The Anthrax Letters: The Attacks That Shocked America (43 page)

Surrounded by books and journals, Dr. Tyler Cymet sat in his small office at Sinai Hospital in North Baltimore. He pulled a green sheet of paper from his desk drawer, rolled his chair toward me, and displayed a handwritten list. “These are the symptoms that most of them have complained of,” he said, and then read aloud: “memory loss, weakness, weight loss, diaphoresis [perspiration], muscle aches, lymph node swelling, fatigue, depression, increased and decreased temperatures.” The list was based on his conversations with survivors who contracted inhalation anthrax in the fall of 2001. As we talked, in March 2003, five of the six survivors were in their second year of illness. “I’ve examined Leroy Richmond and Qieth McQue,” Cymet said, “and I’ve spoken by phone with David Hose, Norma Wallace, and Jyotsna Patel.” He had not contacted Ernesto Blanco, who, at that time, was the only survivor back at work. But he called the others every 3 months to ask, “Is this better? Is this worse? What’s going on?”

Tyler Cymet, 40, is an osteopathic physician who completed a residency in internal medicine at Yale University Medical School. Head of family medicine at Sinai Hospital, he is also a professor of internal medicine at Johns Hopkins, 15 minutes from Sinai. He is a marathon runner, and his slender face is framed by a dark beard and mustache. When the telephone rang, he answered softly, “Hi, Tyler here.” His first name informality extends to patients and fellow physicians alike. On the wall opposite his desk is a bookcase full of titles like
Pharmacology
and
Principles of Ambulatory Medicine
. He reached to a lower shelf and pulled out a loose-leaf volume bulging with articles and reports about anthrax. Dr. Cymet smiled, “I have three more loose leafs like this one.”

What prompted his extraordinary and continuing interest in anthrax? William Paliscak arrived at the emergency room of Sinai Hospital on October 25, 2001. The 37-year-old postal inspector had developed a hacking cough along with heavy perspiration, chills, and severe chest pain. Six days earlier, on October 19, he had been in the Brentwood postal sorting center, before the extent of anthrax contamination there had been recognized. Still, he was given a 10-day supply of Cipro as a precaution. Even as he was taking the pills, Bill Paliscak began to feel ill.

When Dr. Cymet was called to the emergency room, he was surprised to see Allison Paliscak sitting there beside her husband. Allison is the director of health information at Sinai Hospital, where she has worked since 1985. “Hi. What’s up?” Cymet asked. Allison introduced him to her husband, who was clearly distressed. “Doc, I can’t do anything. I can’t breathe. I can’t walk. I can’t move.”

“When did all this start?” Cymet asked.

Paliscak told Cymet that he had begun to feel ill a couple of days earlier, after he had been in the Brentwood postal center in Washington. “Some people there got pretty sick, you know.”

By then, Dr. Cymet like people everywhere, knew that four Brentwood workers had contracted anthrax and that two had died.

“I’m scared,” Bill Paliscak said. Cymet put a stethoscope to his chest, felt for swollen lymph nodes, and ordered a chest X ray.

When the X ray suggested a possibly widened mediastinum, Cymet immediately had Paliscak admitted to the hospital. Cymet and his associate, Dr. Gary Kerkvliet, suspecting anthrax, ordered more tests and then placed Paliscak on intravenous Cipro. But by week’s end the tests for anthrax had come back negative, Bill seemed improved, and he was sent home. A month later his condition deteriorated, and he was in the hospital again.

