GETTYSBURG MEDICAL CENTER
The Clinical View
By P. E. Hoffsten, M.D.
25 October 2006

What Kind of Infections Are There, Anyway?

          The gentleman was 52 years old and, as far as he was concerned, a picture of health.  He was flying his one engine plane from the upper New York state to Seattle, Washington for “recreational purposes.”  His occupation was growing grass sod for commercial buildings.  He was a very physically strong individual in that he cut and laid sod on a daily basis.  He was the owner of the business and a hard driving individual.

          As he was returning from Seattle, Washington to New York, he became sick with a 102 degree fever.  He flew as far as he could and landed in Pierre because he said he just couldn’t fly any further.  He came to our emergency room with diffuse body aching and a 102 degree fever.  A routine blood count showed a very high white blood cell count and a very high CRP.  The CRP blood test is an indicator of infection, although it doesn’t tell where the infection is or what kind it is.  Viral infections tend not to raise the CRP very much, but there will be a slight increase in most viral infections.  Thus, we can use this test as a measure of the seriousness of an infection.

          As you might imagine, this private entrepreneur from the state of New York was a little short on patience and not real skilled in the manner department either.  He had not picked up any “midwestern charm” in his brief stay in Pierre.  His being clinically ill didn’t help at all.

          The morning after admission he wanted to know what kind of infection he had, what should be used to treat it, and when he could get out of the hospital.  I indicated to him that we had no localizing finding to suggest what type of infection he had at this time.  He didn’t have a pneumonia.  There was no abnormality in the liver functions.  His kidneys seemed to be working fine.  There was no bladder infection.  There were no sore areas on his body to suggest a localized abcess.  There was nothing that would really give us an index of what might be wrong.  As further history was being elicited, he blurted out, “What kind of infection do I have?  How many kinds are there?  How hard can this be?”

          With relative calm, I explained to him that there were at least seven different types of agents in this world that can infect the human body.  There is nothing like going into the Virginia Satir “computer mode” to calm one’s nerves and diffuse confrontations.  That is what I did as I explained to him.

          I told him the most common infections healthcare providers encounter are bacterial.  Bacteria are single celled organisms that can grow outside the body or inside the body. They tend to invade through breaks in our skin defensive barriers, the intestinal lining defensive barriers, or the lung lining defensive barriers.  Once they enter the body, we are the richest source of nutrient they have ever seen and they grow very fast.  This is the type of infection that overwhelms a person and can cause a fatal pneumonia or “blood poisoning”.  I explained that bacterial infections can present in many different ways.  The best way to diagnose them is to obtain a culture from the site of the infection, identify the type of bacteria, and then treat it directly.  This gentleman had no localizing area from which bacteria might have been grown.  Blood cultures, urine cultures, and sputum cultures had all been obtained but had not grown anything abnormal.  Although he was being treated “as if” he had a bacterial infection, I couldn’t tell him that there was definitely a bacterial infection present.  This was very little satisfaction for him.

          I then explained that the condition he had could be viral in as much as there were no localizing findings, but that he had a high fever and diffuse muscle aches.  Viruses often affect a person systemically in this way and fortunately clear up in the course of a week to ten days.  Influenza A, Influenza B, and West Nile Virus titers were all checked and they were negative.

          I explained that there were infections often caused by organisms called fungi.  These infections can be the same kind of mold that grows on cheese or moldy bread and require very different treatment than bacterial infections.  Fungi are not susceptible to the usual antibiotics.  I explained to him that there are only four types of fungi that normally infect humans and he did not have any of the characteristics that would suggest the need for antifungal treatment.

          I next explained that there are organisms called protozoa or “parasites.”  These are diseases such as malaria and a host of other infections common in underdeveloped countries, but rare in the United States.  He was not in an area that would have been suspected to have malaria infected mosquitos and I told him I doubted that was the problem.  Next I told him that there are very rare types of infections called prions that infect the brain and cause diseases such as kuru or Jacob-Creutzfeldt disease.  He surely did not have this type of infection.

          I explained that there are such things as worms that can infest the human body and cause problems very much like he was having, but he was not from an area where one would expect such a problem.

          Lastly, I explained that there is a type of organism that is almost like a virus and almost like a bacteria, but not quite like either one.  These organisms called rickettsia only grow inside of a cell and cause diseases such as Rocky Mountain spotted fever or typhus.  We had submitted blood tests to see if this was the type of problem that he had, but the tests had not returned to this time. 

          He remained very impatient, now on the third hospital day, still with a fever but definitely improving.  He had been started on antibiotics to treat what was most likely a bacterial infection.  On the fourth hospital day, his blood tests returned showing that he had Lyme disease and that the antibiotic he had been started on when he was admitted was appropriate to cure the illness.  As you might expect, he complained that the diagnosis had taken too long to achieve and he wanted to know when he could leave.  As far as I was concerned, it was not soon enough.  When he got up and tried to walk around the hospital on the fourth hospital day, he was still very weak and didn’t feel he could fly his airplane back to New York.  Arrangements were made for him to fly commercial back to New York and come pick his airplane up at a later time.

          Somehow Lyme disease has found its way into the news media and because of the news media’s terror tactics  I get a number of inquiries from patients with nonspecific clinical illnesses thinking they have Lyme disease.  This gentleman is the only one I have ever seen that had lyme disease.  He lived and worked in an area where the lyme disease carrying tick is present.  That tick is not a common finding in South Dakota and I have never seen a case of Lyme disease here except this one.  In order to diagnose the disease, a blood test has to be done with a confirmatory test two weeks later.  But the test has to be sent to Sioux Falls and takes several days before a definitive answer returns.  So we got him diagnosed about as fast as it could be done even though treatment was started on the first day to treat him “as if.”

          “As if” means that we start an antibiotic program that will cover a large number of possible infections.  The general rule is that infections treated earlier do a whole lot better than infections that are not treated appropriately until much later.  Therefore, antibiotics are started before the diagnosis is ever achieved and then the ones we don’t need are discontinued once the diagnosis is made.  This is a safety step to ensure that we don’t miss treating infections that can cause major problems.

          The healthcare providers at your local clinics are well aware of these considerations and it is part of their job to separate out those people that have “a little flu” and those that have something more serious such as lyme disease.