Medical Mysteries: She couldn’t stop coughing. Were fragrances to blame?

Woman’s labored breathing was not caused by allergy, smoking or poor air quality

To Jean McCathern, it seemed that the barrage of allergies — to pollen, mold, dust mites and cats — arose out of nowhere. In 1980 McCathern, then a 24-year-old Air Force staff sergeant assigned to the National Emergency Airborne Command Post at Offutt Air Force Base near Omaha, began gasping for breath as she carried equipment onto an aircraft. Although McCathern had been in excellent physical condition, a doctor informed her a few weeks later that she had allergies and asthma, a diagnosis that remained unchanged for the next 24 years, even as her lung problems grew steadily worse. McCathern’s infirmities would cost her the career as a cryptographic repairman that she loved, lead her to part with her beloved cat and force her to give up one of her passions — attending hockey games — because the risk of illness from exposure to crowds was too great. It wasn’t until 2004 that a simple blood test identified the malady that had plagued her for more than two decades — and it wasn’t asthma or allergies. “It was a pretty big shock,” said McCathern, soon to be 56, who lives near Harrisburg, Pa. Knowing earlier what was wrong, she added, “might have made a difference with what I did with my life.” After her first allergist prescribed allergy shots, which didn’t help much, McCathern assumed that her intermittent respiratory problems were something she just had to get used to. In 1982, McCathern was deployed to Ankara, Turkey, where her health worsened. That was not surprising, since Turkey burned coal as a fuel source and many people were affected by air pollution. “In the winter, you’d cough up this black stuff,” she recalled. Doctors prescribed prednisone, a corticosteroid that reduces inflammation; it seemed to help. She continued to get allergy shots. In 1983, when she left Turkey for a Royal Air Force base near Cambridge, England, her health improved. Doctors there decided her problem was mostly seasonal allergies — pollen again — but she remembers that “it wasn’t something I had to worry about every day.” The good days outnumbered the bad in England and at her next assignment in Southern California. By the mid-’90s, when she was deployed to Cheyenne, Wyo., her asthma had worsened significantly. “Doctors told me I had to get rid of my cat or I wouldn’t be able to walk up the stairs when I was 40,” she recalled. Her allergist rebuffed her request for a methacholine challenge, a test used to help manage hard-to-control asthma or to rule out an asthma diagnosis. McCathern said the allergist told her the test was unnecessary because her diagnosis was not in doubt. Because parting with her cat now seemed a necessity, McCathern sadly gave her to her sister. Even so, her condition did not improve. From 1995 to 2002, McCathern lived in suburban Maryland and was attached to the presidential support unit at Andrews Air Force Base. Although catless, she suffered more-frequent and more-severe respiratory infections, and her allergist seemed at a loss. Too sick to take another overseas assignment — the Air Force wanted to send her back to Turkey — she retired on medical grounds after 25 years of service. It was a very difficult time, McCathern recalled, because she loved her job and wanted to continue working, but it was clear that her health had become too precarious. Largely because she had grown to loathe Washington traffic, McCathern decided to move back to central Pennsylvania, where she had been raised; she got an IT job with the state’s Transportation Department. But by 2003, she was battling pneumonia. Her new allergist, confounded by his inability to control her asthma and her repeated lung and sinus infections, prescribed more drugs. “I was sick all the time and couldn’t go six weeks without getting something,” she recalled. “The guy across the cubicle kept saying, ‘You need to see my wife’s pulmonologist,’ but I ignored him,” she said. In January 2004, she broke down and made an appointment. ****At her first visit, the pulmonologist ordered a blood test for a genetic disorder, just in case. “I really don’t think you have this,” she recalls him saying, “and you really don’t want to have it.” McCathern, who was contending with another bout of pneumonia, gave it little thought, returning a few weeks later for a follow-up appointment. She remembers that the doctor first glanced at her test result, then did a double take before telling McCathern that it was positive. He ordered it repeated, along with an additional test. Several weeks later, the results were in and they were definitive, upending a quarter-   century of repeated misdiagnosis. McCathern had an inherited disorder called alpha-1 antitrypsin deficiency, which can cause disabling and progressive lung and liver disease. She also learned that she had the most serious type — ZZ — which results from the inheritance of two damaged genes, one from each parent. She had never had asthma. “Everything stopped,” McCathern recalled. The pulmonologist told her she would need weekly infusions of an intravenous drug and, most likely, a lung transplant by the time she was 62. Her mother, a nurse, was appalled by the diagnosis and, McCathern said, initially called the doctor “a quack. I’d say she was in denial. It was a pretty big shock.” McCathern herself was ****“pretty upset.” She wondered why the many doctors she had seen over the years had never thought to test her for the disorder **.** First described in 1963, the condition is among the most common inherited disorders affecting Caucasians, usually those of Northern European descent, and is caused by the deficiency of a protein made in the liver that allows the lungs to function properly. About one in 2,500 Americans is ****believed to be affected, according to the National Human Genome Research Institute. Those who inherit one normal and one damaged gene are considered carriers and may live healthy lives, particularly if they do not smoke. Among the 100,000 Americans with the most severe form, studies have estimated that only about6 percent know they have the condition. Although infants can show symptoms, most “alphas” develop initial signs of the disease, often shortness of breath, between ages 20 and 50. There is no cure; treatment involves weekly infusions of intravenous medications including Prolastin, which replaces the missing protein. Some patients require lung transplants; others develop liver cancer or may need liver transplants. “Most doctors don’t even think about the diagnosis, unfortunately,” said allergist Timothy Craig, a professor of medicine and pediatrics at the Penn State Hershey Medical Center in Hershey, Pa., who has treated McCathern for the past five years. “That’s unfortunate, because the test is really easy.” Many physicians assume that a patient with breathing problems is suffering from asthma or chronic obstructive pulmonary disease, particularly if he or she smokes. McCathern says she never did. “Early diagnosis can make a _big_ difference in the outcome,” Craig said. “If you’re an alpha and you smoke, your chances of having serious lung disease vastly increase.” Craig notes that medical guidelines recommend that people with an asthma diagnosis who are not responding to treatment should be tested for alpha-1 deficiency. A methocholine challenge, the test McCathern sought in the mid-1990s, would probably have accelerated the diagnosis because it would have revealed that she did not have asthma. By the time McCathern received her diagnosis, she was battling emphysema and bronchiectasis, a condition that results from injury to the airways and impedes the ability to clear mucus. “Her lung disease is advanced,” Craig observed, “but not to the point that she can’t carry on a normal life.” McCathern began receiving weekly infusions of Prolastin almost immediately. Close relatives, including her daughter, were tested; some were found to have inherited one damaged gene, but, she said, “I’m the only one that has both.” For several years, McCathern has participated in studies of the disease. As a coordinator for AlphaNet, a national support group, she speaks with other patients, many of them new to the diagnosis. McCathern says she wishes she had known what was wrong much earlier, because treatment could have blunted the severity of her illness. “I could have been on medication in 1988, not 2004,” she said.“Just knowing that you have it, and taking the medication, can really make a difference.” But McCathern remains philosophical, because earlier diagnosis would have ended her satisfying military career sooner. “I did have all those years,” she said, “and that was kind of nice, too.”

‘Textbook’ of frightening coughing spells was not diagnosed immediately

Nancy Welch wasn’t taking any chances. For several weeks this summer, she walked around her house clutching her cellphone, prepared in case she again had to dial 911. The memory of her terrified 13-year-old son racing down the stairs of their Northern Virginia home unable to breathe remained uppermost in her mind. At night she slept on a blow-up mattress on the floor next to Joseph, the youngest of her three children, jolting awake whenever he gasped for breath and vomited sticky mucus, his lips briefly turning blue. Although her son quickly went back to sleep, Welch, 47, was rigidly alert. She wondered why specialists were unable to agree on a diagnosis, instead performing increasingly invasive and sometimes painful tests that seemed to lead nowhere. Welch’s growing unease was augmented by the feeling that she knew what was wrong — a suggestion doctors had either brushed aside or failed to pursue. “I’m just shocked that these pediatric specialists didn’t have it on their radar,” Welch said. “I’m thinking that if I hadn’t taken him to the ER, I still might not know.” On July 3, Welch took Joseph for his annual checkup. Other than a slight cough — his mother thought he was getting a cold — he seemed fine. But the pediatrician, who heard the cough, told Welch he suspected asthma and prescribed an inhaler. “I brought it home but didn’t consider using it,” Welch said. Joseph had never had asthma, and the cough seemed too minor to warrant medicine. Three mornings later, she was shocked to see Joseph run downstairs, bug-eyed with fear because he was unable to catch his breath. Welch dialed 911 and tried to calm her panicked son — and herself. Paramedics arrived within minutes; after Welch mentioned the newly prescribed inhaler, they helped Joseph take a few puffs and advised that he use it. Within minutes, he was breathing normally. Mother and son went back to the pediatrician that afternoon. The doctor, who reiterated his belief that Joseph had asthma, added two drugs to the medication regimen: a common antacid for reflux and azithromycin, an antibiotic to be taken for five days. “He didn’t say why he was prescribing them, and my first mistake was not to ask,” Welch said. This time, she had her son use all of the medicines the doctor prescribed. That night, Welch recalled, her son had two or three coughing episodes. “He’d jump out of bed, cough spasmodically for about 30 seconds, spit out some sticky mucus and go back to sleep.” Several days later, the pediatrician arranged for Joseph to see a pediatric pulmonologist. The lung specialist, whose office was an hour away from the family’s home — an ordeal because Joseph gets carsick — concurred with the probable asthma diagnosis. A chest X-ray and a lung function test were both normal. During that visit, Welch said, Joseph did not cough, although he tried to re- create the high-pitched wheezing, called stridor, which characterized his coughing episodes, as his mother described the sound. The pulmonologist added a second inhaled medicine and advised continuing with the anti-reflux medicine. But instead of improving, Joseph seemed to get steadily worse. Three days later, when he began having coughing and gasping episodes every half-hour or so, Welch called the pediatrician, who told her to take him to the emergency room of Inova Alexandria Hospital. At the hospital, Joseph, whose breathing problems had subsided, was seen by physician assistant Lynette Sandoval. A day earlier, Welch had recorded the sound of an episode on her cellphone, hoping it might provide a clue. After recounting the events of the past few days, Welch played the recording. Sandoval said she suspected a new possibility: To her, Joseph’s high-pitched cough sounded like whooping cough, also known as pertussis, even though she had never seen a case of the once common childhood disease in her 12-year career. “It was textbook in my mind,” Sandoval recalled. “The nocturnal, staccato cough, the desperate inspirations,” or attempts to inhale, and the fact that Joseph was largely normal between episodes all seemed to point to it, she said. But there was one factor that suggested otherwise: Joseph had been fully vaccinated against the disease, even receiving a booster shot when he was 11. Sandoval reported her suspicion to Welch and called the pulmonologist’s partner — Joseph’s doctor was out of the office that afternoon — to discuss his treatment. He concurred, she said, with her plan to order the swab for pertussis. Several hours later, the Welches left the ER. The following day, Welch said she played the cellphone audio for the original pulmonologist and asked whether he thought pertussis might be the problem. The specialist, she said, was adamant that it was not. He had seen pertussis in teenagers, she recalls him telling her, and “this doesn't sound like it.” He advised continuing the medicines he prescribed. He also arranged an appointment with a pediatric ear, nose and throat specialist after Welch asked about another potential cause: Might Joseph have unknowingly swallowed one of the rubber bands he uses with his braces? A few hours later, the ENT performed an endoscopy, threading a tiny camera down Joseph’s throat to check for anything that might be causing his cough and vomiting. Finding nothing, he recommended an evaluation by a speech pathologist in his office for possible vocal cord dysfunction. The speech pathologist quickly rejected that possibility, Welch said, because Joseph’s problem seemed mostly to occur at night, unlike vocal cord dysfunction. By now, his mother said, her son was having as many as 15 episodes in a 24-hour period. Doctors decided another test was in order: a bronchoscopy to inspect the inside of the lungs. The procedure, performed under general anesthesia the following week, left Welch shaken. “It was awful seeing him waking up from anesthesia, so disoriented with his throat so irritated. And we still didn’t have an answer,” she recalled, adding that the procedure found nothing to account for his symptoms. Welch had begun researching pertussis online and had become increasingly convinced that Sandoval’s suspicion was correct. Every day, she called the pediatrician’s office to check for the result of the pertussis test, which was inexplicably delayed. On July 23, the pediatrician called with the result Welch had anticipated: Joseph had whooping cough. Pertussis produces violent coughing that can make breathing difficult — coughing so violent that it can crack a rib. Some patients also vomit sticky mucus. The airborne disease, which is highly contagious, typically surfaces about two weeks after exposure to the _Bordetella pertussis_ bacterium. In teenagers, it can be difficult to diagnose because of its resemblance to other respiratory illnesses and because the telltale “whoop” after a cough may be absent. The disease is treated with antibiotics and usually lasts about six weeks, although the cough often lasts longer and is sometimes called “the 100-day cough.” In the past few years, the disease, which can be fatal to infants, has experienced a dramatic resurgence. Federal health officials say that this year is on track to be the worst in 50 years; so far, nearly 31,000 cases have been reported to the Centers for Disease Control and Prevention, almost three times the number for the same period last year. Last month, a study in the New England Journal of Medicine found that a vaccine introduced in the 1990s may be partly responsible for the resurgence. Researchers who studied a 2010-11 outbreak in California found that the effectiveness of the vaccine appears to wane significantly among children after they receive the fifth and final dose, usually by age 6. (A booster shot is recommended by CDC around age 11; in Joseph’s case, it is not clear whether the booster he received was sufficiently strong, his mother said.) Welch’s family was put on antibiotics immediately and was told to stay home and avoid other people for five days, in case they were carriers. Joseph, who had taken the five-day course of azithromycin prescribed by the pediatrician in early July, was given a second round of the drug as a precaution. Welch, who suspects her son might have contracted the disease at a high school graduation ceremony he attended about two weeks before he got sick, said she felt both vindicated and irritated. “I told my family, ‘Mom was right!’ ” she said, “but my first thought was ‘How did all these people miss it? Why didn’t the pediatrician swab him, instead of pushing asthma? Why did we have to go through all that wasted effort and putting my child under procedures he didn’t have to go through?’ If this had been an obscure childhood disease, I would have understood them missing it — but I’m shocked these pediatric specialists didn’t have it on their radar” since the surge in pertussis has been widely publicized in the past year. Welch said she was so grateful to Sandoval for listening to her that she called to thank her. But when she asked the lung doctor whether he would have done anything different, he told her no. Sandoval speculates that the diagnosis may have been missed because some of Joseph’s doctors did not hear his tortured breathing, as she did. “The recording was key,” she said, “because not everybody is going to use terminology in the same way to describe it.” And she speculated that some doctors may have been misled because Joseph had been fully vaccinated. Joseph is fully recovered, his mother said; his cough disappeared after 100 days. Looking back, Welch said she thinks she should have asked the pediatrician why he was prescribing an antibiotic and sought the guidance of an infectious-disease specialist before agreeing to invasive and expensive tests. Mostly, she said, she remains puzzled. “Why, with whooping cough making a resurgence, wasn’t it given any serious consideration?”

