Public Health, U.S./Mexico: respiratory illness in college kids

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I havenít been around here lately, and I notice a recent thread asking "Where is everyone?" Well, in my case, Iíve just been too busy to visit.

The two newspaper articles below give a hint as to why I havenít had time to drop by... Please note that both articles contain numerous inaccuracies, the most important of which is the emphasis on histoplasmosis. Yes, this might be a cause, but we just donít know yet. Weíre not even certain it's fungal, despite what is claimed in the articles. Don't believe everyting you read in the newspapers!

If this outbreak is of interest to anyone, I suggest you keep alert to the usual news sources; I expect more will be made publically available soon. Itís a rapidly changing situation.

Cheers, --Andre

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Headline: Health officials probe clusters of flu-like illnesses

After Mexican trip, 11 Muhlenberg students reported symptoms.

Source: 04/06/01 By ANN WLAZELEK Of The Morning Call [Allentown PA]

URL: http://www.mcall.com/html/news/regional/b_pg003_e65fungus.htm

Federal health officials are investigating clusters of flu-like illnesses reported by college students who spent spring break at a hotel in Acapulco, Mexico, including nearly a dozen students at Allentown's Muhlenberg College.

A spokeswoman for the U.S. Centers for Disease Control and Prevention in Atlanta said it could take two weeks to identify the cause of the students' symptoms, which included fever, dry cough and fatigue.

However, a spokesman for the Pennsylvania Department of Health and the medical director at Villanova University in Bryn Mawr said they believe dozens of students from Pennsylvania, New York, New Jersey, Rhode Island and Maryland were sickened by an unusual and sometimes serious lung infection called histoplasmosis.

Histoplasmosis is caused by fungus found in some soils here and abroad. Spores from the fungus are inhaled when the soil has been disturbed. Histoplasmosis cannot be spread from one person to another, but can be treated with antifungal medicines. It presents no danger to young people with healthy immune systems. However, for those whose immune systems have been weakened by HIV, chemotherapy or anti-rejection medicines, the illness can be fatal.

"It appears everyone is recovering," said Richard McGarvey, spokesman for the state health department.

Sam Miranda, Muhlenberg's health services director, said 37 students from the Allentown campus went to Acapulco for spring break, but only six went to the student health center with symptoms. Miranda referred all six to the emergency rooms of local hospitals and offered the services of a local group of infectious disease specialists.

Doctors at St. Luke's Hospital-Allentown Campus admitted one of the six overnight because of dehydration, but the rest were examined and sent home or back to school, he said.

"All have improved and have returned to classes," Miranda said.

Vicky Kistler, manager of communicable diseases for the Allentown Bureau of Health, said there could be as many as 11 Muhlenberg students who got sick after being in Acapulco.

Until a full investigation can be done, she said, it is difficult to know who became ill from the trip to Mexico versus other causes. The bureau's investigation awaits a definitive diagnosis from the state health lab in Lionville.

"We're holding tight until we know what we are dealing with," Kistler said.

Dr. Richard Pacropis, Villanova's medical director, alerted state and federal health officials to the potential problem after 29 Villanova students started showing up at the student health center March 28 with lung infections after staying at the same Acapulco hotel the week of March 3.

Many of the students remembered inhaling dust from the construction of a nearby parking garage while sunbathing at the hotel. Thirteen or 14 were admitted to hospitals.

"We know it is fungal," Pacropis said Thursday. Doctors suspected histoplasmosis, based on the students' chest X-rays and exposure to the dust.

Pacropis reported the illnesses among students from Villanova, Muhlenberg and Georgetown University in Washington, D.C., because he feared that some people who stayed at the same hotel and got sick might have been misdiagnosed and are being given antibiotics for what appeared to be a pneumonia. Antibiotics work on bacterial illnesses, not those caused by a fungus.

Histoplasmosis can create cavities and scarring of lung tissue that makes a person more susceptible to pneumonia and chronic obstructive pulmonary disease, he said, adding, "Thankfully, I have not heard of any." Lehigh Valley infectious disease specialists Dr. Luther Rhodes and Dr. Jeffrey Jahre said histoplasmosis is not common in Pennsylvania but happens here. "We are on the border of the histoplasmosis belt, which runs along the Ohio River Valley," Rhodes said.

"It's a geographic fungus," Jahre added, with Indiana and other Midwestern states being at greater risk. "If you lived in Indiana, you've probably been exposed."

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Headline: Villanova students contract lung infection in Mexico

The respiratory ailment can resemble pneumonia.

They caught it while vacationing in Acapulco.

