Monday, September 12, 2016

What Hillary Clinton’s pneumonia diagnosis means, medically-speaking

The Washington PostWashington Post - Washington Post

The Washington Post

Ben Guarino 2 hrs ago


On Labor Day, in the middle of a Cleveland campaign rally, Democratic presidential candidate Hillary Clinton paused to fight back a cough. She sipped from a glass of water, turned from her microphone and then shrugged the spell off. “Every time I think about Trump,” Clinton said, “I get allergic.”

If only stump speech quips could defeat microbes. Six days after the Ohio rally, traveling from a Sept. 11 memorial service held in New York, Clinton lost her balance and had to be helped into a waiting van. Passersby caught the stumble on video and forced the campaign to come clean: Clinton had fallen ill. A few days before, it turned out, a physician diagnosed the 68-year-old candidate with pneumonia.

“Secretary Clinton has been experiencing a cough related to allergies,” Clinton’s physician Lisa R. Bardack said in a statement, as The Washington Post reported Sunday. “On Friday, during follow up evaluation of her prolonged cough, she was diagnosed with pneumonia. She was put on antibiotics, and advised to rest and modify her schedule. While at this morning’s event, she became overheated and dehydrated. I have just examined her and she is now re-hydrated and recovering nicely.” Clinton canceled a planned trip to California.

Although Bardack said her patient was on the way to recovery, the diagnosis of pneumonia may have left some voters wondering: Isn’t pneumonia, after all, a serious health concern?

  • Democratic presidential candidate Hillary Clinton arrives for ceremonies to mark the 15th anniversary of the September 11 attacks at the National 9/11 Memorial in New York, September 11, 2016.

  • Democratic presidential candidate Hillary Clinton attends ceremonies to mark the 15th anniversary of the September 11 attacks.

  • Hillary Clinton and New York Mayor Bill de Blasio attend the ceremonies.

  • Democratic presidential candidate Hillary Clinton, New York Mayor Bill de Blasio and Senator Chuck Schumer attend ceremonies.

  • Hillary Clinton and her traveling press secretary Nick Merrill attend ceremonies.

  • Democratic presidential candidate Hillary Clinton, center, accompanied by Sen. Chuck Schumer, D-N.Y., left, and Rep. Joseph Crowley, D-N.Y., second from left, speaks with New York Mayor Bill de Blasio, center right, during a ceremony at the Sept. 11 memorial, in New York, Sunday, Sept. 11, 2016.

  • Hillary Clinton left the memorial event after about 90 minutes while it was still underway, Nick Merrill, a Clinton spokesman, said.

  • Hillary Clinton leaves ceremonies marking the 15th anniversary of the September 11 attacks. After some U.S. media reported she had fallen ill, reporters traveling with the candidate did not get an immediate response from the campaign to questions about her whereabouts and her health. About 90 minutes elapsed before the campaign issued its statement.

  • Clinton, 68, was taken to her daughter Chelsea's home in Manhattan, and emerged later wearing sunglasses and telling reporters that she was "feeling great," around two hours after she left the event on a hot and muggy morning.

  • US Democratic presidential nominee Hillary Clinton leaves her daughter's apartment building after resting on September 11, 2016 in New York. Clinton departed from a remembrance ceremony on the 15th anniversary of the 9/11 attacks after feeling 'overheated,' but was later doing 'much better,' her campaign said.

  • A girl runs out of the crowd to greet Hillary Clinton as she leaves her daughter Chelsea's home.

  • U.S. Democratic presidential nominee Hillary Clinton greets a girl on the sidewalk after leaving her daughter Chelsea's home in New York, U.S. September 11, 2016 in this still image taken from video.

  • Hillary Clinton had no more events on her schedule for Sunday and went, as previously planned, to her home in Chappaqua, New York, 30 miles (50 km) north of New York City.

  • The incident comes less than 60 days before the Nov. 8 presidential election and at a time of intense campaigning against Republican rival Donald Trump.



The short answer, at the moment, based on the limited available information about Clinton’s case and viewed independently of any unknown other health issues she may or may not face, is no.

“At this point, there is no reason to believe that Secretary Clinton will be disabled” by pneumonia, American Lung Association scientific adviser Norman H. Edelman told The Washington Post by phone Sunday night.

The long answer to pneumonia’s seriousness begins more than a hundred years ago, when pneumococcal bacteria were discovered in the 1880s. Around the dawn of the previous millennium, that disease had replaced consumption, or what we would now call tuberculosis, as the primary cause of death in cities like Chicago, according to Canadian physician William Osler. He made a scrupulous study of the disease and described it in almost poetic terms. In 1901, he wrote that “The most widespread and fatal of all acute infectious diseases, pneumonia, is now the ‘Captain of the Men of Death’.”