Previously Bill Paliscak had been in superb physical shape. An athlete who worked out regularly, “he was an avid hockey ‘nut,’” his wife Allison said. “He played pick-up games, played in a men’s league, wherever he could.” That all changed after he went to Brentwood, 4 days following the discovery of the anthrax letter to Senator Daschle. While there, Paliscak, who as a postal inspector is a law enforcement officer, was evaluating the machine that had processed the letter. Cymet and Kerkvliet were lead authors in an article about his case. Appearing in the
Journal of the American Osteopathic Association
(January 2002), the article was titled “Symptoms Associated with Anthrax Exposure: Suspected ‘Aborted’ Anthrax.” The authors noted that:

After reviewing his subsequent medical condition, the authors concluded:

Eighteen months after Cymet first saw Bill Paliscak, Cymet said, “He’s still sick. He’s in the hospital, again, right now.” In addition to his other symptoms, Paliscak’s arms and legs recently, and unaccountably, had become swollen. Later, in a weak and hesitant voice, Paliscak told me that he cannot get around now without using a walker. “And I can’t walk more than 80 feet without getting tired.”

Dr. Cymet waved his hand through the air as if tracing the path of a roller coaster. “He’s had a rocky course,” the doctor said. “I’m trying to figure out where our patient is going and what we should be expecting.” Cymet summarizes for me a year and a half of Paliscak’s numerous hospital admissions and discharges. After the first 6 months of illness, Paliscak seemed somewhat better. He went home again, but by the summer of 2002 he was back in the hospital. “He had decreased energy, and his blood pressure had fallen to 80 over 40,” Cymet said. Normal pressure is 120 over 80. Then in recent months Paliscak began to show some deterioration in brain activity. “That is the same as we’ve seen in three of the other anthrax patients—low blood pressure and brain involvement,” Cymet noted.

I asked if Paliscak had other symptoms similar to those in the other anthrax victims. “Actually he’s been
leading
. He’s had the symptoms
before
the other inhalation cases,” Cymet responded. Why? I wonder. “That might be because he had an incredibly large exposure. He opened the filter of the machine that the mail was being sorted through and spilled the dust on his face.”

Dr. Gary Kerkvliet joined our conversation. Unlike the more reserved Dr. Cymet, Kerkvliet is bouncy and ebullient. He laughs easily. Beneath his helmet-style blond hair, his large glasses magnify his light blue eyes. He said he felt frustrated by the CDC’s reluctance to say this case is related to anthrax. He rolled his eyes and glanced at Dr. Cymet: “What do you think, Ty?” Cymet offered a silent, knowing smile.

“The CDC kept saying, ‘He doesn’t have anthrax,’” Kerkvliet said, shaking his head in frustration. “Well, fine,” he continued, “but the patient was adamant about wanting to be seen by the CDC.” A CDC physician did come up to examine him in December 2001 but never returned.

Since October 2001, Allison Paliscak said, she and her husband have “been living a nightmare.” She was grateful for the care and attention Bill had been receiving from Dr. Cymet and Dr. Kerkvliet. But she was less warmly disposed to the CDC. “After visiting my husband that one time, they seem basically to have dismissed him,” she said with a tinge of resentment. For Allison and Bill, the CDC’s refusal to allow that his illness is related to anthrax is a signal that the agency is uncaring.

Bill Paliscak’s tests were negative for anthrax, and the CDC is surely justified in not calling his case “anthrax.” But refusing to classify him as a “suspect” case seems arguable. On October 19, 2001, two weeks after Bob Stevens died, the centers issued an expanded case definition of anthrax. A case would now be deemed “confirmed” if the bacteria could be cultured from a patient’s specimen or if two other lab tests were positive for anthrax. The new criteria also allowed for a “suspect” case to be considered even in the absence of a positive test result. That part of the bulky definition reads:

Bill Paliscak would seem to be a candidate for the second criterion: clinically compatible signs and symptoms linked to an environmental exposure.

In March 2003, I asked Brad Perkins, one of the CDC’s lead investigators during the anthrax outbreak, what the agency’s position had been about Mr. Paliscak. “We could never find any evidence that he had anthrax,” Perkins said. “We certainly have had an open mind, but we’ve extensively reviewed his medical records and could not find reason to apply the definition.”