Breathlessness has many causes, and they’re not all connected to disease

Marvin M. Lipman, Consumer Reports’ chief medical adviser, had a longtime friend, age 82, who was always known to be in excellent health. But she complained that, for the past few weeks, she had had trouble breathing. She was fine at rest but became short of breath with the least exertion. Normally, she could climb several flights of stairs with ease. Now, she could barely negotiate one flight — one step at a time — and became breathless after just a minute of walking. She said she had no associated symptoms, such as fever, chest pain, cough, leg swelling or wheezing. She hadn’t smoked since her college days. Her exam, chest X-ray and routine lab tests were normal. Seeing, smelling, swallowing, walking and even digesting are activities that we don’t think much about until a cataract, cold, strep throat, arthritic knee or heartburn intervenes. Then, what was taken for granted suddenly becomes a focus of attention. Breathing is one such unconscious activity. Most of us do it automatically at least 20,000 times a day. Its purpose is to supply the body with oxygen and rid it of carbon dioxide. If anything interferes with that exchange of gases, causing a deficit of oxygen or a surplus of carbon dioxide, the breathing rate will automatically increase to compensate. You perceive that as shortness of breath or, in medicalese, dyspnea. The mechanics of normal breathing involve not only the heart and lungs but also the muscles of the chest wall and the nervous system, so the causes of dyspnea are many. Nevertheless, with proper evaluation, the diagnosis is apparent about two-thirds of the time. Risk factors such as smoking, chronic exposure to irritating chemicals or the use of certain medications, notably beta blockers (such as atenolol or metoprolol), can be important clues. Signs and symptoms such as cough, bloody or colored sputum, wheezing, chills, fever, chest pain, ankle swelling and heartburn are giveaways for diagnoses such as pneumonia, asthma, pulmonary embolism, heart failure and acid reflux. Anemia, a deficiency of oxygen-carrying red blood cells, also commonly produces dyspnea on exertion. But not all shortness of breath is caused by disease. When we exercise, our muscles require more oxygen than they do when we are at rest. Therefore, our breathing rate increases and our heart beats faster to satisfy that need. Visitors to high altitudes, where the oxygen content of the air is lower than what they’re used to, often find breathing difficult. People who live in such regions become acclimated when their red-blood-cell count increases, thereby improving their body’s oxygen content. And what pregnant woman hasn’t complained of shortness of breath from respiratory stress caused by her swollen belly and increased weight? Chronic anxiety can produce a type of air hunger characterized by “sighing respirations,” often described as being “unable to get on top of a breath.” This differs from the hyperventilation episodes that are more likely to be associated with acute anxiety and that result in intense tingling of the extremities, faintness and, occasionally, loss of consciousness. Lipman’s friend’s shortness of breath on exertion was a puzzle — until he asked her to walk around his office building and checked her oxygen level and pulse rate before and after that mild exercise. Imagine his surprise when her pulse rate dropped instead of increasing, as expected. An electrocardiogram showed that with exercise, each electrical impulse, initiated in an upper heart chamber, had an increasingly difficult time activating the lower heart chambers to cause a heartbeat. This condition is called heart block and sometimes, as in her case, occurs only upon physical exertion. It prevented the increase in heart rate required to supply her tissues with oxygen, which in turn caused her breathing to speed up in an effort to make up the deficit. A cardiologist colleague suggested implanting a permanent cardiac pacemaker, which was done a few days later and solved the problem immediately. She has resumed her usual activities and continues to do well. Attempts at finding a cause for the heart block came up empty. Copyright 2012.  Consumers Union of United States Inc.

The amazing woman who can smell Parkinson’s disease — before symptoms appear

Joy Milne has always had a keen sense of smell, so she was unfazed when her husband, Les, began emitting a subtle musky odor. He was an anesthesiologist who worked long hours, and Milne assumed the smell was just sweat. But with the change in scent came a growing tiredness that was explained by a devastating diagnosis six years later: Les had Parkinson’s disease.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico “I could always smell things other people couldn’t smell,” Milne said during a BBC broadcast Thursday. After attending a meeting for the charity Parkinson’s UK, where the other Parkinson’s patients shared her husband’s musky scent, she realized that the odor might be tied to the condition.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico After the 65-year-old Perth woman off-handedly mentioned this observation to a few scientists, they decided to investigate. Researchers at the University of Edinburgh gave T-shirts to six people with Parkinson’s and six people without the disease. After the subjects wore the shirts, they were passed on to Milne, who then had to determine by smell whether each wearer had Parkinson’s. Her diagnoses were eerily accurate — and have potentially groundbreaking implications for people living with the disease. Milne made correct assessments for 11 out of the 12 cases. In the one case she got “wrong,” she insisted that a T-shirt worn by a member of the control group had the warning scent. Eight months after the study was conducted, she was proven right, bringing her accuracy rate up to one hundred. The supposedly healthy individual contacted one of the doctors and informed him that he had, in fact, just been diagnosed with Parkinson’s. “That really impressed us,” Edinburgh University scientist Tilo Kunath told BBC. “We had to dig further into this phenomenon.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Intrigued by Milne’s abilities as a “supersmeller,” scientists at the universities of Manchester, Edinburgh and London are undertaking a project to identify differences in the skin chemicals of people with Parkinson’s, study sponsor Parkinson’s UK announced this week.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Scientists believe that people with early Parkinson’s experience skin changes that produce a particular odor, the BBC reports. If they find the molecular signature responsible for the smell, it may be possible to develop a diagnostic test for Parkinson’s as simple as swabbing a person’s forehead.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico As our understanding of it stands now, the disease is incredibly difficult to diagnose; doctors still rely on an observational technique developed in the early 1800s. There is currently no cure for Parkinson’s, a degenerative disorder of the central nervous system which causes shaking, slowness of movement and difficult walking as well as behavioral problems like dementia and depression. Arthur Roach, the director of research at Parkinson’s UK, said in the announcement that in addition to having a “huge impact” on diagnostic procedures, “[The research] would also make it a lot easier to identify people to test drugs that may have the potential to slow, or even stop Parkinson’s, something no current drug can achieve.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **More from Morning Mix**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Freddie Gray’s mother attempts suicide, report says    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico

He withered away for 7 years. Doctors didn’t realize his passion was killing him.

By the time the man arrived at the lung disease clinic in Manchester, England, it was almost too late. It was April 2014 and the 61-year-old had spent the past seven years finding it harder and harder to breathe. Once able to run 10 kilometers, he could now barely walk 20 meters. His lungs were operating at a third their proper capacity. Doctors were stumped. Five years earlier, the man had been diagnosed with a serious inflammation of the lungs, known as hypersensitivity pneumonitis, or HP. HP has a variety of other names, each one of which offered a possible solution to the medical mystery: farmer’s lung, hot tub lung, humidifier lung and, perhaps oddest of all, pigeon fancier’s lung. When doctors tried to pin down the cause of the man’s malady, however, it eluded them. He didn’t smoke. His home wasn’t hiding any mold. He didn’t have connective tissue disease, which can cause breathing problems. And he did not fancy pigeons. The only clue physicians at the University Hospital of South Manchester could see was that the man’s symptoms had rapidly improved when he moved to Australia for three months, only for his breathing to deteriorate once again as soon as he returned to the United Kingdom. In September 2014, five months after first arriving at the clinic, the man returned — in worse shape than ever. He was breathing rapidly but suffering from hypoxia, or a lack of oxygen in his blood. When doctors listened to his lungs, they heard crackling like an old vinyl record. An X-ray suggested pneumonia, a blood clot in the lungs or an exacerbation of the still mysterious HP. A CT scan ruled out a clot but showed that the lung scarring that had started seven years earlier had gotten worse. Doctors gave him a cocktail of drugs to treat what they thought was bacterial pneumonia. When those didn’t work, they added Posaconazole therapy, used to treat pneumonia caused by fungi. Despite their efforts, the man died on Oct. 10, 2014.  Now, however, nearly two years after the man’s death, doctors say they have solved the medical mystery.  “Bagpipe lung.” According to the paper, when doctors initially tried diagnosing the man’s illness, they overlooked his daily hobby: playing the bagpipes. Tests conducted on the man’s bagpipes found a slew of fungi and yeast living inside the musical instrument.  There was pink yeast on the instrument’s mouthpiece as well as fungi on the neck, chanter, chanter reed, chanter reed protector, bass drome and tenor drome, researchers found. Even the bagpipe carrying case had mold inside. The moist, airtight bagpipes made an ideal home for the spores. Unknown to the piper, who was not named in the study, every time he played his instrument, he was inhaling a mixture of mold that caused his illness. His brief recovery in Australia had coincided with him leaving his bagpipes home in the U.K.  This mystery, however, had been all too real. “If that had been identified earlier, and he had stopped playing the bagpipes or cleaned them regularly, he may well have just gotten better,” Jenny King, the study’s lead author, told the newspaper. The study noted similar illnesses befalling saxophone and trombone players, although they were fortunate enough for their instruments to be identified as the cause before it was too late. According to the Guardian, however, it wasn’t the first time that bagpipes have been identified as a health hazard. In 2013, professional piper John Shone fell seriously ill with similar symptoms of breathlessness and weakness. Doctors discovered the fungus lurking inside his instrument just in time.   The “bagpipe lung” case hold lessons for both doctors and musicians, according to the study. “This case highlights the importance of a careful clinical history including hobbies,” researchers wrote. “Thorough clinical history exploring occupation, environmental triggers and pastimes is very important in cases of HP.” Wind instrument players, meanwhile, need to regularly clean their instruments.

