A Most Exotic Cough Washington Post

[Guest guest]

" To this day, neither the 57-year-old lawyer for the _Department of Health

and Human Services_

(http://www.washingtonpost.com/ac2/related/topic/U.S.+Department+of+Health+and+H\

uman+Services?tid=informline) nor her physicians know

how she came to be infected. "

Medical Mysteries

A Most Exotic Cough

Symptoms That Went From Bad to Worse Could Have Been Fatal

_Discussion Policy_ (javascript:void(0)

By _ G. Boodman_

(http://projects.washingtonpost.com/staff/email/sandra+g.+boodman/)

Washington Post Staff Writer

Tuesday, February 5, 2008; Page HE01

Vicki Schulkin's cough was driving her crazy. Every time she caught a cold or

her allergies flared, so would the wracking, phlegmy paroxysms that had

waxed and waned for nearly four years.

Diagnosed with mild asthma when she turned 40, Schulkin, who has never

smoked, was frustrated, and her doctors were puzzled. Ratcheting up her asthma

medications didn't help. And antibiotics never seemed to knock out infections

that might be causing a cough.

On a family trip to _Hawaii_

(http://www.washingtonpost.com/ac2/related/topic/Hawaii?tid=informline) several

years ago, the _Arlington_

(http://www.washingtonpost.com/ac2/related/topic/Arlington?tid=informline)

lawyer realized her

problem was more serious than just an incessant cough. Always a strong

swimmer, the exertion of a short fast swim in deep water left Schulkin so

breathless " I came as close to drowning as I've ever been, " she recalls.

Schulkin says

her memory of frantically signaling a nearby boat to pick her up remains

vivid.

Years later, Schulkin would learn that the cause of her persistent cough was

not worsening asthma, chronic sinus infections or something more ominous but

not uncommon, like lung cancer or tuberculosis. A diagnostic procedure

revealed the potentially lethal cause, a rodent-borne malady so exotic the

specialist who treated her had seen only one other case in 20 years -- and

never in a

patient like Schulkin.

To this day, neither the 57-year-old lawyer for the _Department of Health and

Human Services_

(http://www.washingtonpost.com/ac2/related/topic/U.S.+Department+of+Health+and+H\

uman+Services?tid=informline) nor her physicians know how

she came to be infected.

After the Hawaii trip, Schulkin began a series of visits to her family doctor

and her allergist, who ramped up her steroids and antibiotics thinking that

her asthma had gotten worse or that an underlying infection was to blame.

When that didn't work, their focus shifted to her allergies.

When new allergy medications failed to help, she had sinus surgery in the

belief that the cough might be the result of drainage problems.

" It was a fabulous cure for my chronic sinus infections, " Schulkin recalled,

" but it didn't help my lungs. " CT scans, chest X-rays and other tests

revealed nothing. But her family doctor and allergist were " in awe of the awful

breathing sounds I produced whenever I got a cold or allergies. "

In the meantime, Schulkin said, her quest for an answer receded in the face

of a serious crisis. Her husband was diagnosed with Stage IV colon cancer,

which required a year of grueling treatment. He is currently in remission.

" I just learned to live with it, " Schulkin said of her cough. " I thought,

'Well, this is the way I am.' "

By 2005, her health had deteriorated. She contracted one respiratory

infection after another, including a bout of double walking pneumonia, and felt

perpetually exhausted.

In May, her family physician sent her to a pulmonologist. He performed a

bronchoscopy, a test using a flexible scope threaded down a patient's throat and

into the lungs enabling a doctor to inspect the breathing passages and take

fluid and tissue samples for analysis.

The doctor suctioned " a lot of slimy gunk, " Schulkin remembered, which he

sent to the lab. Testing revealed mild bronchiectasis, a condition that

indicates destruction of the large airways and is caused by recurrent infection,

inflammation or cystic fibrosis. Schulkin tried using a device to loosen lung

secretions, but that didn't help.

Feeling worse, she returned to the pulmonologist.

Looking at her chart and the results of tests he had performed four months

earlier, the doctor announced, " Oh, you've grown a fungus, " Schulkin recalled.

Apparently, she said, no one had reviewed the lab report when it arrived

weeks earlier.

After an antifungal drug failed to clear up the cough, the pulmonologist

referred Schulkin to infectious disease specialist Buesing.

Buesing, who practices in Arlington, was impressed by two things: Schulkin's

cough was bad and getting worse, and the organism the lab found was anything

but ordinary -- and so implausible that her doctors suspected it was an

error.

The fungus had been identified as Pe nicillium marneffei, which is

classified as an emerging infectious disease by the _Centers for Disease Control

and

Prevention_

(http://www.washingtonpost.com/ac2/related/topic/Centers+for+Disease+Control+and\

+Prevention?tid=informline) . It causes an opportunistic lung

infection in patients with advanced AIDS or cancer whose immune systems are

already ravaged by disease. The fungus is common in _Vietnam_

(http://www.washingtonpost.com/ac2/related/topic/Vietnam?tid=informline) ,

_Thailand_

(http://www.washingtonpost.com/ac2/related/topic/Thailand?tid=informline) and

parts of

_China_ (http://www.washingtonpost.com/ac2/related/topic/China?tid=informline)

, where it is transmitted by bamboo rats that deposit infected feces in soil;

humans can become infected after inhaling the soil.

Schulkin had never been to _Southeast Asia_

(http://www.washingtonpost.com/ac2/related/topic/Southeast+Asia?tid=informline)

.. Her only trip to China was

in 1986. She did not have HIV, cancer or a weakened immune system. And she did

not spend time in rat-infested areas.

Buesing was surprised that Schulkin wasn't sicker: The fungus typically

causes severe lung damage in far less time. And if it gets into the bloodstream,

it can be fatal. " She was lucky, " Buesing said.

The specialist searched for other explanations: Schulkin was only an

occasional gardener, so she did not spend a lot of time around soil. Her teenage

children had no exotic animals or rats as pets -- only a domestic guinea pig and

a lizard.

" It was pretty unusual considering her background, but we see unusual

things, " Buesing said, noting that a second culture revealed the same fungus as

the

first. " She probably inhaled it from soil somewhere, but who knows? "

Schulkin says she is equally mystified.

Buesing prescribed itraconazole, a potent antifungal drug sold as Sporanox.

She told Schulkin to immediately stop using her steroid asthma inhaler. Along

with the antibiotics, steroids had provided a " playground " for the fungus,

the doctor told her.

If the diagnosis was accurate, Buesing said, improvement should begin after

about two weeks on the drug. At the two-week mark, Schulkin started to feel

better.

" I've been quite fine since then, " said Schulkin, who took the medication for

three months. Treatment had an additional benefit, she added.

" My toenail fungus cleared up. "

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