Doctors from a rural hospital have contacted you for help in solving a strange series of illnesses in patients throughout the hospital and clinic. A large number of patients presented symptoms one to two weeks ago. Not all of the patients display the same symptoms, but they have been grouped together due to location and timing. The outbreak was first noticed in the pediatric wing of the hospital. A number of newborns and pediatric oncology patients presented with a dry cough and mild respiratory symptoms. The medical staff was initially not concerned with what appeared to be a circulating respiratory infection. Within days, however, adult patients in the oncology, transplant recovery, and intensive care units began showing similar symptoms.
Symptoms included cough, fatigue, nausea, chest pain, fever, loss of appetite, headaches, and night sweats. Within a week nearly 40 patients from different floors and wards of the hospitals displayed some or all of the above symptoms. There is no preference for sex or age among the afflicted patients. Since many patients with post-surgical wounds are on antibiotic treatment, the doctors have ruled out a bacterial infection. None of the hospital staff have presented with any symptoms. Most patients have stabilized and some patients appear to be recovering. However, new patients continue to be diagnosed.
This past week saw the first fatalities, when several patients accumulated symptoms of swollen glands, abdominal pain and swelling, bone pain, and migraines. The hospital staff is quite confused and is hoping you can provide some help

Day one: afternoon

You have received blood, urine, sputum and CSF samples from one of the case patients. Additionally, this patient’s stool has been cultured and the plate has been sent over for you.

Day two: morning

There are two more fatalities today, bringing the total death toll to 5 people, about 10% of the infected population. These patients were both being treated for hodgkins lymphoma. The cases have appeared in people who were not previously hospitalized. A radiology technician who works at the hospital and a construction worker who had been working next to the hospital tearing down some old farm buildings and clearing the property for a hospital addition. Both of these individuals are displaying minor symptoms only a cough and chest tightness, however, both have been quarantined at the hospital until this outbreak is contained. Chest X-rays from some of the patients who display stronger coughs have shown multiple small dense nodules, suggesting some kind of lung damage. Patients displaying pneumonia like symptoms remain unresponsive to antibiotic treatments and it is a rare time of year for a pneumonia outbreak.

Day two: afternoon

Two male HIV-positive patients who were in the hospital less than two weeks ago for regularly scheduled treatments have now shown up positive for symptoms consistent with the outbreak. However, both HIV patients have very strong symptoms, high fevers, terrible headaches, blurred vision, stiff necks, numbness and tingling. These symptoms are rarely associated with pneumonias. A few other patients are also complaining of stiff neck and sensitivity to light.
To make things worse, a few patients previously infected with this respiratory disease have also developed bed rashes and lesions, what appears to be a molluscum contagiosum infection. These poxvirus rashes are extremely rare in the U.S. climates and are usually related with STDs. Samples from sputum as well as these rashes are provided for examination of reactivity with serum from infected individuals. The doctors are concerned, but also confused by how a viral pneumonia could cause skin lesions.
Due to the post-9/11-paranoia, the local newspaper has blamed the military base 25 miles away for testing biological weapons in the area. Certainly the doctors have tried to keep the appearance of skin lesions quiet to lull any fears of smallpox. The absence of the infection in healthy individuals has helped the hospital staff keep newspapers away from bioterrorism concerns.
The hospital staff has been extensively cleaning the hospital for fear that something inside the building is causing the infection since no other cases have been reported in the community. One female HIV patient was in the hospital during the same period as the two sick patients, but doctors have not been able to contact her yet.

Day three: morning

There are no new cases to report today. Two more fatalities among transplant recipients and one of the HIV positive patients. In total 49 patients have displayed symptoms of respiratory infection, pneumonia, or illness with severe headaches and neurological problems. There have been 8 fatalities, and almost all patients were people who had been previously hospitalized. Most patients were immuno-suppressed either medically or due to illness. Both healthy individuals (radiologist and construction worker) appear to be recovering. A few more construction workers have mentioned experiencing a slight cough that went away quickly. Apparently only workers who were hired for destruction of an old barn, chicken coup, pheasant house, and carrier pigeon breeding pen were afflicted with even a slight cough.
The interviews with construction workers working on the hospital addition have confirmed why the hospital appears to be a hot zone for the infection. The ventilation system pulls in air on the side of the building closest to the construction site and distributes it into the air handling system. Furthermore, hospital maintenance workers found some faulty air filters that had been installed the month previous to the outbreak.
The last HIV-positive patient has been tracked down while on vacation out of state. She has displayed no symptoms and had no suggestion of illness. She is on the same medical regiment as the two other HIV patients, however, she had also been taking Diflucan to cure a yeast infection.