An unusual coincidence solved the mystery of the scary nosebleeds and low platelet counts

Sheryl Stein lay in a Northern Virginia hospital , terrified that whatever was attacking the platelets in her blood might kill her before doctors figured out what was wrong. Alone late at night after her husband had gone home to be with their two young children, she worried about how they would cope if she died. Stein’s symptoms had emerged in February 2006, when she began having frequent nosebleeds. Those were followed by purplish bruises that seemed more excessive than her natural klutziness would warrant. Then came a gushing menstrual period heavier than any she had previously experienced. A subsequent  blood test revealed a dangerously low platelet count. Doctors hospitalized her immediately and began transfusions to boost her blood count, which worked — but only briefly. Less than three days after her discharge she was rehospitalized, as doctors sought to determine what was destroying her platelets — cells that help blood to clot. Stein, who lives in Arlington, said she kept telling doctors and nurses about an odd coincidence involving her oldest brother — one she increasingly believed was relevant to her medical problems — but no one seemed to pay much attention. “They were all sort of scratching their heads about what might be wrong, and I was getting so frustrated,” recalled Stein, now 48. Uncertain about how to make herself heard, she offered to arrange a call between the hematologist treating her and her brother, who is a physician. “Doctors talk to doctors happily,” she said. “It’s sometimes hard to get them to listen to patients.” She hoped that such a conversation might lead to an answer that could help spring her from the hospital, or at least enable doctors to investigate — or to rule out — a potential disease and get to the bottom of her medical problem. That phone call proved to be pivotal: It led to a diagnosis that explained Stein’s frightening symptoms as well as a string of recurring illnesses that had plagued her for decades. And it cemented a bond between siblings. At first Stein attributed her recurrent nosebleeds to allergies, winter dryness and chronically infected sinuses. The bruising was harder to explain, even for someone who describes herself as “a true klutz.” When she banged her arm on a post in a restaurant, it turned a ghastly shade of mauve. Then parts of her body that she didn’t remember bumping became bruised. After an episode of dizziness, she saw her internist, who ordered blood tests. On Feb. 17, the internist called Stein. Her results looked fine, he said, except for one test that was probably a lab error and needed to be repeated. Her platelet count was in the low thousands — virtually nonexistent. A normal count ranges from 150,000 to 400,000 per microliter; people with counts below 10,000 are at risk for spontaneous bleeding that can be fatal. Stein, who had just started an unusually heavy period, mentioned it to the doctor. He told her to go straight to a nearby emergency room to get her blood retested. Freaked, she telephoned her brother, a doctor, who concurred. Arriving at the ER with her husband on a busy Friday evening, Stein said, she waited for several hours, bleeding so heavily that she soaked through blankets. Doctors ordered blood tests and quizzed her about her health; she told them that both her children, then 3 and 7, were sick — one with strep, another with a viral infection — and that she had had a headache and a mild sore throat. After the blood test results came back, a nurse entered the cubicle and asked, “Did you not notice that you were tired?” Stein, who had worked a full day as the Web site director at Washington’s Urban Institute before picking up her children at their schools, replied, “I’m the mother of young children — I’m always tired.” The nurse told Stein that her platelet count was so low, a condition called severe thrombocytopenia, that she was at risk of a fatal brain hemorrhage. She was being admitted to the hospital for immediate transfusions of platelets to boost her count while doctors searched for the underlying cause. Among the possible culprits: cancer, lupus or a viral or a bacterial infection. Stein remembers feeling too stunned to reply. Around midnight, after her husband had gone home, the hematologist stopped by. “He was very calm, which made me feel better,” she recalled. “He said, ‘Something’s happening and we’re not really sure why.’ ” “At that point I wasn’t too worried because I thought, ‘Well, they’ll figure this out,’ ” she recalled. Doctors suspected her low platelet count was probably the result of a condition called immune thrombocytopenia purpura (ITP), a clotting disorder that can occur when the body mounts a defense against an infection ranging in severity from a simple virus to hepatitis or HIV. Stein’s brother was at first disbelieving: Several years earlier, he had been given a diagnosis of ITP. “He said, ‘That’s so weird — you can’t have it, because I have it.’ ” ITP was not known to be a genetic disorder and no one else in their family had a similar problem. After two days in the hospital she was discharged: The nosebleeds had lessened, her period had nearly stopped and her platelet count was on the rise at 36,000. But a day later the hematologist found that her count had nosedived to 4,000. Stein was sent back to the hospital for more transfusions and tests. Leukemia or another blood cancer seemed increasingly unlikely; a bone marrow biopsy showed nothing amiss. An infectious-disease specialist wondered whether her body was mounting an overly aggressive immune response to a disease she had avoided as a child but had contracted from one of her children. But after researching ITP online and talking to her brother, Stein kept circling back to his experience: His ITP had been the result of common variable immune deficiency (CVID), a disorder that affects one in 25,000 Americans. The disorder results from the failure of the body to produce sufficient antibodies to ward off disease, resulting in frequent infections. ITP can be one of its symptoms. Because this form of immune deficiency mimics other diseases and causes a variety of disparate ailments, it takes an average of six years for patients to receive a correct diagnosis. Most cases are diagnosed in people between the ages of 20 and 40, according to the Immune Deficiency Foundation. “A weird little bell went off in my head,” Stein said, “and I thought maybe I had it, too.” Since childhood she had been a magnet for all kinds of respiratory problems: She had frequent colds, strep and sinus infections and seemingly every bug to which her children were exposed. When she contracted both strep throat and pinkeye after assisting at an elementary school party, her husband jokingly asked, “What did you do, lick the desk?” At her brother’s suggestion, Stein said, she kept telling doctors about his CVID diagnosis, but no one seemed to follow up. “They’d say, ‘Yeah that’s interesting.’ ” Frustrated, she decided to offer to arrange a call between her brother and the hematologist, figuring that they might speak the same language. The hematologist was receptive, and after the two men talked, “that’s when things started to click.” During her first hospitalization, testing had revealed that the levels of two key antibodies, IgG and IgA, were low, a key clue to possible immune deficiency. The hematologist decided to treat her with an infusion of intravenous immunoglobulin (IVIG), a solution containing antibodies extracted from the plasma of multiple blood donors, to see if that would boost Stein’s immune system. It worked. A few days later, after two more infusions that took about 12 hours each, Stein’s platelet count had jumped to more than 140,000. For the next six months, doctors monitored her counts and gradually weaned her off prednisone, a steroid that reduces the chance of platelet destruction. In May her ITP was found to be in remission. While it appeared that Stein had CVID, a definitive diagnosis would rest with immunologist Shelby Josephs. In October 2006 Stein saw Josephs, who practices in Montgomery County. To test her immune response, he administered a diphtheria and tetanus booster and a shot to prevent pneumococcal pneumonia, a vaccine Stein had never received. Several weeks later, he measured her production of antibodies. “It wasn’t an open-and-shut case,” Josephs said, because Stein’s body did make some antibodies. But overall, her response to both vaccines was weak. Josephs decided that her history and hospitalizations, combined with the vaccine and other results, made her a candidate for continued IVIG therapy to prevent serious infections. Josephs said there is no way to know when or why Stein developed CVID. “My assumption is that people are born with a tendency” to develop it, he said. The immune system weakens over time and an unknown trigger results in the disease. The fact that Stein’s brother has the same disorder has attracted attention from researchers interested in exploring possible genetic underpinnings. Both siblings, as well as their brother, who has a normal immune system, have participated in studies at the National Institutes of Health. So far, neither of Stein’s children shows signs of an immune disorder. Loath to receive infusions for the rest of her life and hoping that the CVID diagnosis was wrong, Stein sought a second opinion in 2007 at the University of Pennsylvania. “I didn’t want to believe I had CVID,” she said. “There is no cure for this and I’m potentially susceptible to lymphoma and all sorts of other nasty things.” An immunologist at Penn retested her, confirmed the diagnosis and echoed Josephs’s recommendations. Since then, Stein has received monthly infusions, which take about six hours and leave her with a headache and fever for several days afterward. She still gets sinus infections and colds, but has had no recurrence of the bleeding or low platelet count. “I don’t want to live in a bubble and I’ve tried really hard to live a regular life,” she said. “It sucks to have this, but there’s power in knowing that I do.” The diagnosis has resulted in an increased closeness with her brother, whom she credits with helping her discover what was wrong far more quickly than many people with CVID. “I know when weird stuff happens I can call him,” she said. “There’s something wonderful about knowing that he’s there and that he understands.”

Here’s everything we know about the medical histories of Hillary Clinton and Donald Trump (it’s not much!)

Clinton's health scare comes after months of chatter in conservative circles about whether the Democratic nominee is hiding some broader and more serious illness, based in large part on Clinton's coughing fits, the most recent of which came at a campaign event on Labor Day. It also comes in the same week Donald Trump is scheduled to appear on "The Dr. Oz Show" to talk about his overall health.  Here's my best attempt to cut through all of these theories and conjecture. This is exactly what we know about the overall health of the two candidates for president. Let's start from Sunday and work backward.   Six days prior, at a Labor Day rally in Cleveland, a fit of coughing forced Clinton to stop speaking at the start of her address. Clinton has been bothered by these coughing attacks periodically on the campaign trail, usually ascribing them to "allergies."  The bulk of Bardack's letter is dedicated to Clinton's fall in late 2012 that led to a concussion and a blood clot. Here's the relevant part of her description of those events:

I saved an old man’s life. He didn’t want it.

The dilemma for the critical-care team was not uncommon: An elderly patient with a life-threatening illness and in severe pain, not understanding the nature of his situation. A decision needing to be made about how aggressive to be. A doctor trying to convince the patient to pursue a rational approach, one based on understanding the limits and capabilities of life-supporting interventions. This situation plays out in emergency rooms and intensive care units hundreds of times a day. But two factors made this incident unique. First, this patient — struggling to breathe, battling low blood pressure and in tremendous pain — was my wife’s grandfather. Second, the doctor recommending aggressive measures, contrary to the patient’s advance directives, was I. Herb Lee, a healthy, independent 87-year-old, had gone out to dinner. Something must have been wrong with the food because he vomited all night long. In the emergency room the next morning, doctors diagnosed him with severe shock and kidney failure from severe pneumonia. (He had aspirated some material into his lung.) His breathing was labored, his oxygen was low and his pulse was fast and weak. But Herb was unable to process any of this. Sciatica pain down his lower back and leg had become excruciating from lying on a hospital gurney, and the only thing he wanted was pain medicine. And he wanted it now. But none was forthcoming, given his tenuous blood pressure and marginal breathing. Before this, Herb had been clear about treatment if he ended up in a hospital. After watching his wife battle metastatic cancer years ago, he knew what he did and did not want: No life support. No breathing machines. This left Herb and his doctors in a bind. The medical team at the ER wanted to treat Herb’s pneumonia and sepsis. But antibiotics take time, often 48 hours, before they have an effect, and patients often get worse before they get better. The pain medication he was desperately calling for was out of the question, as it would further lower his blood pressure and impair his breathing The medical team was failing Herb on all fronts. Not only were they not giving him the best chance to survive, but allowing him to continue on in significant pain while struggling to breathe was unacceptable. He was in no condition to make complex life-or-death decisions. So my wife’s family looked to me, a young internist in the second year of specialized pulmonary and critical care training, and a moonlighter in that same ICU, to help make decisions. What do you do when you disagree medically with a patient on matters of life and death? When there is no ability to have a thoughtful, patient, nuanced conversation over life support? For Herb, was it a “hard no” to any intubation? Were two days okay if there was a high likelihood of recovery? Or was even one day too much? When doctors disagree with patients and families, it is usually the family choosing aggressive care in the face of overwhelming illness even though the benefits of life support are negligible or nonexistent. It gives a reprieve of sorts, allowing for further discussion. But what if it’s the reverse? What if the patient’s decision for no intervention leads to a potentially premature or unnecessary death from a treatable illness? What if a patient’s limits were stated without ever considering the current context? And what if this is your own family member writhing in pain, struggling to breathe? We often talk about decisions of life and death, of aggressive care or comfort, of full “code” — do everything possible — vs. do not resuscitate/do not insert a breathing tube. One or the other. Binary options. But in real life, applying these decisions can get messy. There is nuance and context and uncertainty. And what happens when, in these shades of gray, in this fog, you disagree with your patient? What if you are a knowledgeable critical-care doctor, and it’s your family member? If you choose to treat, you take away his autonomy and right of determination. If you choose to limit care, you are choosing an irreversible path to death and a future full of what-ifs. What do you choose when you are in the fog? With Herb, I chose to treat, not to limit. I chose paternalism over autonomy. I chose a time-limited trial of life support over a morphine drip. I chose not to be the grandson-in-law who made the last decision leading to Herb’s death. He had pneumonia. As a doctor, I knew it was treatable. Reversible. Curable. And so a breathing tube was placed. Once his breathing and blood pressure were stabilized, morphine was administered to treat his pain. We bought some time to allow antibiotics and his immune system to turn the tide on his pneumonia and sepsis. At 48 hours he made enough progress to push forward another day. The breathing tube was removed 24 hours later, and he was able to leave the ICU shortly thereafter. He avoided most if not all of the potential complications and pitfalls that often plague patients in the ICU. A week on the regular medical floor was followed by a transfer to a nursing facility. Within six weeks, Herb was back home. In my world of critical care, this is a win. It does not get much better than halting the progress of a life-threatening illness, supporting the body while it heals and nursing the patient through a hospitalization to an ultimate return home. Over the following months, Herb would see another great-grandchild born and celebrate family birthdays. And at one of those dinners, sitting next to Herb, I took the opportunity to finally ask: “Herb, I made the right choice, right? Overriding your ‘do not resuscitate’ order?” He looked at me and simply said, “I wouldn’t want to go through that again.” He told me of the countless sleepless nights, lying in the bed, scared, confused, not knowing when light would finally come to end his darkness. It was hell, and not one he wanted repeated. If he could do it over again, he said, it would be no. No breathing tube. No life support. I was shaken. What does it mean when an unequivocal win in my world is not a win in the eyes of the person for whom it matters most? The intersection of critical illness, advance directives and end-of-life decisions is an uncomfortable place. It is hard to talk about these issues when in good health, much less in sickness. But we must run toward — and throw ourselves into — the discomfort. We need to talk to our family and friends and share what it is that makes life worth living — and when it’s not. We need to explore what “quality of life” means for each of us. By doing so, we inject some much-needed light into the darkness and the fog, and help bring claritywhen it’s needed most. A few months later, Herb developed another severe pneumonia. There were no tense conversations, no anxious looks among family. There was light where before it had been dark. And as we focused on Herb’s comfort, that light remained. He died a few days later in the hospital, with the palliative assistance of hospice. It has been more than 13 years since Herb passed away. Over that time, I have been involved in countless frantic discussions with patients and their families about goals of care in the midst of critical illness. It’s never easy, but because families often ask me what to do, I share with them Herb’s story. And by doing so, he continues to help shed light when it’s needed most and to help determine what a “win” means for each of us. **health-science@washpost.com** Topin blogs about life and medicine at Balance. Twitter: @jtopin1.

