Murder and Mayhem (14 page)

This may be a case of the cure being worse than the disease.

Fortunately for your lady, seasickness tends to resolve over a few days. Of course, "land sickness" can occur with the cessation of the sloshing of the fluids in the canals when the victim steps onto shore. Just when the canals become accustomed to the erratic signals, things return to normal, and once again the system is thrown off. Go figure.

DISEASES AND THEIR TREATMENT

How Do Heart Disease and Angina Limit My Hero's Activities?

Q: My protagonist is a sixty-seven-year-old man who has heart disease. He has frequent minor heart attacks for which he uses nitroglycerin. He suffers one of his attacks when another man dies at his dinner party. He takes a pill and goes to bed. In the morning I have him resuming his regular activities. Is that feasible?

A: The mistake you're making in terminology is extremely common. Don't feel bad: I see it all the time. Books, newspapers, patients, and TV reporters make the same mistake.

The coronary arteries course over the surface of the heart and supply blood to the heart muscle. A heart attack (myocardial infarction, or MI) occurs when a portion of the heart muscle dies due to complete blockage of one of these arteries (Figure 8). This is a potentially lethal and emergent situation, and requires immediate hospitalization and treatment. Some MIs are silent, meaning there is no pain, while others are associated with mild and brief pain as you describe. However, most often the pain is severe and lasts for hours unless treatment is given. Yes, some people have heart attacks and go on about their business, but this is not the norm.

What you are describing is angina pectoris, "angina" for short. This is pain coming from the heart muscle due to poor blood supply because of a partially blocked coronary artery (Figure 8). Angina does not lead to damage or death of the heart muscle itself.

As you noted, the pill taken for this is nitroglycerin (nitro for short). It is placed under the tongue (not swallowed), dissolves quickly, and is absorbed directly into the bloodstream through the lining of the mouth. Nitro dilates (opens up) the coronary arteries, which increases the supply of blood and oxygen to the heart muscle and lowers the blood pressure (BP). This, in turn, lessens the work that the heart must do to move the blood around the body. The workload that the heart must carry is directly related to the blood pressure. The higher the BP, the more work—like weight lifting. Nitro increases supply and lessens demand, thus relieving the angina pain.

Angina pain is typically a pressure-like heaviness in the middle of the chest, possibly with the spread of the discomfort into the left arm or jaw Other associated symptoms might include shortness of breath, sweatiness, a cold and clammy feeling, nausea, weakness, and mild dizziness. Anyone who sees your protagonist would know something is wrong. He would likely appear scared, sweaty, and perhaps pale.

An episode of angina typically lasts one to five minutes if untreated. Nitro will resolve it in one or two minutes. After a bout of angina the person may feel tired or fatigued, but in a matter of five to ten minutes he would likely feel okay and be able to go ahead with normal activities.

Obviously, people with angina are at risk for a true MI since any one of the pain episodes can evolve into a full-blown MI. The nitroglycerin would lessen this probability if taken immediately. That is why we tell patients with angina to keep their nitro with them at all times—not in the glove box or a desk drawer or the medicine cabinet but in their pocket or purse so that it is available at a moment's notice.

A diagnosis of coronary artery disease with angina would fit your character's situation well. Throughout your story you could add a note of menace by having him suffer angina attacks whenever he is in a physically or emotionally stressful situation. An uphill walk, an argument, a fight, an emotional reunion or separation, or, as you suggested, the death of a friend or loved one could trigger an attack. Maybe he could have an angina episode and not have his nitroglycerin in his pocket and have to ride it out. This is a situation that would produce great fear. He might later feel foolish for not having his medication with him.

How Would an Allergy to Bee Stings Affect My Character's Lifestyle?

Q: I have a character with a potentially lethal allergy to bees. How would she live her life? Would she have a Medic-Alert bracelet or an antidote in the fridge? Would bees be attracted to her any more than they would be to a non-allergic person? Would she wear an insect repellent?

A: Bee stings can result in several reactions. In a nonallergic person the sting site would burn and swell, but the reaction remains localized and fades in a couple of days. In allergic persons more severe and painful swelling of the area, which could involve the entire leg or arm, is likely to occur. It would swell like a sausage and be fiery red, painful, and itchy. A worse allergic reaction would involve breathing problems that result from spasm (narrowing) of the bronchial tubes—like a severe asthmatic attack. The victim could die from this without prompt treatment. The worst reaction is full-blown anaphylaxis. Here the swelling and bronchospasm are joined by cardiovascular collapse, which means the blood pressure drops into the basement. Shock and death follow quickly.

Bee sting kits are available. These contain a small syringe of injectable epinephrine (adrenaline), which reverses the allergic effects quickly. The person would then go to an ER for more definitive treatment that would include more epinephrine, if needed, along with an antihistamine (such as Benadryl) and steroids.

