By AMBER SMITH
Every doctor has that patient he or she can’t forget.
Jerrold Abraham, MD, and Donald Blair, MD, took care of a man with a mysterious infection 15 years ago, but only recently was their diagnostic quandary solved, thanks to advanced DNA testing that wasn’t available back then.
“I remember setting the sample aside and saying too bad we can’t figure this out yet,” recalls Abraham, a professor of pathology and family medicine at Upstate.
Years later, a scientist from the Centers for Disease Control and Prevention got back in touch with him. Now, when virologists study the hundreds of known poxviruses, the one called “NY_v014” is noted to have been identified at Upstate Medical University in Syracuse.
Abraham, Blair and a pathology resident, Nelli Lakis, MD, who is now doing a neuropathology fellowship at Brown Alpert Medical School, wrote about the case in the August 2015 issue of the journal Clinical Infectious Diseases.
It started with a lesion
It was 2001 when the 45-year-old man first noticed a blisterlike lesion under his right arm. For three weeks he watched a rash spread on the right side of his chest, becoming progressively rougher, more tender and reddened. When he went to his rural community hospital, the man was admitted, so he could receive intravenous antibiotics. The rash got worse. The doctors tried another medication that also had no effect.
After five days, they transferred the man to specialists at Upstate. By now the rash area was a wound about 6 inches wide, and other lesions were developing. The man felt ill, was in pain and soon developed a fever.
Doctors struggled to determine what was causing the infection. To help spur healing, surgeons removed dead tissue from the wound and sent the man for hyperbaric oxygen therapy. Nothing helped.
Blair, a professor of medicine with decades of experience in infectious disease, had never seen anything like it. “No matter what we did, it got worse.”
Tissue samples from the wound revealed that it wasn’t caused by a bacteria. That’s why the antibiotics had not helped. It wasn’t caused by a fungus, either. The man’s infection turned out to be viral.
Solving part of the mystery
Using an electron microscope, Abraham could tell that the virus was a poxvirus, but it was unlike any of the hundreds of known poxviruses. Cidofovir, the medicine used to treat poxviruses, can cause severe or fatal kidney problems. Since this man had received a kidney transplant two years before, Blair couldn’t risk giving him the medicine.
“We just kept holding off, and holding off, and it was tough. That wound kept getting bigger and bigger,” Blair recalls. Doctors kept removing the dead tissue, and they kept the man as comfortable as possible. Finally, his body’s immune system kicked in and fought the virus.
Abraham, Blair and other doctors remained stumped: How had the man had become infected with a poxvirus no one had seen before?
He had not traveled outside of the country. He hadn’t even left Upstate New York. He lived a somewhat isolated, rural life. He had no contact with animals, other than a feral cat. The man recalled treating an abscess on the cat’s back.
Since the cat came out of nowhere and had since disappeared, no one knows for sure that the man contracted the poxvirus from direct contact with the cat’s abscess. But it’s Abraham’s and Blair’s best guess.
Recovery, and the rest of the story
The man, who asked not be identified, was hospitalized for two months.
Six weeks after he went home, he returned for a skin graft procedure, which helped repair the wound site. Ten years after that, he remained free of complications. Earlier this year, he told Blair that his health remains good.
Like all organ transplant patients, the man’s immune system is suppressed, making him more susceptible to the transmission of a poxvirus or any virus.
He recovered from the infection, but Abraham and Blair were still curious to learn more about his particular poxvirus.
After isolating the virus at Upstate, they sent a viral culture to the CDC. Scientists there could only say that it was not one of the known poxviruses. Since then, advances in molecular biology and DNA sequencing improved, and new technology became available. Abraham got the call last year from CDC virologist Inger Damon, MD, the director of the division of high-consequence pathogens and pathology.
The poxvirus that had infected the man back in 2001 was unique and previously unidentified. No cases have been reported since. The closest cousin to the NY_v014 poxvirus is one that was identified in a mosquito collected in 1972 in Central Africa.
About pox viruses
Despite its name, chickenpox (caused by varicella-zoster virus) is not from the family of poxviruses. Chickenpox is a herpes virus. One of the more well-known poxviruses is smallpox (or variola virus.) Of course, smallpox is essentially eliminated, but some of the findings in this patient’s tissues resemble those reported many years ago with smallpox.
This article appears in the summer 2016 issue of Upstate Health magazine