BLACKWATER FEVER

“Sounds like maybe you should have gotten off at the psych-ward floor.” Winn unconsciously opened her small pocketbook and took a quick glance at herself in her mirrored compact. She picked up a file from her desk. “I’ve been looking through your file. And you can see now it’s over two-inches thick. When you first came to us a few years ago, you were one of over a hundred Middle East veterans with chronic recurring falciparum malaria.”

“How many out there now?” Swanson raised his eyebrows.

“Actually, the number has decreased. We’ve been able to virtually eliminate the chronicity of all but a handful of your strain of plasmodium.”

“And the others? Are they identical to my case?”

“Only two, David. You and they are unique. There are reports of others that have had mild falciparum attacks, and those were related to having an acute, concurrent illness such as a bad case of influenza.” She opened the file. “In your case, the episodes seem to the unrelated to anything physical.”

“Nothing physical? Are you implying my mental state could trigger the release of the parasite?”

“I don’t think that’s possible as a general statement. I’ve run your case by our medical director several times now and still running up against a blank wall.” Winn saw the slight look of despair on Swanson’s face. “David, it doesn’t mean we won’t or can’t find a solution to your problem.”

“But if it isn’t physical, what mental implications are you talking about here?”

“You familiar with PTSD?”

“Post Traumatic Stress Disorder? I’ve already been checked out for that. Everyone who returns from Middle East service goes through a PTSD screen.”

Winn paused as Denton Bird brought in two boxed lunches from the cafeteria. “There’s a bottle of water in each lunch. It’s why the box is so heavy. Toodle-oo.”

“Go ahead and start eating and I’ll begin my thought. With PTSD patients a majority of the presenting symptoms can be physical. It’s because of stress. Stress does something to the immune system. Specifically, it’s well known that the adrenal glands become overactive in stress situations. Surely you’re familiar with adrenalin–it comes from the adrenal glands. Every soldier knows that. The adrenal gland also puts out other stress hormones we call corticosteroids. The main one is cortisol.”

Swanson swallowed a mouthful of ham-and-cheese sandwich, took a swig from his water bottle and widened his eyes at the statement. “I remember being told over-and-over again to avoid steroids of any kind because they set up the body for potential infection. Are you saying that includes malaria?”

“Within the VA experience we’ve become experts with PTSD. It’s possible that a stressful situation could lower your immune system’s ability to maintain the dormant phase of your falciparum parasite.”

“Barbara, what you’re saying does make sense…but…Dr. Binelli would’ve already considered this, wouldn’t she?”

“I would think so although there’s no mention of it in any of her consultations. She’s never even brought up a hint of PTSD or any kind of other stimulating stress reactions. She’s never even considered the possibility of a relationship between stress and a falciparum attack.”

Swanson stood up. “Then why am I seeing Dr. Bergan Krantz? He keeps telling me I’m loaded with stress related to my malaria attacks.”

“Really? And does this stress occur before, during, or after the attacks?” She stood up to motion him to calm down. She was only a few inches shorter than Swanson’s six-foot height. At 5-foot-8-inches she rarely wore heels and at the VA she lived in Crocs® clog-like shoes. Today’s Crocs® were pale blue matching something bluish beneath her VA white lab coat.

“From my perspective, I get stressed out afterwards because I have no memory of what happened immediately before or during each episode. The first year-and-a-half of my attacks, all I remembered was the shaking chills, fever and rigors of each malaria bout.”