Source: By Faye Flam, Philadelphia Inquirer Staff Writer, 5 April 2001

URL: http://inq.philly.com/content/inquirer/2001/04/05/city/MOLD05.htm

While vacationing in Acapulco, Mexico, 29 Villanova University students contracted what appears to be a rare and potentially dangerous lung infection called histoplasmosis, sending many to the hospital.

Caused by a fungus, the illness can mimic severe pneumonia but does not respond to antibiotics. "It's actually very serious," said Richard Pacropis, Villanova's medical director, who said he feared that many other cases might be lurking among people who visited Acapulco recently.

The illness cannot spread from person to person. All 29 students are expected to recover.

While younger people usually make a complete recovery, histoplasmosis can leave permanent scarring of the lungs in older people, even those in their 40s and 50s. In rare instances, the disease can be deadly, especially for those with AIDS or other conditions that weaken the body's immune system.

Pacropis said he has notified the Pennsylvania Department of Health and the U.S. Centers for Disease Control and Prevention. "My suspicion is that there are a lot of people being treated for pneumonia who are misdiagnosed" and getting the wrong drugs, he said.

The illness is caused by inhaling spores of a soil-borne fungus. Because most pneumonia cases are caused by bacteria, doctors tend to prescribe antibiotics, which have no effect on fungal infections. The proper medicine for histoplasmosis is an antifungal, which clears up the infection in two to three days.

The first of the Villanova students came to the university's student health center March 28 with symptoms of pneumonia. Each day after that, four or five more students came in, some with flulike symptoms, others with severe coughing, fatigue, and fevers as high as 103. Pacropis said 13 or 14 of the students were hospitalized.

Pacropis and a radiologist realized it wasn't pneumonia after taking chest x-rays.

"The appearance of the x-rays was extraordinary," he said. They showed white spots, indicating pockets of calcification - a sign of histoplasmosis. Further tests backed up the hypothesis that the students had a fungal infection.

After talking with the students, Pacropis found that they had all been to Acapulco during the week of March 3 and had all stayed in the same hotel. Nearby, bulldozers were moving dirt to construct a new parking garage, and the students remembered breathing in some dust while sunbathing by the hotel pool.

Pacropis said students from Muhlenberg College in Allentown and Georgetown University in Washington had also contracted the disease.

He said he was not sure whether they, too, stayed near this construction site. Pacropis said he was concerned that many other tourists could have breathed in spores and taken home an infection masquerading as an antibiotic-resistant pneumonia.

The organism that causes histoplasmosis is found in dry areas such as Arizona and New Mexico, and people from those areas often develop immunity. People who do pick up an infection generally get better on their own, but these students appeared to get an extremely high dose.

All but two of the students have been released from area hospitals. Because the infection has an incubation period of 20 to 21 days, Pacropis said, he is unlikely to see any more cases.

But the Villanova students said that students from Arizona and Texas arrived at their hotel as they were leaving. Pacropis said they could start coming down with the illness over the next few days.



-- Andre Weltman (aweltman@state.pa.us), April 06, 2001

Answers

The following was released by CDC late on Friday, and can be viewed at www.cdc.gov. I am not planning on posting here too much more on this situation, but if you are interested watch the usual news sources: I expect much more will be forthcoming.

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April 6, 2001 Contact: CDC Media Relations 404 639-3286, until 7 p.m. After 7 p.m., 404 318-2380 (press officer pager)

Press Release

Update: Acute respiratory illness among U.S. travelers to Mexico

The Mexico Ministry of Health and the Centers for Disease Control and Prevention (CDC) are investigating an outbreak of acute respiratory illness among U.S. travelers returning from Acapulco, Mexico, during March.

The source of the exposure has not yet been determined. However, preliminary information has revealed that all ill persons either stayed in or spent time on the premises of the Calinda Beach Hotel in Acapulco.

This cluster of illness was reported to CDC after a number of U.S. university students, who traveled to Acapulco during March, sought medical care for acute respiratory illness, with symptoms that included high fever, headache, dry cough, and chills. Laboratory testing for the cause of the illness is ongoing; however, initial tests indicate that the illness is probably histoplasmosis. Histoplasmosis is a disease caused by a fungus and primarily affects the lungs. The disease is not transmitted from an infected person to someone else.

U.S. travelers to Acapulco during March, especially students who visited or stayed at the Calinda Beach Hotel, should consult their primary health care professionals if symptoms develop. CDC has contacted all 50 state epidemiologists to begin identifying other possible persons with acute respiratory illness who recently traveled to Acapulco. Persons concerned about this outbreak should contact their health care professional or state health department for more information.