Clinton’s running mate won’t say when he first heard of her pneumonia diagnosis

Kaine, who was campaigning in the swing state of Ohio, said at a rally here that he emailed Clinton shortly after learning of her abrupt departure from the ceremony due to what an aide later described as feeling overheated. “I can tell you this,” Kaine said. “Within a few minutes after I heard the news, I had reached out to communicate to her and she reached right back out to me and said, ‘I’m going to be fine.’ And then she started making fun of me because I was sitting reading endless debate prep memos.” Kaine, a senator from Virginia, added that he continues to be impressed by Clinton’s stamina.  Fielding questions from reporters afterward, Kaine would not say when he first heard Clinton has pneumonia. The diagnosis — which her doctor said was made Friday — was disclosed Sunday, several hours after Clinton’s stumbling departure from the event in New York. “The first time I talked to Hillary about this was Sunday, so I’ll just say it like that,” Kaine said. “I don’t want to get into the character of communications. But I reached out to her as soon as the incident happened on Sunday, and we had a good dialogue there.” Asked whether he had learned about the diagnosis prior to Sunday, Kaine said the last time the two discussed Clinton’s health was at an event they both attended in Cleveland on Labor Day. At that event, Clinton had a prolonged coughing fit at the outset of her remarks. “I obviously knew from Monday, when she was coughing, that she had a cough, and it was likely an allergy,” Kaine said. “The first time we talked after we were together Monday was — I reached out to her after yesterday in New York.”   Kaine said he had a similar episode with pneumonia when he was running for the Richmond City Council in 1994. “I lived through something very similar in my first race, and I kind of know what [Clinton's] thinking was, which was, ‘Okay, I’ve got a diagnosis. It’s serious, but it’s something that a lot of people manage.’ ”

@Work Advice:

_The inbox has coughed up several letters on the same topic._ **Reader 1:** A co-worker sounds like she has hairballs. She coughs and then sounds like she’s throwing up at the end, and never even says “excuse me.” She said she went to the doctor and is taking medicine, but I WISH SHE WOULD STAY HOME!!! How are the rights of a sick employee balanced against the rights of those who wish to remain well? **Reader 2:** The employee in the office next to mine has a horrible smoker’s cough that ends in gagging. People on the phone and clients can hear it, and she reeks of smoke. It is hard not to be judgmental, because my father died young of lung cancer from smoking. **Reader 3:** For months, my cube neighbor has had a dry hacking cough, eight hours a day. I leave work stressed out and angry, and dread arriving in the morning. I told the office manager about my frustration and the adverse effect it has on my ability to work. She said she has sent him home many times, and he has no more sick leave. He has also been sent to HR. He says that he suffers from asthma and allergies, but that this cough (in his opinion) is not related. To my knowledge, he hasn’t seen a doctor. **Karla:** Flu season, dry air, pollutants, nervous tics, barnyard upbringing … whatever the cause, a barking co-worker can drive you barking mad. Infectious or not, constant coughers should do what they can to curtail the consternation they cause colleagues — including lozenges, soothing drinks, medical care and telecommuting. Managers should be willing to entertain reasonable temporary solutions: the aforementioned telecommuting, or desk swaps, or setting up quiet space for client calls. And they should avoid trying to diagnose a worker’s condition — besides triggering the protections afforded by the Americans With Disabilities Act, it’s presumptuous — and focus on the work environment. Similarly, complaining co-workers should focus on disrupted productivity, not opinions about the cougher’s health or habits. If management is deaf to both coughing and complaints, you’ll have to resort to other measures: earphones, white noise, reassignment to Tibet. Or you might try to muster some sympathy. Offering throat-calming treats may bring you both relief — and make a colleague more receptive when you note: “You’ve had that cough a while. Have you had it checked out to make sure it’s not something serious?” You’ll catch more flies (and fewer other bugs) with honey sticks than sour looks. For stories, features such as Date Lab, Gene Weingarten and more, visit WP Magazine. Follow the Magazine on Twitter. Like us on Facebook. E-mail us at wpmagazine@washpost.com.

‘My name is Amanda, and I smoked while I was pregnant…’

The ads have been visceral and jarring: A North Carolina woman, diagnosed with oral and throat cancer, warning about the consequences of smoking through the gravelly sound of her artificial voice box. An Army vet and long-time smoker whose diseased lungs make him wonder whether he will be around to see his grandchildren grow up. A 31-year-old man who had his legs amputated due to Buerger’s disease, a disorder closely linked to tobacco use.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday The Centers for Disease Control and Prevention’s “Tips from Former Smokers” campaign, which began in 2012 with money from the Affordable Care Act, is aimed at getting current smokers to quit by showing the potentially deadly path they are on. By the agency’s account, the ads have prompted more than 1.5 million Americans to try to kick their tobacco habits, with an estimated 100,000 people expected to stop permanently.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday Given that apparent success, the agency is launching another round of ads intended to highlight additional tobacco-related conditions, from gum disease to lung cancer. The latest installment in the CDC’s campaign arrives Tuesday, and it includes one of the most sobering ads yet. “My name is Amanda, and I smoked while I was pregnant,” the spot begins. Amanda Brenden was newly engaged, in college and unexpectedly pregnant. She tried to kick her pack-a-day habit but kept smoking during her pregnancy. The result: Her daughter was born two months premature, weighed three pounds and spent her first days in a neonatal intensive care unit. “I wasn’t able to hold her. She couldn’t suck or swallow, so she had a feeding tube in her nose,” Brenden, of Eau Claire, Wis., recounted in an interview. “I just want other women to know that they can quit, especially women who are smoking during pregnancy. They can quit and avoid walking down the painful path of having a baby prematurely.” Brenden has quit smoking, but too late to prevent the health problems that still affect her otherwise healthy daughter, now 7. “My family’s whole life really revolves around what triggers an asthma attack for her,” she said. “We really have to plan our days around possible asthma flare ups.” According to the CDC, the new ads will begin running July 7 in a wide range of outlets, including television, radio and print, as well as on billboards and in movie theaters. The campaign will last roughly two months and, combined with a similar effort earlier this year, cost an estimated $60 million. Officials said the latest campaign also will focus on reaching lower income groups, who tend to have among the highest smoking rates. , Spanish-language ads will run on Hispanic television stations and Asian-language print ads will run in cities that are home to large Asian populations. The campaign also features one last ad from Terrie Hall, the North Carolina woman and outspoken anti-tobacco advocate who became a centerpiece of the CDC’s initial anti-smoking campaign. After battling smoking-related cancers for years, Hall died in September 2013. She was 53.

Clinton's health scare comes after months of chatter in conservative circles about whether or not she is hiding some broader and more serious illness -- based in large part on Clinton's coughing fits, the most recent of which came at a campaign event on Labor Day. It also comes on the same week that Donald Trump is scheduled to appear on "The Dr. Oz Show" to talk about his overall health.  Here's my best attempt to cut through all of this theories and conjecture. This is exactly what we know about the overall health of the two candidates for president. Let's start from Sunday and work backward.   Six days prior, at a Labor Day rally in Cleveland, Ohio, a fit of coughing forced Clinton to stop speaking at the start of her address. Clinton has been bothered by these coughing attacks periodically on the campaign trail, usually ascribing them to "allergies."  The bulk of Bardock's letter is dedicated to Clinton's fall in late 2012 that led to a concussion and a blood clot. Here's the relevant part of Bardock's description of those events:

Medical Mysteries: It wasn’t the vaccine — so why did baby have seizures?

