Flesh-eating bacteria not threat to public health

By Timothy Hurley
Advertiser Maui County Bureau

WAILUKU, Maui — Jeff Gage was bitten by a centipede on a Wednesday. He died less than two weeks later.

The 48-year-old self-employed construction worker is one of three Maui residents to die in the last three months of necrotizing fasciitis, a rare flesh-eating bacteria. Another three Maui residents contracted the disease since November but have recovered.

State health officials and doctors at Maui Memorial Medical Center yesterday said there's no cause for panic, because a handful of cases of the disease — a severe form of the common Group A streptococcal infection, which also causes strep throat — are reported in Hawai'i every year. The six cases are within the "normal" range and do not pose an immediate hazard of an imminent or substantial threat to public health, State Health Director Bruce Anderson said.

Studies indicate that as many as 17 percent of the population carry the bacteria at any given time, said Dr. Paul Effler, Interim Communicable Diseases Division chief. But in rare cases, where a victim's immune system is weak or an infection is not tended to, the Group A streptococcus can become invasive, infecting areas inside the body where the infection can spread rapidly.

One of the most common results of the dangerous invasive Group A streptococcus is an illness called necrotizing fasciitis, Effler said. In it, the bacteria get into the fascia, or tough layers between the muscles and organs, and begin simply to kill the tissue, spreading rapidly over the fascia pathways.

That is the illness commonly called "flesh-eating" disease.

Effler said it is possible for Group A streptococcus to be spread from person to person, but that there was no indication of a connection between the Maui cases, which occurred months apart. Medical authorities do not even recommend isolation or quarantine for family members that have it.

"The bottom line is this is nothing new to us. I've seen it every year for the last 14 years while I've been on Maui,'' said Scott Hoskinson, an infectious disease specialist who treated all of the victims.

But he did concede that the cluster of cases was unusual and that doctors on Maui need to look out for it.

The state Department of Health issued an advisory yesterday, warning physicians on Maui to watch carefully for wounds accompanied by fever, swelling, redness or severe pain around the wound site.

Other bacteria can also cause necrotizing fasciitis, as in the case of Alyshia Shimizu of Waipahu. She was 5 years old when she came in contact with "clostridial" bacteria found in the soil two years ago.

In addition to Gage, the Maui victims include a 51-year-old man and a 48-year-old woman. Hoskinson said the woman was a surfer who suffered a coral cut on her heel. She was brought to the emergency room with nausea, vomiting and diarrhea, and appeared to improve after initial treatment but then succumbed to the infection.

The 51-year-old man bumped his left knee while walking down steps, but there was no break in the skin. Within 24 hours there was swelling and pain, and the man went to the emergency room. Doctors removed his left leg above the knee, but the infection could not be stopped.

Doctors said that because the man had had his spleen removed in the 1980s, he was more susceptible to the infection.

In each case, he said, the victims were healthy people who died within a few days to a week or so of infection.

Hoskinson said nothing other than living on Maui links the fatalities and those who survived the disease, except that one of the people who died may have been a distant relative of one of the survivors, and had visited the survivor a few weeks before they were each infected.

All of the cases were contracted on Maui.

Generally, Hoskinson said, those who were infected in the last six months were brought to the hospital's emergency room by ambulance within two to four days of acquiring the bacteria, suffering from high fever, severe pain and confusion.

Gage was bitten on the foot Feb. 13 by a centipede, according to his brother-in-law, Clyde Sakamoto, a Maui Community College administrator. That was on a Wednesday, and two days later he went to a community clinic.

By Saturday morning, his foot was inflamed and his internal organs began to shut down. He called a friend, and as she was helping him into a car in Lahaina he collapsed. Paramedics found him in cardiac arrest, and he was resuscitated and taken to the hospital.

Doctors found that his left leg was black and blue and swollen, and his right foot was mottled. He was immediately taken into surgery and his left leg was amputated.

Sakamoto said the man improved slightly on the following Monday and the family was hopeful. But his condition deteriorated over the week, and he died Feb. 24.

The family took the death hard, because it was so sudden, he said.

Hoskinson said the three Maui residents who survived the disease range in age from 21 to 70. Although they lived, the disease took its toll: There were leg amputations, skin grafting and surgery to stop its spread.

Health officials recommend proper and immediate wound care to reduce the likelihood of getting the disease. That means washing with soap and water and applying hydrogen peroxide.

Wounds should be kept clean and dry until completely healed, and watched for signs of infection such as redness, swelling, drainage and especially severe pain.

"People should pay attention to their cuts,'' said Dr. Steven Moser, chief medical officer at the Maui hospital. "Clean out your wounds and have a higher sense of what's happening with your body.''

Hawai'i residents may be slightly more prone to the infection because the climate encourages folks to wear less clothing and to go without shoes, increasing the chances for cuts and other wounds, said Anderson.

Bacteria in general also probably survive better in the warm, moist Hawai'i environment than in colder climates, he said.

Cases of the invasive bacteria appear to have increased in Hawai'i in the past five years, but are still far below the levels being reported in the mid-1990s. Anderson said some of the fluctuation in the number of cases reported could be caused by the amount of attention paid to the illness at different times by the doctors who make the reports.

Advertiser staff writer Walter Wright contributed to this report.