-- Andre Weltman (aweltman@state.pa.us), April 09, 2001.


Headline: Lung disease is cropping up on campuses

The infection was first detected in Villanova students. Scientists have traced it to Acapulco and spring break.

Source: Susan FitzGerald, Philadelphia Inquirer, 11 April 2001

URL: http://inq.philly.com/content/inquirer/2001/04/11/city/LUNG11.htm

[My comment: Oh well, I spoke to this reporter for at least 10 minutes but I guess I wasn't quotable enough. The article is accurate, especially concerning the diagnosis: it does look like the problem is probably histoplasmosis. Just how the infection was acquired remains under investigation. --Andre]

Outbreaks of a fungal lung infection first identified in Villanova University students returning from spring break in Mexico are showing up on college campuses around the country.

Federal health officials are investigating more than 200 cases of students who developed an acute respiratory illness that they suspect is histoplasmosis.

The students are from 37 colleges and universities in 18 states, and nearly all had vacationed in Acapulco in March and stayed at or visited the Calinda Beach Hotel there, according to the federal Centers for Disease Control and Prevention (CDC).

The first outbreak was picked up by an alert student-health physician late last month at Villanova, where 29 students got sick about two weeks after returning home. Similar cases have been identified from Massachusetts to Missouri. Locally, some students at Rutgers University, Muhlenberg College in Allentown, and Pennsylvania State University got sick.

Histoplasmosis is a fungal disease that primarily affects the lungs and can be deadly in people with other health problems. The fungal spores involved thrive in dirt rich in bird and bat droppings and can be breathed in when soil is disturbed.

"There was some construction going on around the hotel," said Rana Hajjeh, a CDC epidemiologist in Atlanta, who is heading the investigation. But she said it would be premature to conclude the hotel site was the source of the infection because "the hotel is not the only link that is common."

She said there was also construction near certain bars and nightclubs the students frequented.

Hajjeh said CDC officials were consulting with Mexico's Ministry of Health, which is conducting its own investigation. The Calinda Beach Hotel has not been closed, she said.

While it suspects histoplasmosis, the CDC so far has tentatively confirmed only one of the more than 200 cases under investigation, Hajjeh said. That was from a lung biopsy done on a student at Washington University in St. Louis.

Richard Pacropis, an internal-medicine specialist who directs student health at Villanova, set off a national alert among college campuses after he figured out what was likely bringing so many students into his infirmary.

On March 28, a student came in with a high fever, muscle aches, chest pain, dry coughing and weakness, and she was soon followed by others with similar symptoms.

"We had 29 students over a four- to five-day period," Pacropis said. Six of them ended up at Bryn Mawr Hospital, where Pacropis is on staff. In taking medical histories on the students, he learned that all had spent the March 3-11 spring break in Acapulco.

They did not appear to have the more predictable illnesses, such as flu or mononucleosis. But chest X-rays revealed a fungal infection of the lungs.

"It looks like large areas of infection with nodules," he said. Because the infection has an incubation period of two to 21/2 weeks, the students had felt fine when they first came back to campus. Carissa Giardino, 21, a Villanova senior from Doylestown, said she was part of a group of 30 Villanova women who spent about $850 each for a package deal that included airfare and a week's stay at the Calinda Beach Hotel.

After getting back to classes, she said, she began to experience a high fever, muscle aches, fatigue, "and a lot of soreness in the chest; it hurt to breathe normally."

When she did not get better after a week and heard of a friend who had a suspected case of histoplasmosis, she went to the emergency room at Bryn Mawr Hospital.

The sickness wiped her out. "I didn't do anything but go to classes for two weeks," Giardino said.

Pacropis said the sickest students were given a 28-day course of antifungal medicine. All 29 have recovered. Pacropis reported the suspected histoplasmosis cases to the Pennsylvania Health Department, which entered the investigation and alerted the CDC.

From the students he examined, he learned the names of other schools whose students stayed at the same hotel, and he took it upon himself to alert those schools' medical directors. Since news broke Thursday about the Villanova outbreak, he said, he has received calls from around the country.

Last week he conferred with the medical director at Rutgers University, where about a dozen or more students may have the lung infection, Pacropis said.

The American College Health Association, which represents college health centers and workers, also sent out an alert about the Acapulco problem.

One Penn State student who stayed at the Calinda Beach Hotel is now being evaluated for histoplasmosis, according to a university spokesman.

Sam Miranda, head of student health at Muhlenberg, said his center had identified seven possible cases among students who spent spring break in Acapulco. All are back to good health.