Osler also observed that pneumonia frequently struck those whose health was already compromised. He gave the illness another name — “the old man’s friend” — meaning it was a terminal, though by standards of the time painless, affliction among the elderly. As it were, Osler would get to befriend the disease personally. He succumbed to pneumonia in 1919.

Had he lived for two more decades, the doctor would have seen penicillin change the world. After World War II, the development of penicillin and other antibiotics slashed the disease’s mortality rate to nearly a third compared to the early 1900s. Pneumonia fell from its perch at the top of lethal causes, though not very far. Together with influenza, the disease was still the eighth-leading cause of death in the United States in 2013. That year, it had a mortality rate of 17 deaths per 100,000 people, according to the Centers for Disease Control and Prevention.

Death remains a part of the pneumonia spectrum. Not all pneumonias, however, are created equally.

“The problem is we have one word for a disease that comes in lots of different iterations,” as Edelman told The Post.

At its most basic, pneumonia simply means that a germ has inflamed the lung’s air sacs. Cold viruses infect the nose and throat; bronchitis concerns the airways; and pneumonias afflict the dark, wet and warm parts of the lung itself. Making matters more complicated, the pathogens chewing into the lung tissue could be any one of a motley crew of bacteria, viruses or fungi.

The severity of pneumonia is as broad as its possible culprits. At the far end lies a mild disease. The illness is known colloquially as walking pneumonia, so named because the illness rarely knocks anyone out of commission and into bed. Here is likely where we find Clinton, at least based on what her campaign has revealed so far.

The CDC estimates that 2 million people a year fall sick with such milder forms of pneumonia. “Developing walking pneumonia does not mean you have poor health,” Stanford University pulmonologist Mark Nicolls said in an interview with The Washington Post. “Young and healthy people develop walking pneumonia.” It is possible there are even more cases than that CDC estimate, too, as walking pneumonia is hard to diagnose. Symptoms rarely stray from coughing, fever, fatigue and other average maladies.

If Clinton indeed has walking pneumonia, there is a decent chance — odds range between 1 to 50 and 1 to 5 — that the culprit is a bug named Mycoplasma pneumoniae. Among bacteria, M. pneumoniae is an oddity. It is both exceptionally small — one of the smallest organisms on earth — and unusually vulnerable, as it lacks the cell walls that sheath most other bacteria. As far as is known, it is an exclusive human parasite, unable to reproduce outside of warm and wet human organs. M. pneumoniae is spread person-to-person, through droplets expelled through the respiratory tract.

But that is just one possibility. “The bugs that cause pneumonia are common,” Edelman said. “Lots of people carry those bugs in their nose and throat.” (This was about as close as an expert would speculate about the risk factor of shaking sweaty hands by the millions on the campaign trail.)

It is too soon to say with certainty if M. pneumoniae or any other given microorganism is responsible for Clinton’s pneumonia. The laboratory tests to determine a type of mild pneumonia, in fact, frequently take longer that the disease itself lasts.

Even the fact that Clinton is taking antibiotics offers little insight into the nature of her illness. (Antibiotics are only effective against bacteria, not viruses.) Physicians may administer such drugs in suspected bacterial cases. A chest x-ray, in the meantime, will give at least some insight. Such an x-ray can “show a diffuse whiteness that can look worse than the patient does,” Nicolls said. Viruses, generally speaking, are inclined to spread out, appearing on a lung x-ray in a smothering white fog. Other sorts of microbes stay close. “The bacteria tend to get localized to a lobe of the lung,” he said.

No matter the specific bug, this sort of pneumonia is what’s known as community-acquired pneumonia. That is, it was caught anywhere but in a health care system. Hospital-acquired or healthcare-associated pneumonias are much more severe diseases, often involving drug-resistant pathogens. Those diseases are a large part why the umbrella of pneumonia continues to have a high mortality rate.

What is far less likely, too, is that Clinton caught the pneumococcal form of the disease. The Centers for Disease Control and Prevention recommends anyone over the age of 65 to be vaccinated for the more severe pneumococcal. At 68, Clinton falls within this demographic. (The American Lung Association’s advice, for what it’s worth, is a vaccine beginning at 55.)

Walking pneumonia is ultimately self-limiting, which means the disease should pass on its own, even without antibiotics. “It’s common. It occurs at all ages,” Edelman said. “It occurs in perfectly healthy people as well as those who are sick.” 

In fact, on Friday, the day of her diagnosis, Clinton attended several events, including a CNN interview and national security meeting. “If she’s had it for more than a week or so,” Nicolls told The Post, “you could say that it indicates a certain amount of stoicism.”

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