“Men in Black” was flickering on the screen, and Laura Cossolotto and her husband were enjoying a rare night at the movies in their home town of Centerville, Iowa, when her brother-in-law rushed into the darkened theater. The couple’s third child, 6-month-old Michaela, had just suffered a serious seizure and was at a nearby hospital. As Cossolotto raced to be with the baby, she immediately remembered that Michaela had been running a fever after receiving a vaccine against diphtheria, pertussis and tetanus (DPT) three days earlier. “I thought the shot must have something to do with it,” Cossolotto recalled. “I had three kids, and nothing like this had ever happened, so what else could it have been?” At the hospital, doctors reassured her that Michaela had suffered a febrile seizure, a frightening and usually harmless event they said was unlikely to recur. As a precaution, the baby was admitted for observation. Hours later, after doctors had trouble controlling a second, more severe seizure, the infant was whisked by helicopter to a larger hospital in Des Moines, 100 miles north. That night in July 1997 marked the beginning of a 10 1 / 2-year ordeal, as more than a dozen specialists in four states tried without success to find an underlying cause for Michaela’s frequent, intractable seizures — and a treatment that would control them before they caused irreparable brain damage or death. For years Cossolotto held the DPT shot responsible for Michaela’s problems, joining legions of parents who have blamed various ingredients in pediatric vaccines for triggering serious medical and developmental ills, most notably autism. Since the early 1980s these allegations, based on discredited theoriesand more recently on an influential British study that last year was deemed an “elaborate fraud,” have flourished, largely because of their enduring popularity on the Internet. As a consequence, fearful parents have refused to immunize their children, resulting in outbreaks of vaccine- preventable diseases, including measles and whooping cough. Cossolotto, who spent hours online desperately seeking answers, found the vaccine hypothesis persuasive, particularly after doctors failed to offer another explanation. The belated discovery of what was wrong with her daughter would upend Cossolotto’s long-held views and lead to major improvements in Michaela’s life. ****It was quickly evident that Michaela’s seizures were not just febrile: They occurred when she had no fever, and doctors suspected she had epilepsy. “She would be in her bouncy seat and both arms would just shoot straight up in the air,” Cossolotto recalled. “I knew nothing about epilepsy.” She soon learned. At times Michaela’s seizures were so severe that doctors had to place her in a drug-induced coma to save her life. Eight times before she was 3, she was helicoptered to Des Moines or Iowa City for emergency treatment. “I remember sitting by her bed in the ICU wondering: Would she wake up? And if she did, would she be a vegetable?” Cossolotto recalled. Despite test after test, no doctor could say what kind of epilepsy she had, and no cocktail of medications proved effective in controlling the seizures. Nor did doctors know the reasons for problems that emerged as she aged: delayed speech, mild mental retardation and serious growth deficiency. Specialists ruled out fragile X syndrome, a chromosomal disorder that causes mental retardation, gastrointestinal malabsorption, cystic fibrosis and numerous rare metabolic problems as well as heart defects and brain malformations. Between the ages of 3 and 5, Michaela did not gain an ounce; she entered kindergarten at age 5 weighing 33 pounds, roughly the average weight of a 2 1 / 2-year-old girl. At a growth clinic where she was evaluated for failure to thrive, doctors told Cossolotto “the problem was that I allowed her to graze during the day and that I was a bad parent,” she recalled. Around the age of 4, Michaela began regressing, displaying what seemed to be classic signs of autism: She would rock for hours, avoid eye contact and seem to retreat into her own world. By this time Cossolotto was spending hours a day scouring the Internet. She quickly turned up what seemed to be a promising explanation: pediatric vaccines. Michaela's doctors were skeptical, but Cossolotto became increasingly convinced she had found a possible answer. She began taking her daughter to see a specialist in environmental medicine in St. Louis, five hours away. He embraced the vaccine theory and ran his own series of tests, diagnosing a mold allergy. At Cossolotto’s request, he signed a waiver allowing Michaela to attend kindergarten without receiving the required immunizations. “I wasn’t taking any chances,” her mother recalled. But after several months autism faded from the picture: Remedial help Michaela received in school caused the autistic behaviors to recede. Cossolotto’s belief in the vaccine theory waned, she said, but remained in the back of her mind. When Michaela was 5, Cossolotto’s youngest daughter was born with Down syndrome. At times the pressure seemed unbearable as she struggled to care for two special-needs children. The seizures unabated, Cossolotto called the Mayo Clinic in Rochester, Minn. A pediatric neurologist there began treating Michaela with various antiseizure medications while continuing the search for an underlying cause. At one point the little girl was seizure-free for nearly a year, but the convulsions returned, worse than ever. In September 2007, Cossolotto took Michaela, then 10, to see a pediatric geneticist who had been featured on a TV show about baffling medical cases. “At this time, I do not have a unifying diagnosis to explain her problems,” the specialist, who practices in Iowa, wrote. Neither did Michaela’s doctor at Mayo, who suggested a referral to Elaine Wirrell, the hospital’s new pediatric epileptologist, a neurologist who specializes in treating children with epilepsy. “I had never heard of an epileptologist,” Cossolotto said. In November 2007, Michaela saw Wirrell, the latest in a seemingly endless parade of doctors. The appointment seemed like so many others. After listening to Michaela’s history and reviewing her records, Wirrell told Cossolotto that she suspected a rare disorder and wanted to order a test. “I thought, ‘Oh, more bloodwork; we’re going to rule out another diagnosis,’ ” Cossolotto recalled. Three weeks later, Wirrell called Cossolotto with the definitive answer that had eluded her for so long. The blood test for the SCN1A gene revealed that Michaela had Dravet syndrome, also known as severe myoclonic epilepsy of infancy, a rare and serious form of the seizure disorder named after the French doctor who described it in 1978. Dravet is usually caused by a spontaneous — not inherited — genetic mutation present at birth that affects the functioning of brain cells, according to the National Institute of Neurological Disorders and Stroke. Its hallmark is severe seizures during the first year of life that are difficult to control. Many children with Dravet, which occurs in one in every 20,000 to 40,000 births, also exhibit poor language skills, behavioral problems and cognitive deficits. There is no cure for Dravet, but some medications are effective in controlling seizures. Among them are clobazam combined with stiripentol, a French drug that has not been approved by the Food and Drug Administration but can be legally imported because it treats a rare illness. In many cases Dravet emerges when a baby runs a fever, which can occur after receiving an immunization. But, notes Wirrell, chief of pediatric epilepsy at Mayo, “it’s absolutely _not_ the immunization causing Dravet” but rather the fever that causes the existing disorder to surface. Wirrell, who has seen 20 children with Dravet, said that those who have never been immunized show symptoms after spiking a fever. Several recent studies have explored the relationship between the DPT vaccine and Dravet, which was first suggested as a cause of neurological problems in a 2006 study by a team of Australian epilepsy specialists. A 2010 study in Lancet Neurology found that the vaccine did not affect the outcome of Dravet: Babies whose seizures began after the shot fared no worse than those whose illness surfaced at another time. A 2011 report in the journal Pediatrics found that five children presumed to have neurological damage caused by the DPT shot were later discovered to have Dravet. In Michaela’s case, the combination of seizures that began at six months, soon after the DPT shot, and the lack of any other cause made Wirrell suspect Dravet; the gene test confirmed it, although about 30 percent of children with Dravet do not test positive. For Cossolotto, the diagnosis meant coming to terms with the reality of her daughter’s serious, incurable illness. “I always thought that if I knew what it was, we could fix it,” she said. “But it was Dravet, and there was no fixing it. I had to keep telling myself, ‘You have an answer.’ ” “Five or 10 years ago, many people were not thinking that this is a seizure syndrome,” Wirrell said. She credits parents, especially Cossolotto, who since 2008 has been president of the support and advocacy group called Dravet.org, with raising awareness of the disorder and promoting effective treatment. Epileptologists, she added, are attuned to Dravet, while general neurologists may be unfamiliar with it. “Recurrent prolonged seizures fairly early in life should trigger a referral to a pediatric epileptic specialist,” she advised. As a result of the diagnosis and proper medication, Michaela’s life has dramatically improved. Although she still grapples with cognitive and behavioral problems, her seizures have dwindled to only a handful annually. Now 15, she is a freshman in high school with friends, a Facebook page and other trappings of adolescence. Without a diagnosis, Cossolotto said, she would probably still believe — erroneously — that the DPT shot caused Michaela’s illness. “I understand this is a genetic condition,” she said. “Having an answer does make a difference.”

What Hillary Clinton’s pneumonia diagnosis means, medically speaking

Although Bardack said her patient was on the way to recovery, the diagnosis of pneumonia may have left some voters wondering: Isn’t pneumonia, after all, a serious health concern? The short answer, at the moment — based on the limited available information about Clinton’s case and viewed independently of any unknown other health issues she may or may not face  — is no.     Death remains a part of the pneumonia spectrum. Not all pneumonias, though, are created equally. “The problem is we have one word for a disease that comes in lots of different iterations,” Edelman said. At its most basic, pneumonia simply means that a germ has inflamed the lung’s air sacs. Cold viruses infect the nose and throat; bronchitis concerns the airways; and pneumonias afflict the dark, wet and warm parts of the lung itself. Making matters more complicated, the pathogens chewing into the lung tissue could be any one of a motley crew of bacteria, viruses or fungi. The severity of pneumonia is as broad as its possible culprits. At the far end lies a mild disease. The illness is known colloquially as walking pneumonia, so named because the disease rarely knocks anyone out of commission and into bed. Here is likely where we find Clinton, at least based on what her campaign has revealed so far.   But that is just one possibility. “The bugs that cause pneumonia are common,” Edelman said. “Lots of people carry those bugs in their nose and throat.” (This was about as close as an expert would speculate about the risk factor of shaking sweaty hands by the millions on the campaign trail.)    What is far less likely, too, is that Clinton caught the pneumococcal form of the disease. The CDC recommends anyone older than 65 to be vaccinated for the more severe pneumococcal type. At 68, Clinton falls within this demographic. (The American Lung Association’s advice is also to vaccinate at 65.)  In fact, on Friday, the day of her diagnosis, Clinton attended several events, including a CNN interview and a national-security meeting. “If she’s had it for more than a week or so,” Nicolls said, “you could say that it indicates a certain amount of stoicism.”

Medical Mysteries: It seemed like a heart attack, but the tests said no.

As Pamela Meredith sank onto her living room sofa to watch an action movie with her visiting grandson, she felt unusually relieved that their busy day was over. The sultry heat of a Washington August, combined with the pace required to keep up with an active 12-year-old, had sapped her energy, which had flagged in recent weeks. As she put her feet up, Meredith was alarmed to see that her normally slim ankles were swollen, obscured by bands of puffy flesh. The retired nurse practitioner gingerly pressed her finger into one ankle. The pressure left a visible dent in her skin, a telltale indication of a condition called pitting edema, caused by an accumulation of fluid in body tissues. As Meredith mentally scrolled back through the events of Aug. 1, 2013, for a possible cause, she suddenly worried that her worsening fatigue might portend something ominous. She had dismissed recent sporadic heart palpitations as a mere nuisance, the recurrence of a harmless condition that had first appeared in her 30s. But the combination of pitting edema, worsening fatigue and palpitations seemed to point in one direction: a heart attack. A few hours later, tests at a Northern Virginia hospital quickly ruled out Meredith’s biggest fear. She had not had a heart attack. But her level of potassium, critically important in regulating blood flow and kidney function, was perilously low and her normally low blood pressure was dangerously high. Meredith was admitted to the intensive care unit, where doctors spent the next four days figuring out what had caused her problem — and how best to treat it. The answer proved to be both simple and surprising, revealing a malady with which Meredith, the former editor of a nursing magazine, was unfamiliar. “This is definitely an underrecognized problem,” said Hesham Omar, a hospital-based internist who was not involved in her case. “I think these cases get admitted and treated, but the cause is never figured out. Luckily, it’s not very common.” The fatigue began in July soon after Meredith, then 70, returned from her family’s annual summer reunion in Atlantic, Iowa, an event that drew relatives from as far as Chile. She began having difficulty completing her customary two-mile daily walk through her hilly Alexandria neighborhood, and noticed brief palpitations. They didn’t alarm her. In her 30s, she had experienced similar irregular heartbeats when she was stressed; testing at the time had ruled out a serious problem. “I’d always associated them with anxiety,” Meredith said. Although she did not feel anxious, “I’d just come back from a trip, and it was 100 degrees out.” Her grandson was staying with her for a week, and they relaxed by watching movies in the evening as Meredith snacked on the Dutch salt licorice candy coins she had first tasted at the reunion. On the afternoon of Aug. 1, Meredith had a physical therapy appointment designed to treat a shoulder problem. Two years earlier, she had been diagnosed with psoriatic arthritis, an autoimmune disorder that causes joint pain, swelling and stiffness in people with the scaly skin condition. At the start of her PT appointment, a student took her blood pressure. The reading was unusually high: about 168/90; Meredith’s reading is usually about 100/60. Meredith said she assumed the elevated reading reflected the student’s inexperience. ****“I asked her, ‘Are you sure your monitor’s working okay?’ ” she remembers inquiring. Meredith recalled that blood pressure reading as she considered what to do about her swollen ankles. She chewed an aspirin tablet, something a person suspected of having a heart attack should do to prevent platelets from clumping and blocking an artery. Then she called her daughter, who lives nearby, and told her to pick up her son. “I knew I had to get to the hospital as soon as possible,” she said. ****Then she did something she admits was dumb, partly to avoid upsetting her grandson. Rather than calling 911, as she should have, Meredith got in her car and at 10 p.m. drove three miles to Inova Alexandria Hospital. She parked her car and walked across the darkened parking lot and into the emergency room. “If I had collapsed in the parking lot at that hour of the night, I might not have been found until daylight,” she said. Inside the ER, she waited while another patient discussed a hand injury, then announced to the triage nurse in oddly stilted language, “I think I’m having a cardiac event.” Meredith was quickly whisked by wheelchair to an examining bay. ****Several hours later, after tests ruled out a heart attack, she began to relax. “I was surprised — and delighted,” she said. She figured that a few intravenous bags ofpotassium would restore her count and that her blood pressure could be lowered with medications. But Meredith’s doctors were concerned. Her systolic blood pressure, which measures pressure in the arteries when the heart beats, had risen to nearly 200 at one point, increasing her risk of a stroke. And her potassium level hovered around 2.6, a condition called hypokalemia, considered a medical emergency because it can trigger ventricular fibrillation, a wildly irregular heartbeat that can be fatal. Doctors were perplexed by the cause of her sky-high blood pressure and hypokalemia. Hypokalemia has many causes, among them the use of diuretics (medicines used to treat high blood pressure); other causes include tumors, metabolic disorders, kidney disease and vomiting or diarrhea that leads to dehydration. Blood tests of Meredith’s levels of plasma renin, an enzyme that regulates blood pressure and kidney function, and aldosterone, a hormone produced in the adrenal gland, were abnormally low. “People can die from low potassium,” said Irmindra S. Rana, a kidney specialist who was among the doctors who treated Meredith. Meredith said she was repeatedly asked by her doctors and nurses whether she had taken diuretics or had suffered a recent bout of vomiting or diarrhea; the answer to those questions was no. On the second or third day of her hospitalization, a second kidney specialist asked her a new question, one that commanded her attention. “Have you eaten licorice lately?” he asked. Meredith said, “I sat up in bed and said ‘Yes! What does that have to do with it?’ ” **** Everything, it turned out. Meredith told her doctors she had not just eaten a few black licorice coins. A lifelong licorice lover, she enjoyed the candy coins so much that after the reunion she had ordered two two-pound bags. And in the space of about a week after she returned home, she had eaten one of those bags herself. “My practice with forbidden goodies,” she said, “is to eat them as fast as possible” so they’re not around to tempt her. The type Meredith had eaten is called salt licorice and is popular in northern Europe. It containsglycyrrhizin, which causes the candy to taste sweet. The ingredient is made from licorice root, consumption of which can prompt the kidneys to release too much potassium, disrupting cardiac function and sometimes causing palpitations. Glycyrrhizin is not present in red licorice or in some licorice-flavored candy that uses a sweetener other than licorice root. “We were looking for a unifying hypothesis” to explain her symptoms, said Rana, who made the diagnosis in conjunction with the other nephrologist and the hospital internist. In the absence of other findings, patients with very high blood pressure, fatigue and very low potassium and who have consumed large quantities of licorice are presumed to be suffering from licorice poisoning. And eating a two-pound bag of licoricein a short time is clearly enough to cause it. “The key is to take a good history from patients,” said Rana, who said he has seen one other case of licorice toxicity in his career. Shortly before Halloween 2011, the Food and Drug Administration cautioned consumers to avoid overconsumption of black licorice. The agency warned that people older than 40 who consume too much black licorice in a concentrated period could risk heart rhythm disturbances or muscle weakness. Sensitivity to glycyrrhizin varies and may be affected by genetic factors as well as sex and age. The link between licorice and metabolic problems goes back decades, said Hesham Omar, an Iowa hospitalist who has written two papers on licorice poisoning. Omar, who graduated from an Egyptian medical school, said that the problem is not uncommon among Muslims during Ramadan, when people are forbidden to eat or drink for 12 hours or more each day. Some consume enormous amounts of liquid licorice — sometimes in the form of tea — to blunt thirst, he said, only to wind up in the hospital. Patients who also take diuretics are particularly susceptible to accidental poisoning as are those who binge on licorice. After four days in the ICU, Meredith was discharged from the hospital; by then, her potassium level had returned to normal. Her blood pressure declined slowly but steadily, though it remained elevated for several months, as is common in cases of excess licorice ingestion. “I was dumbfounded by this,” Meredith said. “I certainly had never heard of it.” She regrets driving herself to the emergency room. “If anyone in my family had done this, I would have hit them upside the head,” she said. Meredith, who saw Rana several times after discharge to monitor her blood pressure and kidney function, has recovered completely with no ill effects, as do most patients. She has not touched licorice since, although the second large bag of Dutch candy coins remains in her kitchen cupboard. “I’m not sure why,” she said. “Maybe as a reminder.”

