Dangerous ground

Dean Hunter was losing a battle with a mysterious illness that threatened to take his life - until a Winnipeg doctor tied the source of the trouble to a rare fungus found in the cottage country soil of southeast Manitoba and northwest Ontario.

Dangerous ground
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Battling 'blasto'

Fungal facts

Winnipeg Health Region
Wave, Summer 2009

The first thing to know about blastomycosis - a potentially fatal fungal infection - is that it's very rare. Your chances of getting struck by lightning are only slightly less - unless you are in northwestern Ontario, or parts of southeastern Manitoba. And that's the second important thing to know.

Dean Hunter has never been struck by lightning. But the Winnipeg rock/country musician has been hit with blastomycosis - twice.

"I could have died at any given moment," says Hunter, a father of two whose case was so unusual that the doctor who treated him - Winnipeg infectious disease expert Dr. John Embil - asked if he would be willing to go public with his story. He's quite happy to talk about it if it will help someone else.

"More people need to know about it," Hunter says in reference to blastomycosis. "It mimics other sicknesses. You could have a headache - like I had - for months, and not know. You would think it was a migraine or something."

Stories like Hunter's, plus the local research done in recent years by Embil and his colleagues, have helped make the strange and frightening illness known as "blasto" go from something almost completely unheard of a decade ago to a topic of dinnertime conversation - especially if the dinner table happens to be at Lake of the Woods.

Blastomycosis is an infection caused by a fungus called Blastomyces dermatitidis. The fungus is found mostly in moist, acidic soils. There are three main hot spots of infection in North America - Wisconsin, Mississippi, and northwestern Ontario. It is contracted by breathing in spores and generally affects people with low immunity. It is not a new illness, having been first described in medical literature in 1894. Nor does the number of annual cases of blastomycosis appear to be increasing.

But it can certainly make life difficult for those who acquire it.

Dean Hunter's lengthy ordeal began on the Canada Day weekend of July 2002. He and his band - Damn Straight - had a gig in Sioux Narrows, cottage country south of Kenora. They arrived on a Friday, played two nights at a local bar, and left on Sunday.

About a month later, one of Hunter's friends became ill with a lung infection that was eventually diagnosed as blastomycosis. He was treated and made a full recovery.

When Hunter, a robust, burly fellow who wears his long black hair in a ponytail, started getting headaches in October of that year, it did not seem likely to him or his doctors that his condition could have been related to the pneumonia-like illness of his friend. After all, more than four months had gone by. And the symptoms were completely different. But the sharp pains at the side of his head worsened: "It was like having some guy whack me over the head with a baseball bat, again and again. It's something nobody wants to go through. You can't sleep, you can't eat."

It got worse. Into the new year of 2003, a strange growth appeared on his scalp. "It scared me. This was just growing and growing to the point where I had to wear a hat to cover it. This went on into January, February, March . . . "

It was impossible for him to do his regular day job at a warehouse, so he was put on light duties. And the thing he enjoys most - performing as the lead singer in his band - became tortuous. One day, just as he was getting ready to go on stage for a show, the growth on his head grew so big it burst. His wife, Sharon, cleaned it up the best she could. Then he slapped on his hat and carried on with the show.

By this time it was March of 2003. It had been a long winter of pain, discomfort and unanswered questions. Visits to neurologists and other specialists had yielded no answers. A computed tomographic (CAT) scan, a special type of X-ray, was inconclusive. There were fears of a possible brain tumour. With no relief in sight and his condition growing progressively worse, Hunter grew increasingly despondent.

"I was going to doctors - they were saying, 'Don't know. Here's a prescription. Don't know. Here's another prescription.' I was on every kind of drug you can imagine."

Hunter's family doctor was very concerned. With all other avenues exhausted, his doctor decided to make an emergency referral to Embil, the local expert on blastomycosis. The name meant nothing to Hunter then, but he was later to remember the day he first met Embil with a sense of immense gratitude and relief.

It was April of 2003, a full nine months after the Canada Day weekend spent in Sioux Narrows. Hunter and his wife entered the Emergency Department at the Health Sciences Centre, where they were ushered into an examining room.