The kits can be kept in a purse or pocket. When needed, they are needed "right now," so it's best for allergic people to keep a kit with them at all times, just as heart patients should keep nitroglycerin with them at all times.

The person would live a normal life but would be wise to avoid bees. A walk in the park would require extra vigilance but could be

done without much danger. Insect repellent would be useful. It is believed that some perfumes, soaps, deodorants, and other good-smelling products may attract bees, but this is controversial.

I know of no evidence that allergic persons are more likely to attract bees. Clothing color seems to be an issue, but it's not straightforward. Many people believe that bright colors—reds and yellows—might attract bees, but I recently read of one study that showed black and other dark clothing attracted them, too. Go figure.

What Types of Malaria Exist?

Q: My story is set in Louisiana in the late 1800s and the protagonist suffers from malaria. I understand there are different types of malaria and picture my character having the variety that never completely goes away but causes slow degeneration (anemia? gradual weakening? eventual death?). What type would that be? Also, do the chills always precede the fever? If the protagonist is given watered-down quinine, would the medicine suppress the symptoms, and would he then have milder chills and fever? I've also heard of a fever remedy called boneset. Would that be effective against malaria?

A: Malaria was and is one of the world's leading killers. Currently, at least 300 million people become infected each year, and as many as three thousand die each day. Though it is now rare in the United States, it was not uncommon in the swampy areas of Louisiana in the nineteenth century.

Malaria is what we call a protozoan disease. Protozoa are tiny single-celled organisms at the very lowest level of the animal kingdom. Protozoa of the Plasmodium family cause malaria. There are four types:
Plasmodium vivax,
or
P. vivax; P. falciparum; P. malariae;
and
P. ovale.
The most common type in the southeast United States

and South America is
P vivax. P. falciparum
is the most deadly and even with treatment has a mortality rate of 20 percent. For your scenario,
P. vivax
is the best choice.

The life cycle and the infection cycle of malaria are very complex and vary from species to species. I'll focus on what happens in the case of
P. vivax
and try to simplify it.

Malaria and many other diseases are transmitted to humans via a "vector," or carrier. In the case of malaria the vector is the anopheles mosquito. The mosquito itself becomes infected when it bites an infected person. The malarial organisms enter the mosquito with the blood it extracts. They then reproduce and concentrate in the mosquito's saliva. When the mosquito bites someone else, the organisms are injected into the person's bloodstream. From here two developmental cycles occur.

The first is the hepatic (liver) cycle, and the second is the erythrocytic (red blood cell, or RBC) cycle. In the hepatic cycle the malarial organisms injected into the bloodstream make their way to the liver and set up housekeeping in the liver cells, where they reproduce. This is the incubation period, and the victim usually has no symptoms. This typically last for about eight days, but the organisms may remain dormant in the liver cells for months or years. Sooner or later they reproduce, rupture the liver cells, and reenter the bloodstream. Symptoms begin at this stage.

The organisms then enter the RBCs and the erythrocytic cycle begins. They reproduce in the red blood cells and eventually rupture them, return to the bloodstream, infect more RBCs, and this cycle continues. In
P vivax
this erythrocytic cycle occurs every forty-eight hours, although early in the infection this may be erratic. Eventually, they all seem to get on the same schedule.

Interestingly, the presence of sickle-cell anemia tends to protect those individuals from malarial infection. It may be that the parasite can't reproduce properly in sickled cells. Since malaria is common in many areas of Africa, it is possible that people of African extraction, where most sickle-cell anemia is found, developed this mutation as a survival benefit.

The initial symptoms are like a flu: fever, chills, malaise, headache, muscular soreness and stiffness, poor appetite, nausea, and vomiting. Soon the classic cycle of fever, chills, and rigors (uncontrollable shaking) occurs about every forty-eight hours along with the rupturing of the RBCs and the release of large numbers of the organisms into the bloodstream. Obviously, the continued destruction of RBCs in this fashion leads to anemia. The victim may also appear jaundiced (a yellow hue to the skin). Over time, the liver and/or the kidneys can fail, and death may follow.

Quinine comes from the bark of the cinchona tree, originally found in Peru. The bark was ground and used to treat "intermittent fevers" as early as 1712. In 1820 two French chemists, Pierre Pelletier and Joseph Caventou, extracted quinine from the bark and made a powder of sulfate of quinine that proved to be more effective in treating the fevers than the bark itself.

During the nineteenth century, quinine was the major treatment for malaria. Not a pleasant medicine, it tastes bitter and causes nausea, vomiting, diarrhea, skin rashes, ringing in the ears, and even hearing loss for high-pitched frequencies. Used in smaller doses, as you suggested, it would have fewer of these side effects and would only blunt the symptoms of the disease, as you guessed. Without full and aggressive treatment the malaria would never resolve, and the person would be infected for life. Africa and South America have millions of people who live just this way. Many eventually die of the anemia, liver or kidney failure, or another infection such as pneumonia—victims of malaria are more prone to other infections than the norm.