As we discussed the question further, Perkins made clear that Paliscak’s long-term symptoms had not affected the CDC’s thinking. Indeed, the agency does not consider them relevant to anthrax in any of the cases. “We’ve extensively evaluated all of the survivors that are willing to work with us and found no evidence of long-term sequellae of anthrax.”

Perkins acknowledged that “some of the survivors are functioning at lower levels” than a comparable segment of the general population would be. But their disabilities are not “identifiably related to lab tests or clinical findings associated with anthrax.” A possible explanation for their current condition, he thought, could be psychological, perhaps because of the trauma of being involved in a bioterrorism incident.

Perkins said that he is, of course, aware of the clause in the case definition that could potentially apply to Paliscak as a suspect case. But he added without amplification, “we have not applied that clause” in defining suspect cases.

Dr. Mary Wright’s interpretation is more expansive. She is the principal investigator of a research project at the National Institutes of Health that includes anthrax victims. Since early 2002 she has been overseeing a protocol on the “natural history of anthrax” at the National Institute of Allergy and Infectious Diseases (one of the institutes of the NIH). The purpose is to assess the disease and its effects over time.

Wright has been following the course of Bill Paliscak’s illness, along with those of other confirmed and suspected anthrax cases. Her protocol is based on the CDC’s definitions, and she
does
consider Paliscak a suspect case. She emphasized that her decision should not be construed as a criticism of CDC. Nor is it an institutional decision by her agency, NIAID. “It’s just ‘li’l ole me’ as the principal investigator who made some clinical judgments about what to use.”

Her inclusion of Paliscak as a suspected case is much appreciated by Allison Paliscak and by Drs. Cymet and Kerkvliet, all of whom spoke warmly of her compassion. When sitting with Dr. Cymet, I asked if Paliscak realized he had been exposed to a large volume of dust. “Yes,” Cymet answered, and then said something surprising.

“Bill’s clothes tested positive and his car tested positive for anthrax.”

I had not recalled any mention in his journal article about positive tests results. Did I miss something?

“No, that’s right,” Cymet answered. Cymet was never shown anything in writing about the clothes or car, so he was reluctant to refer to them in the article. “But two CDC officials visited me and told me about the positive results.” Still, all the diagnostic and laboratory tests on Paliscak himself had been negative. “So the CDC says, ‘Based on the definition and our criteria, we cannot call it anthrax.’” Cymet shrugged and turned his palm up as if to ask, “So what can I say?”

In an afterthought Dr. Cymet said that he had a public health student research the deaths among all the workers at Brentwood. I mentioned that Dena Briscoe, president of Brentwood Exposed, told me there was an unusual number of deaths there. Cymet said she was correct. “ Normally there are only two deaths a year there. We found eight deaths, in addition to those of Mr. Curseen and Mr. Morris, in the one-year period after the anthrax attacks. Four of them had enlarged hearts. We can’t explain it.”

The numbers are too small to be statistically significant, he said. But clearly he found them suggestive. How could this be related to anthrax? I asked. It was a question that Cymet has asked himself many times. “Maybe because they had lower-dose exposures and our guy had a much higher dose.”

Dr. Cymet thumbed through one of his loose-leaf books and pulled out a few pages. He showed me a declassified Army review of some laboratory-associated deaths at Fort Detrick. The first reference was to William Boyles, who, while working with anthrax in 1951, became fatally ill. The review indicated that no anthrax bacteria could be “cultivated” from Boyles’s specimens either while he was sick or from his autopsy. But the autopsy report established a diagnosis of anthrax nonetheless. Cymet pointed to a passage that explained why, and he said: “Here’s something that shows the spores could cross the blood-brain barrier and stay hidden.” From the Army report: “Microscopically, after exhaustive examinations, a few degenerative, long, gram-positive bacilli resembling
B. anthracis
were found only in the Pacchionian granulations (of the brain).” (In the 18th century, Italian anatomist Antonio Pacchioni, identified these tiny elevations on the outer surface of the brain.)