Sniffing and sneezing? It might be winter allergies. How to know if it’s not cold.

You’re sniffling and sneezing again. You’re feeling tired and headachy again. Perhaps it’s not your third (or fourth or fifth) cold of the season, but an allergy. Most people don’t consider allergies the cause of their coldlike symptoms in the winter, because the cause of most respiratory allergies — pollen — is usually not drifting about in cold and snowy climes. Yet some of the most common allergies are to indoor things: Dust mites, mold and animal dander top the list. And in the winter, we tend to spend more time indoors with these potential triggers. Allergies are overreactions of the immune system to foreign particles that should be innocuous. For reasons that scientists don’t fully understand, some people react to dust mites or mold spores as if it they were a pathogen. There’s an antibody response and an inflammatory cascade of events that leads to the classic symptoms — itchy eyes, runny nose and sneezing — says allergist Jackie Eghrari-Sabet, founder of Family Allergy and Asthma Care in Gaithersburg. Sometimes the congestion is bad enough to cause sinus pressure and headaches. But how do you know which is which — if you have an allergy or a cold? While they are caused by different things, both a virus and an allergen set off your body’s immune responses. That’s why symptoms overlap — a runny or stuffy nose, a cough and sore throat, and fatigue. Some symptoms are more likely to occur with allergies, such as itchiness of the eyes, ears and back of the throat. Other symptoms, such as aches and fever, indicate a viral infection. Another key difference is the course and persistence of symptoms. “With a cold, first you feel crummy, then you’re sick and then gradually your symptoms go away,” says Joan Lehach, an integrative medicine physician specializing in allergy and asthma at Montefiore Medical Center in New York. With a cold, she says, this sequence may last a week or so. “Allergies last longer.” Lehach says that, in winter, half of the patients who come to her are people whose family doctors have told them they’re not suffering from colds. Eghrari-Sabet says primary-care doctors can miss an allergy diagnosis when their offices are flooded with patients who have colds or the flu. People with allergies are more likely than others to develop asthma, a more serious and chronic condition. Some studies have shown that indoor allergies are associated more strongly with asthma than outdoor (pollen) allergies. What to do if you think you might have indoor allergies? Here’s some suggestions from experts: ●Minimize your exposure. Dust mites live in bedding, upholstered furniture and carpeting; mold grows in damp places such as bathrooms and basements; and pets — well, if you have a dog or a cat, you should at least keep the animal out of rooms where you spend a lot of time, such as your bedroom. And cockroaches. “They are a major allergen,” Lehach says, and are widely prevalent in urban settings — both housing and schools. A study of 831 houses across the country found that two-thirds of the homes had detectable levels of cockroach allergens, and higher levels were found in high-rise apartments and older, urban homes. (Nearly half of the homes had high enough levels of dust mite allergens to produce allergic reactions.) So, vacuum frequently, wash bedding in hot water, remove mold with a bleach solution. Pay special attention to your bedroom, suggests the American Academy of Allergy, Asthma and Immunology, because you spend so many hours there. In addition to keeping a clean house, you might want to invest in a HEPA air filter, which removes particles from air passing through it. ●If you think you might have indoor allergies, there are plenty of over-the- counter products to help relieve the symptoms of allergies, including antihistamines and decongestants. You might also try steroid nasal sprays, one of which — Nasacort — was recently approved for nonprescription sales. Studies generally show that steroid nasal sprays work better than antihistamines for symptom relief. Some allergy sufferers swear by simple saline sprays and herbal remedies that contain butterbur or biminne. ●If your symptoms are ongoing and annoying enough to interfere with work, play or sleep, a visit to an allergy specialist might be in order. In a single visit, an allergist can find out what you’re allergic to with a simple skin test. Once you’ve narrowed down the cause (or causes), you can target the problem more directly. “Allergy shots contain a small amount of the very thing you’re allergic to,” Eghrari-Sabet says. “You become tolerant to it.” The treatment is delivered in a series of shots, typically monthly for up to five years. Allergists can also prescribe other types of medications. But the very first thing they’ll do is counsel you to minimize your exposure. So you still have to clean your house.

This woman’s labored breathing alarmed her friends. Doctors were startled to find the cause.

“What’s _wrong_ with you?” Dianne Hull remembered her friend Vicky Weinstein asking, alarm evident in her voice. The two women had just finished lunch in December 2012, and Hull breathed heavily as she walked across the kitchen of her friend’s home. Hull’s audible breathing — and increasing breathlessness — had been shoved aside in her constellation of pressing concerns. For months, Hull had been focused on a medical crisis affecting her young son. But now Weinstein — a nurse — was delivering a forceful reminder: It was past time for Hull, then 38, to pay attention to her own health. After Hull left that day, Weinstein, unconvinced that Hull would heed her warning, picked up the phone. “You have to do something,” Weinstein told her husband, Philadelphia lung specialist Michael Weinstein. “Something is really wrong with Dianne.” A month later, after Michael Weinstein’s intercession, Hull’s unusual and rare problem was diagnosed and treated. Nine months after that, she ran her first 5K race with no problem. “It was very frustrating, because for more than a year, nobody could really figure out what was wrong,” Hull said, which made her symptoms easier to ignore once her son got sick. “I needed people to say, ‘Something’s really not right.’ ” During a routine appointment in July 2011, Hull’s primary-care doctor remarked that she seemed slightly short of breath. Hull, who lives in Swarthmore, Pa., and works in the career services department at the University of Pennsylvania, said she didn’t think much about it, especially because the doctor didn’t seem concerned. “At that point it had probably been going on for a few years,” Hull recalled. Although she exercised regularly, Hull was pushing 40. Maybe, she thought, she needed to step it up athletically. A month later, she mentioned the problem to Weinstein’s husband, Michael, whom Hull had known since college. He suggested she come to his office. Michael Weinstein did not detect wheezing, but he thought Hull might have developed exercise-induced asthma, which is not uncommon in middle age. He suggested she try using inhalers and an antihistamine before exercising. Over the next year, Hull said, she periodically tried the medicines but noticed no difference. She had never smoked and took Jazzercise classes, walked and swam regularly — but noticed that increasingly she felt winded even when she exerted herself only mildly. “I couldn’t walk up a flight of stairs and talk on the phone at the same time,” Hull recalled. In July 2012, she caught strep throat from her young daughter and saw her internist. “Do you always wheeze?” Hull remembers her doctor asking. She told Hull she should have a chest X-ray and lung function tests after she recovered from strep. Wheezing can be a sign of an obstruction, asthma or vocal cord dysfunction. The tests, performed a month later, were normal. Hull said the most notable aspect was the attitude of the technician who “implied there was nothing wrong with my breathing and it was all in my head.” But Hull noticed that whenever she swam her customary 50 laps, she needed to stop after each to catch her breath. Weinstein was puzzled because he had thought the tests would indicate that Hull had asthma. He urged Hull to schedule the gold standard of asthma tests: a methacholine challenge, which evaluates how the lungs react to inhaled substances. A negative test is believed to definitively rule out asthma. Hull scheduled the test. Before it could be performed, her attention was commandeered by a far more pressing problem: Her 7-year-old son was hospitalized with newly diagnosed Type 1 diabetes, and managing his disease became the primary focus of Hull and her husband. “Any concern about my breathing just sort of went away,” recalled Hull, who canceled the test. “I had two kids and I was overwhelmed. There was no time for me to be sick.” Several months later, Hull’s son had stabilized, but her breathing had worsened dramatically. She cleared her throat continously, coughed frequently and struggled through exercise classes; her breathing sounded like a high- pitched whistle. Her primary-care doctor told her she had stridor, an abnormal high-pitched sound that typically indicates a partially blocked airway. The doctor suggested allergy testing. “I was confident I didn’t have allergies,” Hull said, but scheduled an appointment for January. A few weeks later, she had lunch with Vicky Weinstein. At his wife’s urging, Michael Weinstein called Hull, who told him about her upcoming appointment with the allergist. The allergist was extremely thorough — and visibly alarmed, Hull said. He agreed that something was seriously wrong with her breathing and sent her down the hall for another round of lung function tests, which were normal. He then placed his stethoscope on Hull’s throat, not over her lungs. When she breathed, she recalled, he “recoiled, with a scared look on his face.” “Not what you want to see,” she remembers. She asked the doctor what he had heard, and he told her he thought there might be an obstruction in her throat. “A tumor?” she remembers asking. “I don’t know,” the allergist replied, kindly putting a hand on her shoulder. He referred Hull to an ear, nose and throat specialist, and called on her behalf for an expedited appointment. The ENT, Hull said, was the polar opposite of the allergist: a brusque man of few words and even less reassurance. He told Hull he didn’t know what was wrong but that she needed a CT scan and possibly a bronchoscopy, a procedure that enables a doctor to inspect a patient’s airway using a flexible scope. He told Hull he suspected that her problem was not a tumor, but more likely paradoxical vocal cords, which open in the wrong way. He gave her an order for a CT scan. Uncertain about what this meant, or what to do next, Hull turned to Weinstein. To Weinstein, the paradoxical vocal cord hypothesis was puzzling. It didn’t explain the stridor, which was his greatest concern. In adults, stridor is often caused by trauma to the airway from a breathing tube or smoke inhalation, but Hull hadn’t experienced either of these things. Nor did she appear to have a tumor or obstruction. Way down on the list of possible causes of stridor, Weinstein said, was a very rare disorder called subglottic tracheal stenosis. For reasons that are unclear, nearly all of those affected are white women between the ages of 30 and 50. The disorder involves a narrowing of the windpipe just below the vocal cords. If there is no known cause — as occurs in about 15 percent of cases — the condition is deemed idiopathic. The incidence and prevalence of the disorder is not known. Cases are often misdiagnosed as asthma or, less often, chronic obstructive pulmonary disease. There is no specific test for the disorder, but the narrowing can be seen on a CT scan of the neck. Medications and surgery have been used to treat the stenosis, but because the condition is so rare, it isn’t known what works best. Weinstein told Hull that he suspected she had subglottic stenosis, although he had never seen a case. When he saw the CT scan order, he noticed it was for a lung CT, not a neck scan, and intervened to have the order changed. He also referred Hull to an interventional pulmonologist at Penn’s Lung Center who specializes in treating subglottic stenosis. Hull said she was told that Penn sees about 10 cases annually. The scan showed what Weinstein suspected: a narrowing of Hull’s trachea. The pulmonologist confirmed the diagnosis. He said “I was essentially breathing through a straw,” Hull said. “But it was such a relief for someone to say what was wrong.” A month later, Hull underwent a bronchial dilation, which involves expanding the airway, often through use of a balloon. More-severe cases and those that don’t respond to dilation may involve delicate and difficult surgery to remove the diseased sections and reconnect the trachea. Some patients require multiple dilations, while others need only a single procedure. “The more narrow the neck gets, it’s harder to dilate,” Weinstein said. “Then you need a resection, which is a very big operation.” Hull said the procedure restored her trachea to about 90 percent functioning “which is good enough for me.” So far, she said, she has not needed a second procedure, although she knows from online patient groups that this remains a possibility. “The first year out, there was a lot of anxiety,” she said, wondering if the procedure would work. “I know there are people who’ve had 12 of these” dilations. In addition to coughing and clearing her throat more often than normal, Hull said she notices that colds linger. Recovery from the last one took three weeks. Hull said she is especially grateful to her friend for helping to manage her case and steering her to the right expert. “I’m so lucky I know Mike,” she said. To Weinstein, Hull’s experience illustrates the importance of persistence. Most people with symptoms like Hull’s have asthma and “get treated and feel better,” he said. But when that doesn’t happen, “it’s important to stay on it until you get an answer.” Submit your solved medical mystery to sandra.boodman@washpost.com. No unsolved cases, please. Read previous mysteries at wapo.st/medicalmysteries.

