A Visit to a Dude Ranch
The patient was a slender, energetic man who looked younger than his 62 years, Azar noted when he met the man the following week. Informed by the results of the biopsy, the infectious-disease doctor asked the patient the same questions the C.D.C. raised about his recent travel. Had he been to the Midwest or the South in the past year or so? Maybe around the Mississippi or Ohio River Valleys?
He had, the patient replied, but not for decades. But, he added, he spent several days at a dude ranch in Arizona a few weeks before he got sick. The pneumonia had been awful, but he felt fine now. Azar felt a moment of satisfaction: He was in Arizona just before getting sick? This probably was coccidioidomycosis. And yet the C.D.C. thought it was blasto. Azar needed to be sure of what he was treating. Blastomycosis was a much more serious disease than coccidioidomycosis, requiring significantly longer treatment. He sent a sample of the tissue taken from the man’s lungs to the C.D.C. for genetic identification of the yeast. In the meantime, Azar started the man on an antifungal medication, itraconazole, that worked against both types of yeast.
It took weeks for the results to come back. But finally they had a definitive answer: It was cocci.
Relieved to be free of a possible cancer diagnosis, the patient jumped onto the internet to read up on Valley fever. It was all over Arizona. His sister-in-law reminded him later that there used to be a card about the disease in the rooms of the dude ranch they visited every year for the past 30-something years. He quickly found the Valley Fever Center for Excellence at the University of Arizona College of Medicine-Tucson, only a few miles from the dude ranch. It was set up to teach doctors and patients about the infection. Two-thirds of all patients with cocci got it right there in Arizona. These were the real experts in cocci, the patient told Azar. He should call them. Azar wasn’t sure what he could learn from these folks. But he did have some questions. So when the patient brought it up again, he called.
He had read the guidelines on the treatment of this disease — written, as it turned out, by the physician who led the Center for Excellence — and their recommendation was to stop treatment if the patient didn’t have symptoms. Could that be right? “I learned so much,” Azar acknowledged to the patient. Most important: The man didn’t need the medication. His body had already neutralized the bug.
It’s amazing, Azar told me, that something can be so ordinary in one part of the country and so rare every place else. If that patient had presented to the E.R. in Tucson, it’s more likely that they would have recognized what he had as Valley fever. If he had symptoms, they would have treated him; if he didn’t, they wouldn’t. But they certainly would not have ordered a biopsy. And they would have never thought for a moment that he had cancer.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write her at Lisa.Sandersmdnyt@gmail.com.
