Inwardly I shuddered. At that very moment, countless more spores could be incubating and multiplying in his prostate, lymph nodes, bones, or brain.
The unique susceptibility of certain dark-skinned people (Filipinos and African Americans in particular) to disseminated cocci—for reasons that are still not understood—has been common knowledge among infectious-diseases specialists for decades. In 1940 a landmark article in the American Journal of Public Health reported that African Americans were 23 times more likely to die of coccidioidomycosis than whites were. More recently, similar research in two California counties confirmed that, compared with their Caucasian counterparts, African American men stand a tenfold to thirtyfold increased risk of falling victim to the disease.
In some cases, patients have genetic vulnerabilities that all the high-tech care in the world simply cannot conquer.
The day I met Jackson, I asked myself: Do I really need to share these grim statistics with him? The bottom line was that he needed treatment. Once he grasped that fact, he quickly agreed to our best shot. Amphotericin B, an antifungal drug privately called “ampho terrible” by many former recipients, is just as noxious as its nickname suggests, but it did its job. After two months of infusions, Jackson was out of the woods. I still have the Betty Boop coffee cup he gave me as his parting gift.
Now back to Arthur Lewis. Ten years after treating Jackson, I met Lewis at the university medical center where I now work. A 17-year-old high school student who had just been transferred from another hospital, Lewis presented in far worse shape than Jackson: febrile, emaciated, doubled over in pain. Not only did he have scattered fungal scabs on his skin, but his scans showed multiple abscesses in his liver and spleen. Even more discouraging was his record of prior treatment. By the time I saw him, he had already received the same total dose of amphotericin B that had cured Jackson.
Over the next week, Lewis wasn’t dying, but he had little energy or appetite and even less motivation to study the textbooks next to his bed. Meanwhile, my team pushed his daily amphotericin dose while adding newer antifungal drugs to his regimen. We also tried immunologic therapies such as interferon and something called granulocyte-monocyte colony stimulating factor, a bioengineered molecule meant to boost Lewis’s ability to mount a strong immune-cell attack against C. immitis. Eventually his body temperature normalized, his pain abated, and he went home on long-term oral treatment. We hadn’t won the war, but we had made progress. Lewis felt well enough to start college in a nearby state.
My contact with him was sketchy for a year or two until I received a call from a doctor at his college. Lewis had never before complained of headaches, but now he was having migraines. Or so his doctor thought; I wasn’t so sure. Soon after, a CT scan and a spinal tap confirmed my worst fear. The fungal infection had invaded the base of his brain, producing cocci meningitis.
Over the next year, Lewis received amphotericin directly into his spinal fluid via a special injectable reservoir. The treatment helped, but only for a while. In the last months of his life—like so many patients with an incurable disease who continue to receive maximal high-tech care—Lewis experienced one complication after another, and he was in the ICU more than once. Finally he had a full-blown cardiac arrest and was gone.
Toward the end Lewis knew he was dying. But one thing brought him joy. While at school he had fathered a child. Despite his tragic downward spiral, talking about his little girl always brought a smile to his face.
In fact, a few months before he died, Lewis brought his gurgling daughter—the image of health and hope—to my outpatient office. As I sat her on my knee and gazed into her shining brown eyes, I couldn’t help but wonder what science might someday reveal about her father’s fateful genes—and perhaps her own.
Claire Panosian Dunavan is an infectious-diseases specialist at UCLA Medical Center and past president of the American Society of Tropical Medicine and Hygiene. The cases in Vital Signs are real, but names and certain details have been changed.