Treating chronic illness with cough syrup: Life in the coverage gap

MIAMI — Genesis Matos Rodriguez wakes at 6:30 a.m. and shuffles to the kitchen, where garlic ropes hang on beige walls. Air cleansers, her grandmother calls them. Her mom lays out **** Robitussin cough syrup and a glass of Alka-Seltzer, substitutes for the prescription pills they can no longer afford.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Rodriguez was born with asthma and Middle Lobe Syndrome, which causes mucus to build in her lungs. Two years ago, her right lung collapsed; surgeons removed half. Her monthly medical bill to ward off fluids, including Pulmozyme and Albuterol, can hit $4,000. She slipped into what policy analysts call the coverage gap. Three months before her 20th birthday, on an otherwise ordinary July day, the state declared Rodriguez independent and no longer eligible for Medicaid. Her mother, legally the head of their household, made $9,000 last year working part-time — a few thousand dollars short of qualifying the family for premium subsidies under the Affordable Care Act.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Nearly 4 million Americans and 800,000 Floridians live in this limbo of patchwork health care: They are not eligible for Medicaid; they don’t make enough money to afford ACA coverage. Florida, like many states that recently elected (or reelected) Republican governors, has decided not to expand Medicaid eligibility under the Affordable Care Act.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico As a result, many low-income Americans with chronic illnesses are bracing to make it work for the next four years — or simply through the day. They swap prescriptions for CVS bargains. They rely on family remedies: whiskey for a sore throat, tea leaves for asthma. They tumble into debt when an ailment demands medical attention. “They come to us with high hopes,” said Santra Denis, community health director of the nonprofit Catalyst Miami, “and expect to find a solution, a way to get insurance. We have to let them down.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico On this December morning, Rodriguez drowns her over-the-counter medley with red Powerade. She sits at a wooden table and breathes into the plastic nozzle of a Intrapulmonary Percussive Ventilator. Bursts of air and medicine open her airways. Medicaid funded the $10,000 machine. Refills, however, still cost hundreds. She often skips the recommended daily doses to extend her supply. The sun climbs over Little Havana, creeping through her blinds, touching the poster of a white Porsche Cayenne and, above her bed, advice from her favorite writer, Henry Miller: **“** _Every man has his destiny; the only imperative is to follow it, to accept it.”_    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Her destiny, Rodriguez believes, starts with auto mechanic training — with or without health insurance. **** Even if car fumes trigger asthma attacks. Even if asthma attacks send her to the emergency room. Even if a mere upper respiratory infection kept her home last week.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico She quit running to avoid coughing fits. She ditched salsa dancing at the Batting Cage. She missed Art Basel, the annual Miami gallery parties. But she won’t give up school. *** Before the Affordable Care Act passed in 2010, Medicaid eligibility requirements differed across the country. A low-income family could qualify for the benefit in California, for example, and lose coverage if they moved to Texas. In most states, poor adults without children did not qualify for Medicaid. Obamacare sought to curb the nation’s eligibility discrepancies with the Medicaid expansion, opening coverage to people earning 138 percent of the federal poverty line — and providing health insurance to millions more poor Americans.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico But the Supreme Court struck down the provision, granting states the power to opt out. Twenty-seven states have since expanded Medicaid eligibility, providing no-cost care to a larger pool of low-income workers. Florida has not.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Democratic leaders say the expansion was meant to protect poor adults, who typically have no safety net unless they become parents. Republican leaders argue that it could strain state budgets and discourage people from working.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico The coverage gap became a hot-button issue in Florida during last year’s midterm elections. Then-gubernatorial candidate Charlie Crist, a Democrat, vowed to fight for the Medicaid expansion. Rodriguez **,** meanwhile, emerged as a reluctant symbol in Florida’s Medicaid debate. In September, Crist visited her apartment, a subsidized housing unit above a public library. Her mother, Mariamee (who works part-time for minimum wage and also lacks insurance) sent him a letter about her family’s conundrum: “We’re too rich for Medicaid, too poor for Obamacare.” (Rodriguez missed the politician for school. She had a quiz.)    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Crist lost to Gov. Rick Scott by a narrow margin. Scott, a conservative, publicly supports the expansion but has done little to push it through the Florida legislature. When he was reelected in November, Mariamee recalls Rodriguez saying: “That’s it. I’m dead.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico That month, Rodriguez applied for disability insurance, her last-ditch hope for stable coverage until she graduates from auto mechanic training in June and, hopefully, lands a full-time job with benefits.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Weeks later, she caught the respiratory infection, couldn’t breathe and landed in the emergency room. The trip cost about $1,900. The antibiotics, $170. Mariamee sent the bills to the Department of Children and Families, which reopened her daughter’s Medicaid through Florida’s Medically Needy Program for the remainder of the month.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico On New Year’s day, Rodriguez lost her insurance again. Mariamee started collecting January bills to send to DCF and prove her daughter’s need again. That week, the state denied Rodriguez’s disability application. “It’s like they need you to be in bed, covered in tubes,” Mariamee said.  “It’s like they need you to quit school and become a coach potato and lose any progress you’ve made for this to happen.” *** This afternoon is Rodriguez’s first day back to class since the respiratory infection struck. Anxiety grips her: _I’m at least three lessons behind_ , she thinks. The five-pound “Modern Automotive Technology” textbook in her crossbody satchel helps. Learning, however, clicks in the garage.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico She’s the only woman in her class at Braman Motors Miami, a partner of the Lindsey Hopkins Technical Center, and starts a year-long internship this month at a Braman dealership. Someday, she wants to open her own body shop. For now, she works on her ’94 Honda Civic: Beastie, a near-junkyard purchase for $1,000. She painted it matte black and installed red rims. It’s not ready to drive — yet. For now, she takes the bus. Rodriguez ties her dark, waist-length curls into a topknot. Mists herself with Axe Body Spray, “just like a man.” Buttons up her blue, short-sleeved mechanic’s uniform, which hides the tattoo over her heart: _Veni , vidi, vici._    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico “Stay warm, okay?” Mariamee calls. “Come home if you keep coughing.” “I’ll be fine, mom.” “You have your inhaler?” “I’ll be _fine_.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico *** Nearly 55 percent of Americans in the coverage gap work part-time or full- time, according to Kaiser data. Two-thirds live in a household with at least one breadwinner. The majority work for firms with less than 50 employees, which aren’t legally required to provide health coverage. Seventeen percent live in Florida, Kaiser reported. Many earn minimum wage. Many can barely afford to pay the rent.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Florida, like most states that did not expand Medicaid, offers no assistance to people without dependent children, except in rare cases. Young adults who grew up receiving the benefit often stop seeing their regular doctors once coverage halts.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico When Crist lost in November, Catalyst Miami’s Denis said, reality sank in. Floridians, she believes, will likely stay four more years in the coverage gap: “We felt defeated.” She works with 400 clients monthly. Ninety percent, Denis said, fall in the coverage gap. She can connect them to charities. To free mammograms, for example. But some require surgeries. “It’s the norm around here,” she said. “We see people who’ve always gone to doctors and need their prescriptions. … They lose access to that and don’t have a way to get it back.” Shahriar Shahzeidi, a Miami pediatric pulmonologist, has treated Rodriguez for nearly five years. Dozens of his patients, he says, live in the murky world between Medicaid and subsidies. “Many are worse off than Genesis,” he says. “Many need a ventilator, which keep them breathing. Or maintenance on a ventilator. … There are countless needs not being met.” Shasehdi wrote a recommendation letter to Florida’s Department of Social Security: “Genesis’s condition is chronic. … There is no cure. [It could] interfere with her daily life and job.” He worries about patients who search for insurance without relief. He watches them fall out of jobs, into hospital beds — and into debt. “Genesis is a very careful person,” Shasehdi said. “She goes out of her way to avoid environmental allergens. But, I tell her, she needs to stay on her medicine. If she doesn’t take her medicine properly. … Within six months, I’d expect she’ll lose another part of a lung.” *** Today’s lesson in Braman Motors Miami garage: Build a circuit. Rodriguez jots shorthand instructions on her right wrist: _Salt   __Tase   __Ready   __Land   __Ground_    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico She puts on plastic goggles and studies a printed diagram. Students in black work boots stand below an elevated PT Cruiser, fiddling with red gauge wire. Someone whistles “Pop Goes the Weasel.” A poster on the gray wall reads: _DRIVEN_.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico “Wanna work together?” a classmate asks. Rodriguez nods. They put the wire in a vice. She holds one end in her pink glitter fingertips. He aims the soldering gun. Smoke rises. Into her nose. Into her throat. “Ah! It smells _bad_. Burnt plastic.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico The coughing starts. Rodriguez forces it down. Her mind wanders to a class she missed last week. Her classmates fashioned metal into rings. She stayed home playing Kingdom Hearts. “I wanted to be here when you guys made _jewelry_ ,” she tells her classmate. “That would have been my favorite class.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico He laughs. The urge to cough vanishes. Victory, for now. She reaches for the soldering gun. Her turn. “It’s really soft metal,” Rodriguez says, staring up-close at the wire. “It melts really fast.” In these moments, she forgets her lungs. She thinks about her Honda Civic, Beastie. She’ll fix the push-start button soon. The cylinders next. The process, like her health-care options, will be slow and uncertain. She will apply soon to body shops across South Florida — or get hired at Braman, if she’s lucky. She will send medical bills each month to the state and hope to qualify for the Medically Needy Program. She will start sick days with Robitussin and Alka-Seltzer.

Surprise! Donald Trump suggests he still has doubts about Clinton’s health explanation

For 24 hours, Donald Trump had been pretty hands-off in his reaction to Hillary Clinton falling ill at a 9/11 memorial on Sunday morning: first silence, then a relatively low-key Monday morning reaction. But if you look closely at his first comments about the Clinton campaign's pneumonia diagnosis, it's clear he can't quite help but cast doubt on the whole explanation.  "You know, it was interesting because they say pneumonia on Friday, but she was coughing very, very badly a week ago, and even before that, if you remember. This wasn't the first time," Trump said. "So it's very interesting to see what is going on." And he seemed to hint, while saying that campaigning is "grueling work," that Clinton's campaigning wasn't nearly as demanding as his. "If you look at my scheduling and compare to anybody else's scheduling, there's not a contest." These comments were tossed into a bunch of boilerplate about Trump wanting Clinton to feel better and return to the campaign trail. But it's classic Trump: he's suggesting something is amiss without saying it directly.  It wouldn't appear particularly helpful for Trump to insert himself into this debate, and his campaign seems to know that. As The Post's Robert Costa tweeted Sunday night, his team said he wasn't planning to tweet about the incident.  Similarly, on this, Trump seemed to be making an effort to avoid inserting himself into the story -- and politically, that would have been the best call as well. He almost pulled it off.