Embil entered the room, a bright, energetic man with an affable, confident manner who quickly put the Hunters at ease. He asked questions that sounded irrelevant, such as: Did he spend much time at Lake of the Woods? Examining the ominous-looking growth on Hunter's head, he immediately ordered an MRI - a magnetic resonance imaging scan. Then he brought out a long hypodermic needle - "Do you mind?" he asked, before plunging the needle into Hunter's head and withdrawing some fluid.

"I'll be right back," the busy doctor said as he quickly disappeared down the hospital corridors with the specimen in hand. He literally ran to the Thorlakson Building, where he rode an elevator up to the sixth floor, burst through the doors of the microbiology laboratory and handed off the sample to Brenda Binda, a senior technologist in the lab, who immediately processed the sample.

Embil returned to the emergency room about a half hour later. "I've got good news and bad news," he told Hunter. "The good news is that you're going to finally get some sleep. The bad news is that you've got blastomycosis."

A person isn't usually happy to learn they have something that dire sounding, but Hunter was immensely relieved, for he was aware that this was treatable. The neurosurgeons deemed that surgery was too dangerous because of the extent to which the infection had spread into the brain. Embil put him on a two-month course of an anti-fungal drug called amphotericin B. It's the gold standard for treating severe cases of blastomycosis, but, like many drugs, it can have dangerous side-effects, and can be especially hard on the liver and kidneys. "Medical students jokingly call it ampho-terrible," says Embil. "If people are critically ill, you give them this."

For four hours a day, every day, Hunter received the "ampho-terrible" into his bloodstream via an intravenous shunt in his arm. Unable to work during treatment, his mother and father, Patricia and Ivan Hunter, and mother-in-law, Myrna Turner, pitched in to help out the family while wife Sharon worked outside the home.

In time, Hunter recovered, was taken off the medication with no apparent ill effects, and resumed a normal life. That would have been the end of his battle with blasto. But against all odds, he suffered a relapse.

It happened two years later, in April 2005. Ironically enough, the problem revealed itself just as he was getting ready to return to northwestern Ontario - Kenora this time - to play another gig. He had not been to Ontario since the Canada Day 2002 weekend. The day he was to leave, his arm went completely numb as he was taking a shower. "It just died on me. I thought for sure I was having a heart attack."

The doctors at Grace Hospital thought so too. They sent him to Health Sciences Centre for further testing. There, a CAT scan showed a small grape-sized growth in his brain. An intern said it looked like a tumour. It was not what Hunter wanted to hear. "When you hear something like that, your life flashes before your eyes. All I could think about was, 'I'm dying.'"

His diagnosis had gone from light heart attack or stroke to possible brain tumour. Embil weighed in. He suspected the initial treatment had not completely gotten rid of the infection. A tiny amount might have survived and slowly grown back. He recommended surgery to remove whatever it was.

The surgery went ahead, blastomycosis was again confirmed and Hunter once again was put on the anti-fungal medication. This time the infection cleared up completely. That was five years ago. Dean Hunter has had a clean bill of health ever since.

For Embil, Hunter's case, along with the 15 to 25 cases of blastomycosis that occur any given year, are medical mysteries that cry out for someone to investigate them. "I'm originally from Halifax. Do you know how much blastomycosis we saw or heard about? Zero."

Embil, who is now the Director of the Infection Prevention and Control Program for the Winnipeg Health Region, came to Winnipeg in 1990 as a resident in internal medicine. He heard rumblings about this unusual ailment - which is known as the "Great Mimic" because it can resemble a lot of other illnesses - but the first time he came up close and personal with it was about a 15 years ago.

A young man was admitted to hospital with an ugly sore on his foot. Surgery was done to clean up the affected bone and soft tissue. A few days later he developed a lung infection and other complications. His condition was deteriorating rapidly and he was inching close to death. Embil was mystified.

As Embil puts it, illnesses are like crimes. Doctors are like detectives lining up possible suspects. Not until the most likely repeat offenders are deemed innocent of the crime does the doctor-detective turn to other, less usual suspects, such as blastomycosis.

In this case, the culprit was indeed blastomycosis. "It was like: 'What?'" recalls Embil. "You put it all together. He had skin and bone involvement in his foot and basically had a horrific pneumonia and kidney failure from the medication he was given. He just about died - yet (after treatment) he lived to tell the tale!"

That case, and others, prompted Embil to find out more about this "real unique and small volume disease." While studies had been done elsewhere, "No one had ever documented our local experience," he says.

