He couldn’t think, eat, or recover — and no one knew why | Medical Mystery

Andy McDonald told his wife he wasn’t feeling well as they drove to the Cowlitz County Fair in July 2022. The fevers that had been plaguing McDonald just kept coming.

“It was weird,” said McDonald, a retired sawmill worker in Clatskanie, Ore., about 60 miles northwest of Portland. “I’d be sleeping and a fever would come on, and when I woke up, the sheets were wet — like someone dumped water on them.”

He remembers thinking: “I just can’t live this way.”

McDonald, now 54, knows about living with illness: He suffers from Crohn’s disease, a form of inflammatory bowel disease that causes swelling and irritation in the digestive tract. To control his symptoms, McDonald took the medication Humira, which also suppresses the immune system.

But Crohn’s had never made him feel so sick, McDonald said. A couple of days after the fair, his temperature spiked above 103 degrees and he became dehydrated and mentally foggy. His wife, Beth, rushed him to the nearby emergency department in Longview.

There, doctors suggested his symptoms were due to a Crohn’s flare-up. They prescribed steroids and sent him home.

But McDonald began feeling even worse. The fevers continued, uncontrolled even by round-the-clock Tylenol, and so did the brain fog. He went to a clinic in nearby Scappoose, where a doctor told him to head directly to Oregon Health & Science University, a major medical center, in Portland.

At OHSU, McDonald waited for 12 hours in a crowded emergency room as his fever and chills worsened. Eventually, he said, he was admitted and diagnosed with sepsis based on his fever, increased heart rate, and high white blood cell count. He was given vancomycin and zosyn — intravenous, broad-spectrum antibiotics that are effective against a wide range of bacteria.

After five days, it seemed as if the antibiotics were beginning to work, so McDonald was discharged. But he was losing weight rapidly and suffering from persistent diarrhea and vomiting, he said. He ultimately lost more than 40 pounds during his illness.

“There were times I was praying for death,” he said. That’s when, during a virtual appointment with his gastroenterologist, Beth joined the call to express her concern. She remembers saying: “I think he is dying, he’s just so out of it.”

So McDonald returned to OHSU. By this time, his symptoms included a dry cough and white, foamy sputum.

It would take disease detectives, a slew of theories, and a highly detailed review of McDonald’s recent history before his unusual diagnosis finally emerged.

During this OHSU hospitalization, which lasted 10 days, doctors tried yet again to identify the problem. Specialists in gastroenterology, oncology, pulmonology, and infectious disease were consulted.

McDonald was administered the same course of antibiotics he’d been given during the earlier hospitalization, then switched to a different combination to treat what doctors thought was “atypical pneumonia.” But five days later, those drugs were stopped. McDonald seemed even sicker.

Leah Werner, a primary care doctor and assistant professor of family medicine at OHSU at the time, was one of the attending physicians caring for McDonald. She said numerous tests were conducted to pinpoint the culprit, including blood and urine cultures, a lumbar puncture, and chest CT scan.

But all those tests came back negative, ruling out disorders such as fungal pneumonia, tuberculosis, nontuberculous mycobacteria, and leptospirosis.

The team also considered another hypothesis: cancer. McDonald had inflamed lymph nodes and pleural effusion, or excessive liquid between the lungs and the chest wall; he was short of breath and needed oxygen. And he’d lost weight rapidly. Cancer, possibly lymphoma, could be a cause.

“Everyone thought he had lung cancer,” said Werner, who now leads a community healthcare system in Portland. “We thought this patient was going to die.”

McDonald was scheduled for a bronchoscopy, a procedure in which a camera-equipped tube is inserted into the airways to evaluate the area and collect samples, including a biopsy to test for cancer.

At the same time, the infectious disease department was weighing in.

Tim Menza, an infectious disease doctor formerly at OHSU and now at the University of Washington Medical School, had been reviewing McDonald’s case, which he said was initially perplexing.

“Nothing fit,” Menza said. The patient had white blood cells in the pleural fluid, but tests found no bacteria or fungi. A viral panel showed nothing respiratory.

“It looked infectious, but didn’t act like anything we knew,” Menza said. He said he stayed late at the hospital one night racking his brain, then decided to interview McDonald again to determine whether there were any recent exposures that might explain his condition.

It turns out there were many. McDonald had spent years in the sawmill, working in dusty environments without a respirator. Over the previous year, he drank untreated spring water while working on his property. Most recently, he’d been demolishing and rebuilding a wooden deck on his house and remodeling the kitchen, where he saw rodent droppings in the walls and insulation. Still, he said, he hauled out about 80 loads of the insulation in a large garden wagon wearing only a spandex neck gaiter to cover his face.

McDonald, a father of six, said his children had spotted rat remains under the old deck. His dogs had rolled around in the dead rats before jumping into his SUV. When the work was done, McDonald said, he donned gloves, dumped shampoo on the dogs, and hosed them down.

McDonald was also digging up the ground with a backhoe to make soil for the garden, mixing it with mushroom compost and sand. “It was very dusty,” he said.

Also, “we were battling skunks,” so McDonald had been trapping the animals and driving out to the country to set them free.

After reviewing McDonald’s many potential exposures, Menza had an aha moment. He remembered a well-known paper published in the New England Journal of Medicine that described an outbreak on Martha’s Vineyard among adults doing outdoor work involving brush cutters or lawn mowers. Could McDonald be suffering from a similar condition?

Menza ordered another round of blood tests, as well as a PCR test looking for a range of bacteria. When results came back, the diagnosis was confirmed: pulmonary tularemia, a rare, potentially serious bacterial infection with a mortality rate of about 30% if left untreated, and in immunocompromised patients like McDonald, about 60%.

People can be infected with the bacterium Francisella tularensis in various ways, including by inhalation, by drinking contaminated water, or by exposure to infected animals, such as rodents and rabbits. The bacteria is classified as a high-risk potential bioterrorism agent, in part because it is highly infectious and can be inhaled when aerosolized.

In Oregon, there are fewer than 10 cases of tularemia per year, with only two in 2022, the year McDonald was infected, Menza said. In the United States, about 100 to 200 cases per year are reported nationwide, with 196 cases in 2023, according to the Centers for Disease Control and Prevention.

“I had never seen a case of tularemia before,” Menza said. “And I haven’t seen one since.”

The “accumulation” of types of exposure probably led to McDonald’s illness, but it was most likely transmitted through inhaling the bacteria from rodents during the kitchen demolition or from contaminated soil dug up using the backhoe, Menza said. Or, it could have been the skunks. Or dogs.

Because McDonald is immunocompromised, the amount of bacteria he’d need to inhale to get infected may be less than for a person with a healthy immune system, Menza added.

The diagnosis also made it clear why the antibiotics had failed: Tularemia is “intrinsically resistant” to the broad spectrum antibiotics McDonald was initially prescribed.

Luckily, tularemia is curable. McDonald was treated with the common antibiotic ciprofloxacin, and, for the first time in weeks, he improved dramatically. His lungs cleared, the nodules and fluid vanished, the brain fog lifted, and he was sent home.

Menza offered him a piece of medical advice: When dealing with rodents, skunks, and other critters, adequate personal protective equipment is a smart idea.

McDonald is just happy to be over his illness.

“It’s great they figured it out,” he said. “You just appreciate not feeling sick anymore.”

Rachel Zimmerman is a journalist and writer based in Cambridge, Mass. She is the author of “Us, After: A Memoir of Love and Suicide."