may sound strange, but what about his shoes?’ asked C.O. ‘Any unusual markings?’
‘Now that you mention it, I did find an imprint of what seemed to be the brake pedal on the sole to his right shoe. As if he had applied the brake trying to avoid contact with the tree that caused his death.’
‘Chief Benton, do you have photographs of the accident site?’ asked C.O.
‘Yes, as a matter of fact, I do. I've got them here in my office,’ responded Benton as he reached into the file cabinet behind him. ‘Here we are.’ He handed the file over to C.O.
‘Looks like Doc Murphy's car had damage to the right taillight and right rear fender. It was a new car, as I understand. It seemed to have taken an unusual trajectory down the hill from the roadway, as if heading in the direction from which it had traveled,’ noted C.O.
‘That's right,’ said Benton. ‘Nothing but weeds and small shrubs on the way down the hill until he ran into the tree. Never could figure out why his car took the course it did.’
‘If I may, I'd like to leave this map of Hawk Point with you to target residences of those who took ill or died,’ requested C.O. ‘Perhaps there's a geographic clustering of cases for us to identify. I'll leave you with the map while I go next door to interview veterinarian, Dr. Sam Adams.’
‘Good morning, Sam,’ said C.O. as he extended his hand to this quiet and unassuming man waiting patiently for his interview. ‘I've just got a few questions pertaining to the mysterious illnesses that have fallen on Hawk Point over the last 4 to 6 weeks.’
‘Glad to help. Been practicin’ here for nearly 15 years and never heard of anything like it.’
‘What's going on with pets and livestock in the area? Anything unusual?’
‘Haven't heard of any sick dogs, cats, cattle, sheep or horses, if that's what you're thinkin’. I know most of the farmers raising livestock. We had a large hog farm start its operation 3 months ago. Located just north of town on the bluff overlooking Hawk Point. One of them industrial-type factory farms raisin’ more'n a thousand hogs to a barn. Three barns in all. They call it agribusiness. Raisin’ nearly as many hogs as we got people livin’ in Hawk Point. Them animals generate an awful lot of methane and liquid what-all. Their waste is collected in man-made lagoons on the farm. It's not like solid waste generated by cattle or sheep. But I've not received a call from the owner about his hogs takin’ sick. Pretty much keeps to himself. He promised me that he'd be careful, maintain quality control and call me with any problems. We sealed his promise with a handshake.’
‘Thanks, Sam. This has been most helpful,’ commented C.O. ‘I'd appreciate your staying around to help out this afternoon. I'd like for us to visit this hog farm, talk to the owner, and especially to determine if there've been any spills from these waste lagoons into waterways surrounding Hawk Point. What we might term migrating manure.’
Dr. David McGraw, the pharmacist in town, met C.O. with a smile. He was puzzled as to his role in the investigation. ‘How can I be helpful to you?’ he inquired.
‘Just a few questions regarding the sales of antidiarrheals at your pharmacy over the past 8 weeks,’ responded C.O.
‘There were brisk sales from late May until mid-June. Afraid we'd run out. Had to order an emergency supply from our local distributor. But things quieted down after that. Back to baseline, you might say.’
‘Any explanation for the increase in sales?’ asked C.O.
‘Not really. I had no way of knowing if adults and children were involved during this 3-week interval. It tends to be a problem people find embarrassing. Most don't discuss it in public. I thought maybe it had something to do with the opening of the lake for swimming over the Memorial Day weekend. But it's never happened to this extent before. My family and I live in Stetson, just next door to Hawk Point. My kids prefer swimming in a pool. Since there isn't one here, we used the public pool in Stetson. Went several times during the long, hot weekend, but none of us got sick. Lucky, I guess.’
‘Thanks, David. I'll be in touch if we need you for further questions.’
C.O. lastly met with Frank Watkins. ‘I appreciate your coming by on such short notice, and on a holiday weekend at that.’
‘Not a problem,’ responded Frank.
‘Have you noticed anything unusual about the town's water supply in recent months? Turbidity, for example?’ asked C.O.
‘We use two different artesian wells for Hawk Point's community water supply. An eastern one, located in Stetson, is purely an underground well. The other, in Hawk Point, is also underground, but is charged from surface water, particularly during a drought. After a heavy rainfall, our well water appears cloudy. Untreated water from either well is not usually tested, so I can't answer your question more specifically. Depending on their location, potable water is provided all households from these wells. Water is not filtered. However, it is gas chlorinated before distribution. Doc Murphy had called me not too long ago and asked similar questions.’
‘Did Doc Murphy indicate he was suspicious of something? Did he mention anything in particular?’
‘No. Not really.’
‘Frank, I'd appreciate it if you would accompany Chief Benton and me as we tour the area this afternoon looking for clues to the mystery.’
‘Happy to help.’
‘So how goes it?’ asked Chief Benton of C.O. and Frank. ‘Betty and Marvin have completed their phone interviews. Had success reaching everybody, since they stayed in town for this year's July 4th celebration. You're invited, C.O. We'll have a parade, softball games, hot dogs, apple pie and a dance at the VFW Hall.’
‘That's kind, but I'm due back in the office on Friday. I need to report to Cy Litwak on our findings. Brian, would you look over questionnaire findings, see if you can form an impression about the clinical expression of the illness?’
Brian Parsons eagerly reviewed the surveys, and soon thereafter he reported his impressions. ‘It appears symptoms were predominantly diarrhea and cramps, some nausea. A self-limiting illness lasting perhaps several weeks, most commonly 1 week. Began late May, with peak incidence in early June. No cases after June 16th. The occurrence of diarrhea seems related to total daily tap water intake. Swimming in our lake was strongly associated with the illness, but not rivers. And we have don't have a public pool in Hawk Point. Those away on vacation or out of town on business, such as Al Synovitis, were spared, while those visiting the area, like Jake Barnes, became infected. Children at Daisy Day Care were affected, but not those across town attending the Wonder World Center. The unfortunate who died were immunocompromised or on a loop diuretic, as in the case of Gertrude Synovitis, when diarrhea occurred. There doesn't seem to be an association with pet ownership or exposure to farm animals.’
‘Excellent distillation of the information, Brian,’ said C.O. ‘We now need to make a diagnosis.’
What is your diagnosis?
(To be continued)
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