Hajjeh of the CDC said histoplasmosis routinely pops up around the country, particularly in areas such as the Ohio and Mississippi River valleys, where the soil is rich in the fungus.

"We've had a lot of outbreaks," she said. "But this is the first one of such multistate magnitude."



-- Andre Weltman (aweltman@state.pa.us), April 11, 2001.


Morbidity and Mortality Weekly Report, April 13, 2001 / 50(14);261-2

From the Centers for Disease Control and Prevention (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5014a1.htm)

Outbreak of Acute Respiratory Febrile Illness Among College Students - -- Acapulco, Mexico, March 2001

On March 30, 2001, CDC was notified by Pennsylvania Department of Health (PDH) of an acute respiratory febrile illness in 44 students from two colleges who traveled to Acapulco, Mexico, for spring break vacation during March 3--18. Within 7--14 days of their return from Acapulco, 21 students presented to health-care providers with illness characterized by fever, chills, dry cough, chest pain, and headache. Two students were hospitalized. On the basis of clinical symptoms and chest radiographs that revealed bilateral, nodular patchy infiltrates, acute pulmonary histoplasmosis was the suspected illness. While in Acapulco, most of the students stayed at the Calinda Beach Hotel and participated in group activities at other recreational locations.

All state health departments and selected travel agencies were notified to identify additional students who traveled to Acapulco during March and became ill. As of April 9, 37 colleges in 18 states* and the District of Columbia have reported 221 students who returned to the United States from Acapulco with an acute respiratory febrile illness. Ten students in six states were hospitalized.

A case is defined as an acute respiratory febrile illness characterized by fever for at least 3 days and one or more of the following symptoms: cough, shortness of breath, chest pain, or headache in a student who visited Acapulco during March 2001. Preliminary laboratory test results suggest histoplasmosis, an infection caused by Histoplasma capsulatum, a fungus that is present in soil in areas where the disease is endemic, and is acquired through inhalation. Gomori methenamine-silver stain of transbronchial and thoracic lymph node biopsy specimens from a hospitalized student revealed the presence of yeasts consistent with H. capsulatum. In addition, of specimens from 27 students in three states serologically tested for histoplasmosis using immunodiffusion and complement fixation tests, five were positive (1). However, convalescent-phase serum specimens will be needed for confirmation. Testing continues for other possible causes (e.g., Mycoplasma, Legionella, and Chlamydia).

Reported by: Pennsylvania Dept of Health. Council of State and Territorial Epidemiologists, Atlanta, Georgia. American College Health Association, Baltimore, Maryland. Mycotic Diseases Br, Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; and EIS officers, CDC.

Editorial Note:

CDC recommends that students who have traveled to Acapulco since March 1 seek medical care if they develop symptoms of fever and/or cough, shortness of breath, chest pain, or headache. Most cases of acute histoplasmosis in immunocompetent persons will not require treatment; however, persons with severe histoplasmosis can be treated with 200 mg of itraconazole, an antifungal medication, once daily for 6--12 weeks (2). Physicians should notify state health departments of acute respiratory febrile illness among returning college students and other persons.

On April 3, PDH alerted other health departments of the outbreak through EPI-X (the Epidemic Information Exchange); on April 6, CDC issued a travelers' advisory at http://webdev.cdc.gov/travel/other/res-mexico-apr2001.htm. Information on histoplasmosis is available at http://www.cdc.gov/ncidod/dbmd/diseaseinfo. The Mexico Ministry of Health and CDC are conducting an investigation of the outbreak. Additional information is available from CDC, telephone (888) 688- 2732. CDC's Mycotic Diseases Branch (MDB) is interested in receiving reports through state and local health departments of travelers to Acapulco since March who have become ill. MDB will test serum and lung tissue specimens for histoplasmosis received through state and local health departments.

References

1. Kaufman L, Reiss E. Serodiagnosis of fungal disease. In: Rose NR, ed. Manual of clinical laboratory immunology, 4th edition. Washington DC; ASM Press, 1992:506--28.

2. Wheat JW, Sarosi G, McKinsey D, et al. Practice guidelines for the management of patients with histoplasmosis. Clin Infect Dis 2000;30:688--95.

*Arizona, Connecticut, Delaware, Illinois, Indiana, Maryland, Massachusetts, Michigan, Missouri, New Jersey, New York, North Carolina, North Dakota, Ohio, Pennsylvania, Rhode Island, Texas, and Wisconsin.

Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.



-- Andre Weltman (aweltman@state.pa.us), April 13, 2001.


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