Hepatitis C Fatality
In Baltimore Shrouded
In Mystery

From Patricia Doyle, PhD
The time between infection and death is EXTREMELY rapid. Normally, one becomes infected with HCV and it could take decades for the virus to be identified. One is asymptomatic and feels fine for decades.
Hepatitis C Fatality In Baltimore Shrouded In Mystery
By Michael Stroh
The Baltimore Sun
Jan 4 2005
As thousands of other patients do every year, a patient walked into a Glen Burnie cardiology clinic last October [2004] for a routine cardiac stress test. But what happened over the next 2 months wasn't so routine: The 79-year-old retired ironworker developed a hepatitis C infection that ultimately took his life on Christmas Day [25 Dec 2004]. The patient's death -- one of just 6 hepatitis C-related fatalities officially recorded in Maryland since 1999 -- is drawing new attention to an unusual medical mystery under investigation by the Maryland Department of Health and Mental Hygiene.
Officials have traced the patient's infection to a single vial of technetium-99m, a radioactive isotope injected into the bloodstream during stress tests and other routine diagnostic procedures. Investigators won't say how many people have been infected, or where they live. However, the company whose Timonium pharmacy prepared the suspect isotope said the state has identified at least 12 people in the Baltimore area. The 79-year old patient, who lived in Brooklyn Park, is the only fatality.
(The only fatality, thus far! - P. Doyle)
The case has baffled physicians and nuclear medicine experts, who say they can recall no other instance in which a common radioactive isotope has become contaminated with [a] hepatitis [virus]. "It's very unusual and not expected at all," says Fadia Shaya of the University of Maryland School of Pharmacy, who chairs the state's advisory council on hepatitis C. "This kind of thing should not happen."
(But it did happen! P. Doyle)
Hepatitis C, a liver disease caused by a virus of the same name, is typically transmitted through infected blood or semen. The disease kills as many as 10 000 people in the U.S. each year. The majority of new infections are contracted through illicit drug use. The vial of technetium-99m that officials suspect as the cause of the infection here was prepared at a so-called nuclear pharmacy in Timonium. Operated by Cardinal Health of Dublin, Ohio, the pharmacy specializes in preparing radioactive "tracers" for a variety of diagnostic tests. The company has temporarily closed the business until investigators have pinpointed the source of the virus.
John Hammond, a spokesman for the Department of Health and Mental Hygiene, said the hepatitis C outbreak does not pose a public health risk and was confined to the small number of people injected with serum from the tainted vial. Maryland, he said, recorded 26 cases of hepatitis C in 2004, including those in the recent outbreak. The state reported 9 cases the previous year and 14 cases in 2002.
(How many "unrecorded cases"?? -- P. Doyle
One of the central mysteries is how the radioactive isotope could have become contaminated, especially since the preparation of technetium-99m is considered to be a straightforward process. "How in the world did this happen?" says Nicki Hilliard, a nuclear pharmacist at the University of Arkansas for Medical Sciences. "It's bizarre." Hilliard said that the isotope is typically produced in a pinkie-sized container known as a radionucleotide generator. To create a dose, technicians pass standard saline solution through the generator, a process known as "milking." As a result, the generators themselves are sometimes known as "cows." Technicians capture the saline in a small vial and stir in a powdered chemical tracer. The tracer binds to the isotope and ferries it through the patient's bloodstream to the specific organ or tissue that needs to be examined.
The victim's widow said her husband received the isotope during a cardiac stress test at Arundel Heart Associates in Glen Burnie. Before the test, she said, he was in good health, and the procedure was considered routine. As part of the test, doctors typically inject the isotope into the patient's bloodstream and ask the patient to walk on a treadmill for a short period to increase the pulse rate. Then they examine the patient's heart using a radiation-sensitive camera to track blood flow and spot potential blockages.
Dr. Paul Young-Hyman, a cardiologist at the Glen Burnie clinic, said the suspect isotope arrived at the clinic in October 2004 in 8 individually prepared syringes, each in a lead-lined container. All 8 patients who received the isotope on 15 Oct 2004 have since tested positive for hepatitis C, he said. Young-Hyman said that when word started filtering back that several patients who had stress tests that day had been diagnosed with hepatitis, the clinic notified county health officials, who ultimately contacted the state.
The cardiologist said all the clinic's employees have tested negative for the virus, and health officials have examined the clinic's laboratory and found it contamination free. As a precautionary measure, however, stress tests at the clinic are now being performed with a different radioactive tracer. "I'm just hoping that people who need the study don't hold back on getting it," says Young-Hyman. "This case really does fall into the category of bizarre."
Hepatitis C has an average incubation period of 6 to 8 weeks, and the victim was fine until mid-November 2004, when he lost his appetite and started to feel nauseous, family members said. His wife initially chalked it up to stomach flu, from which she was just recovering. But when he didn't improve, he went to see the doctor. A few days later, tests came back positive for hepatitis C. Around this time, state health officials began notifying hospitals and physicians to watch for signs of the disease, including fatigue, jaundice, abdominal pain and nausea. As his condition deteriorated in the following weeks, he was admitted to North Arundel Hospital twice before finally being taken to Harbor Hospital on 23 Dec 2004, and he died on Christmas Day.
[Hepatitis C virus is classified as the type species of the genus _Hepacivirus_ in the family _Flaviviridae_. It is transmitted almost exclusively by parenteral exposure to blood, blood products and substances contaminated with blood. Sexual and perinatal transmission occur rarely. Screening and inactivation procedures now ensure safety of the blood supply. Blood-contaminated syringes, however, have become a significant risk factor.
The circumstance whereby 8 patients receiving isotope from 8 individually prepared syringes delivered from a single pharmacy points to the contamination occurring at the pharmacy preparing the isotope rather than at the hospital administering the isotope to the patients. The level of contamination of the isotope must have been considerable to result in infection of all 8 patients. The staff of the cardiology clinic have tested hepatitis C-negative, which further suggests that the contamination occurred during preparation of the isotope at the pharmacy. - Mod.CP]
Patricia A. Doyle, PhD
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Zhan le Devlesa tai sastimasa
Go with God and in Good Health



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