Baffling Illness Hits Drug Users Abroad

In a scenario eerily reminiscent of the beginnings of the AIDS epidemic, nearly five dozen intravenous drug users in Scotland, Ireland and England have become ill or died since April of a mysterious illness whose origins health officials have not yet identified.

The baffling ailment is characterized by excessive swelling and redness at the injection site, low blood pressure and a high white blood cell count, often followed by heart failure.

More than half of the victims have died--most of them about two days after being admitted to a hospital--despite treatment with broad-spectrum antibiotics and other measures.

And while cultures of their blood and tissue have shown multiple organisms, none has yet been identified as the likely culprit.

The federal Centers for Disease Control and Prevention, called two weeks ago by health authorities in Britain to help in the investigation, said in its first public report on the mysterious illness Thursday that “the emergence of a new illness is possible” but stressed that it appears to be confined to intravenous drug users.

“This is a serious illness among members of this particular community,” said Dr. Marc Fischer, coordinator of CDC’s surveillance project for unexplained deaths and critical illnesses. “Something is going on--but we’re not sure at this point what it is.

“Right now, though, the greatest likelihood is that it is an organism previously known and described and showing itself in a new way,” he said.

But he emphasized that, because the early part of the illness involves a local reaction at the injection site, “this suggests that it is somehow related to that practice.”

No cases have shown up yet in the United States, but the experience of AIDS--believed to have begun in Africa--has taught the public health community a sobering lesson that it has not forgotten: that deadly infectious agents are but an airplane ride away.

“Those of us who have lived through the AIDS epidemic know to take quite seriously reports of unexplained and deadly illnesses,” said Jeffrey Levi, co-director of George Washington University’s Center for Health Services Research and Policy.

“We need to be careful not to assume that the HIV experience will always be replicated,” he added. “But we also know that dismissing carefully documented reports relating to high-risk behavior can come at a very high price.”

With AIDS, which turned out to be caused by a virus, sicknesses and deaths resulting from the collapse of the immune system first appeared in June 1981 among five gay men in Los Angeles, followed a month later by 26 gay men in New York City. In December, the first cases among intravenous drug users were identified. Today, the United Nations estimates that 30 million people worldwide may be living with AIDS or HIV.

“We have ongoing surveillance in the United States for cases of unexplained deaths and severe illnesses for this very purpose--to identify cases that are new,” Fischer said in an interview. “This investigation highlights the importance of maintaining that type of surveillance.”

Surveillance has been heightened in the United Kingdom and Ireland, as well as in the United States. CDC sent letters last week to state health authorities alerting them to the cases and asking them to be on the lookout for them in their jurisdictions. Thus far, none has been reported.

Health officials here and abroad are disseminating information about the illness to health care practitioners and trying to identify possible risk factors for the disease so prevention strategies can be developed.

They are questioning surviving patients to see what they might have in common--specifically, sources of their drugs and the timing of their injections.

Thus far, there have been 59 cases--30 in Glasgow, Scotland; 15 in Dublin, Ireland; and 14 in scattered sites in England, with 30 deaths among them, CDC said.

The illnesses begin with the local inflammation--swelling, redness and warmth and fluid retention at the injection site--and patients become progressively sicker during the next few days. Usually, they are admitted to hospitals about three days after the onset of illness. Among fatalities, patients usually died about two days after being admitted.

Health officials at first feared that the cause might be anthrax because the bacterium had been isolated from the spinal fluid of an intravenous drug user in Oslo who became ill and died. But health investigators have found no evidence of anthrax among any of the British cases.

Cultures, however, have found several different bacteria among some of the patients, including group A streptococcus, Staphylococcus aureus and bacteria from the families of Clostridium and Bacillus, which cause several potentially serious diseases.

While antibiotics can be effective against many bacteria, they do not kill them all. Antibiotic resistance has become a growing problem in recent years.

Because antibiotics have failed to help any of these patients, health authorities speculated that the agent could be a toxin-producing one. Also, these patients typically have a high white blood cell count, which is often the body’s response to an infection or to a toxin-producing agent, Fischer said.

Once a toxin is produced, the illness is difficult to treat unless specific antitoxins are available for the disease.

A few toxin-related illnesses--such as botulism and tetanus--can be treated with antitoxins.

“But we can’t treat a toxin when we don’t know what it is,” Fischer said. He stressed that health officials are still far from knowing all the answers.