In an interview at his office - a busy-looking space in which seriously scientific papers are pinned up alongside pictures of colourful cartoon characters meant to represent nasty organisms such as ebola virus and E. coli - Embil pulls up a photo file. He calls it "the many faces of blastomycosis." One of them shows a man's "before and after" face. In the "before" face there is an innocent looking pimple near the nose. The "after" face six weeks later shows a huge and horribly disfiguring growth. Fortunately, the man's face returned to normal after treatment.

Another file shows an image of Dean Hunter's skull. "If you look here," said Embil, pointing to the healthy side of the skull, "The edges are sharp. But here," and he indicates a jagged area, "it looks like the cookie monster was taking a bite out of it. This has destroyed the bone."

He pulls out another file. A person has severe skin lesions that look like psoriasis. "This patient had every potion and lotion known to man applied to his skin." None of that helped, of course, until the correct diagnosis of blastomycosis was made.

Another image is an X-ray of a man's lungs, filled with white spots. Looks like tuberculosis. Not until it was too late did doctors discover what it really was. "He died a few hours after this was taken."

Pneumonia, cancer, TB,psoriasis - blastomycosis can look like anything. It can also fail to show up in blood tests - which is why it can be so tricky to diagnose.

In his quest to find out more about this "oddball" illness, Embil undertook a number of collaborative projects with the Northwestern Health Unit in Kenora. He worked with Dr. Pete Sarsfield, the now retired medical health officer, as well as Lyle Wiebe and Bill Limerick of the unit's environmental health program.

The most recent was a study undertaken a few years ago that surveyed 100 people who had contracted the illness, plus a control group of 200 relatives and neighbours of infected patients, people who might have been exposed but did not contract it.

Blastomycosis is such a rare illness that rounding up the subjects of the study was "like looking for the proverbial needle in the haystack," says Embil. "We ran ads in the local papers in northwestern Ontario, we posted signs at community gathering places, the grocery and hardware stores, as well as the laundromat and anywhere else anyone could see it."

After crunching the data, the team was able to answer at least one question that was on the minds of many people whose dogs had acquired blastomycosis: If my dog has it, am I at a higher risk? "I'm pleased to report that if your dog had it, you are at no higher risk than someone whose dog did not have it," says Embil.

While this may seem counterintuitive - there was a well-publicized case in 2004 of a 13-year-old Winnipeg boy who developed blastomycosis at around the same time as his dog, when doing cleanup work at his family's cottage in Kenora - Embil points out that there are many factors involved in acquiring blastomycosis.

One, of course, is that blasto is not communicable - you don't catch it from a dog or another human being. It can only infect you when it is in the form of spores, which grow in the ground but can be carried anywhere by the wind. Another factor is that dogs go places in nature where humans don't and, with their noses so close to the ground, breathe in much more organic matter than people living and walking in the same general area. Another important factor is that those who are most likely to get it are those with weakened immune systems. It's believed that most people - or dogs - who are exposed to it do not get sick. The study is due to be published in the Canadian Journal of Infectious Diseases by the end of summer.

In the future, the study team hopes to help answer another question about the illness: Are some people genetically predisposed to getting it? Blood samples were taken from the 300 study subjects. Thes are now in storage, waiting for time and funding for the DNA analysis that could unravel that mystery.

But this is unlikely to happen soon, as Embil's Infection Prevention and Control Unit at Health Sciences is a hive of activity at the best of times, battling everything from superbugs to H1N1 influenza. Blastomycosis makes up a relatively tiny portion of its work.

As for Dean Hunter, he is mystified as to how or why he contracted this rare illness. He was feeling perfectly fine in July 2002, but doctors have told him his immunity must have been low. All he knows is that he's lucky to be alive. As far as he's concerned, Embil saved his life. And his wife of 16 years, Sharon, played no small part in holding him up in what was a wild, painful and frightening journey into the unknown.

"The second time it happened, I was basically telling her, 'I'm going to be going soon. I'm not going to be around.' But she wouldn't have anything to do with it. She said, 'You know what? I don't believe it. I think you're going to be fine.'

"Without her, I don't know what I would have done."

Hunter is back at work, back to playing in his band, back to watching his daughters, now 16 and 12, grow up. Even the bone that the blastomycosis "cookie monster" took from his skull is slowly growing back, he says. "I'm right back to my old self."

Nelle Oosterom is a Winnipeg writer


About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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