The conservative media’s obsession with Hillary Clinton’s coughing

Hillary Clinton has had two public coughing fits in the past week. This is important because ... well, it's not explicitly clear.   This is typical of coverage by right-leaning news outlets whenever Clinton suffers an on-camera coughing spell, as she has on several occasions in this campaign. The recurring headline might as well be "Hillary Clinton has a coughing problem — just sayin'."   In another tweet, which he later deleted, Drudge wrote that "no probe into Hillary's flaring hypothyroidism/Hashimoto's is top media coverup of '16. There is a goiter forming!"  Let's also say that it is fair to ask whether presidential candidates — especially older ones like Clinton — are up to the physical demands of running the country. Clinton will be 69 on Inauguration Day; Donald Trump and Bernie Sanders will be 70 and 75, respectively. All three have released doctors' notes documenting good health. If Clinton actually had a serious medical problem, or otherwise appeared too frail to be president, it would be a big deal. But mainstream media outlets haven't made a big deal of Clinton's coughing because, as Dr. Philip Weintraub explained last fall to an inquiring patient — The Fix's Philip Bump — it probably doesn't indicate anything more than a dry throat brought on by prolonged talking.    Once upon a time, even Matt Drudge thought Clinton's coughing fits were merely a side effect of giving speech after speech — something worthy of a little sympathy and even admiration, not something that might disqualify her from the White House.

Woman wakes up in morgue. The ‘Lazarus phenomenon’ surfaces more than you think.

After 11 hours in the morgue, a 91-year-old Polish woman started stirring. Janina Kolkiewicz had been declared dead by her physician in an eastern Polish town called Ostrow Lubelski. He found her without a pulse and filled out her death certificate, Polish newspaper Dziennik Wschodni reported last week. Her family started making funeral arrangements. Then she woke up in “cold storage” and asked for hot tea and pancakes.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico “I was sure she was dead,” Wieslawa Czyz, a physician who examined her, told TV station TVP, BBC News reported. “I’m stunned, I don’t understand what happened. Her heart had stopped beating, she was no longer breathing.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico But Kolkiewicz isn’t the first to “return from the dead,” as headlines often say. An anatomical pathology technician told the Guardian the woman likely had a pulse — but a very weak one.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico “Even within the medical community there is debate over what really constitutes death, and it is seen less as a single event and more as a process,” Carla Valentine, technical curator at Barts Pathology Museum, wrote in a Guardian op-ed. “It involves several different mechanisms ceasing, not just one, which is why there can be ethical arguments around brain stem death — when the person is in fact deceased but their tissues can be artificially kept alive.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico It happens, Valentine said. In January, a 24-year-old Kenyan man named Paul Mutora woke up in a morgue after he had allegedly tried to kill himself by swallowing insecticide. When the technicians heard noises, “the mortuary attendant and a worker took to their heels screaming,” a witness told a local newspaper.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico “This was a mistake from the start and I apologize to my father,” Mutora said.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico In February, 78-year-old Walter Williams started kicking in a body bag in an embalming room in a Mississippi funeral home. Coroner Dexter Howard called an ambulance and had him taken to a hospital. He said he thought Williams’s pacemaker had temporarily stopped working.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Then he called the family. “He said, ‘Gracie, don’t get upset. We’re fixing to take your daddy to the hospital,’” Williams’s daughter Gracie Williams told the Clarion-Ledger. “I said, ‘What?’ And he told me, ‘He’s back moving.’”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Later, when they asked him what happened, he said he woke up in the hospital. “He said, ‘I had to be sleeping through all this,’ and [Williams’s daughter] Sarah said, ‘Daddy you were dead,’ ” Gracie Williams added. Unfortunately, two weeks later, he really did die.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico There’s a term for such resurrections: the “Lazarus phenomenon,” which refers to the biblical story of Jesus summoning Lazarus from his tomb. The phenomenon is described as “delayed return of spontaneous circulation after cessation of cardiopulmonary resuscitation,” according to a 2007 study published in the Journal of the Royal Society of Medicine. Researchers counted 38 documented cases, including three where the “deceased” made it as far as the morgue before coming back to life.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico However, such cases are likely underreported, the study said, in part because declaring someone dead who isn’t can have legal repercussions, especially if paramedics or doctors ceased resuscitation efforts. **   **    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Example: In April, the family of an 80-year-old grandmother revived a medical malpractice suit, claiming she had been zipped up in a body bag — alive — and put in a hospital morgue’s freezer where she froze to death. Maria de Jesus Arroyo was declared dead in the summer of 2010 after going into cardiac arrest. She was pronounced dead at White Memorial Medical Center in Los Angeles. She allegedly wasn’t. When Arroyo’s body arrived at the mortuary a few days later, it was face down. The body bag was halfway unzipped, and her face was battered — a broken nose, bumps and bruises, court documents said.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico The problem is that even some doctors don’t quite know what death is and rely solely on the absence of a heartbeat and respiration, according to the research. “Death should not be certified in any patient immediately after stopping CPR, and one should wait at least 10 minutes, if not longer, to verify and confirm death beyond doubt,” according to the 2007 study.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico In other words, don’t be so quick to call for a body bag.

The memories that tobacco evokes

Thank you for Timothy R. Smith’s review of Gregor Hens’s book “Nicotine” [“The emotional up and down of lighting up,” Jan. 18, Book World]. It was shocking to read Smith declaring that he was looking forward to smoking his cigar. These days, admitting to anything but contempt for tobacco is practically a criminal offense. I say this as the son of a woman who smoked for 70 years, beginning at age 12. Aside from her family, Pall Malls were the joy of Mom’s life. Nobody believes or understands this when I tell them, so I’ve stopped telling them. Mom smoked while pregnant, she smoked while nursing her three children, she smoked while cooking us dinner. She smoked. All. The. Time. Few are the family photos that show Mom without a cigarette in her hand or at her lips. In fact, a Post photographer found her puffing away at her favorite restaurant, and she was pictured on the cover of the Montgomery Extra, for a story about Montgomery County’s proposed smoking ban. Toward the end, Mom was buying cartons of cigarettes in bulk, to save money. Sin taxes had pushed up the price of a pack to cumbersome levels for a retiree. For a while, she switched to cheaper generic brands, but they lacked that special oomph of Pall Malls. Not enough nicotine, I guess. Mom died at 82, but not from cancer or even emphysema. She died of a broken heart two months after her husband of 56 years passed. At her funeral, we emptied cartons of her unsmoked cigarettes into a basket and set it next to the guest book, with an invitation to pick up a coffin nail in Mom’s honor. Many did just that. Of course, nobody lit up. Because, while it was a gratifyingly large crowd, almost no one was a smoker. And none of Mom’s three kids smoke. One reason is that my folks were smart — they never forbade us. Indeed, whenever we showed any interest, Mom would casually put the cigarette to our lips and let us inhale. Oh my God! We would cough and run away thinking, “How can adults be so crazy?” Today, of course, someone would call Child Protective Services. So while I do not mourn for Big Tobacco or decry the decline in smoking, I do sometimes miss the smell of secondhand smoke. It smells like home. ****Dave Nuttycombe** , Silver Spring**

Consumer Reports Insights: Unexplained fevers can be signs of serious illness

No medical mystery is more challenging than a fever of unknown origin. An FUO is defined as an elevated body temperature that lasts for three or more weeks without an explanation, according to Marvin M. Lipman, Consumer Reports’ chief medical adviser. One famous example — not only because of the belatedly discovered cause but also because of the patient’s identity — harks back to 1962, when a 77-year-old woman was admitted to a prestigious New York hospital with an unexplained fever of about six weeks’ duration. She had lost a significant amount of weight and over the previous year had received several blood transfusions when her bone marrow failed to make red blood cells. Aside from a chest X-ray that revealed an old scar, all her laboratory tests were negative. Her physicians, including several luminaries of the day, were frustrated and mystified. Several weeks before the woman, Eleanor Roosevelt, died in her New York apartment, cultures of her bone marrow grew tuberculosis bacteria. An autopsy discovered that the cause of death was miliary tuberculosis, a rare form of the disease in which the TB bacilli spread through the bloodstream and infect multiple organs. The bacteria turned out to be resistant to the antibiotics available at the time and would have killed the former first lady even if her illness had been diagnosed promptly. That may have helped ease the conscience of those involved in her care. Fevers of unknown origin are always worth investigating because they can be caused by many conditions, including serious ones. One would think that with our current sophisticated diagnostic techniques, FUOs would be less common than in years gone by. Instead, the number has increased, and no one is sure why. Infections are the cause of about one in five unexplained fevers. They include endocarditis, or an infection of the heart valves, as well as such infections as cytomegalovirus, Epstein-Barr virus and toxoplasma, a parasite. The early 1980s surge of immunocompromised people with HIV/AIDS was associated with an increase of previously obscure and hard-to-diagnose viral and fungal infections, all capable of causing weeks of fever. Today, of course, we know to look for those conditions, which have become less common in the United States with the steady improvement in treatments for HIV/AIDS. Cancer accounts for about 20 to 30 percent of FUOs, and that hasn’t changed over the last half- century. Lymphomas, especially of the Hodgkin’s disease type, are the most common cancer-related cause of a prolonged fever. Kidney and colorectal cancers are also frequently to blame, even when they’re small and therefore more difficult to pin down. Long-lasting fevers can also be due to disorders marked by the inflammation of connective tissue, the glue that binds cells together. Rheumatic diseases such as polymyalgia, rheumatoid arthritis and lupus can cause temperature elevation long before more recognizable symptoms appear. The same can be true for inflammatory bowel diseases such as ulcerative colitis and regional ileitis. Medication, too, can cause FUOs, even after people have been taking them for a while. Among the more common culprits are sulfa drugs, phenytoin (Dilantin and its generic cousins), allopurinol (Zyloprim and generics), methyldopa (Aldomet and generics) and isoniazid. Since fever can be a marker for many problems, it’s important to know what constitutes a significant elevation in body temperature. The most accessible site that reflects true internal body temperature is the rectum. Rectal temperature can vary from an early-morning low of 97.9 degrees to a late-afternoon high of 100.4. Oral, armpit and ear temperatures are less accurate and can be affected by environmental factors. Normal armpit temperature can be as low as 94.5. To determine your “normal” temperature, select a site and check it morning, afternoon and evening for three days in a row when you’re feeling well. Then calculate your average temperature for each of the three times of day. Any measurement above your average is a fever, and if you have a fever for three to five days without obvious accompanying symptoms, it’s time to give your doctor a call. Copyright 2011. Consumers Union of United States Inc.

Washington’s wildfires gave this sea otter asthma. Now she’s learning to use an inhaler.

*[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico One-year-old Mishka has spent nearly all her life in the water. But fires burning miles away are threatening her health. The young sea otter, a resident of the Seattle Aquarium, was diagnosed with asthma after inhaling smoke from this summer’s vicious wildfires, according to the aquarium.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Like many people in Washington State and across the west, she has been having trouble breathing the air that’s suddenly full of dust and soot. So, like people, she’ll need to learn to use an inhaler. Feel free to “aww” now. We’ll wait. Mishka’s trainer at the aquarium, Sara Perry, has been teaching her how to use the device through games and treats. She tucks food into the mouthpiece of the inhaler, so that the otter will open her mouth and breathe in. Then Perry can send in a puff of asthma medicine — the same kind of medicine that humans use. “We want to make this as fun as possible,” Perry told local TV station KING-5 News.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Aquarium staff wrote in a blog post that Mishka is the first sea otter known to have asthma, and they’re still not sure why she developed it. The likely explanation may involves some combination of environmental factors and genetics. Seattle’s sea otter population lacks genetic diversity, since it was hunted to extinction in 1910 and only reintroduced a few decades ago by bringing about five-dozen otters down from Alaska. It’s believed that most of those didn’t survive, and that the state’s entire otter population descends from as few as 10 animals. This hurts the otters’ genetic diversity, compromising their immune system and making them more vulnerable to disease.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico All that, combined with the choking smoke from the fires burning in the east, probably caused Mishka’s asthma. And she’s hardly the only one whose lungs are suffering. States don’t yet have health data on how this year’s fires have affected people with asthma and other breathing difficulties. But anecdotally, things don’t look good. “What the fire and particles do is like sunburn in their lungs, putting the smoke right down in their lungs,” Dr. Vipul Jain, a pulmonologist who runs a chronic lung disease program in Fresno, Calif., told the New York Times. “We see a whole bunch of people get exacerbated and getting hospitalized, no matter what we do.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Peter Rabinowitz, a professor in the University of Washington’s School of Public Health, says that cases like Mishka’s are a warning signal, a reminder that we’re not immune to the environmental changes that affect animals. “More and more there starts to be this concept of what we’re calling ‘One Health,’ which really is that there’s a connection between health of people and the health other species,” he told told KING-5. “Sometimes those species can tell us there is a problem in the environment that could be important for human health as well.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico