Critical by Robin Cook

said. “Maybe not quite as bad, at least not all of them, but bad enough. Mine were from a methicillin-resistant strain coming from outside the hospital but which apparently had hybridized with bacteria coming from within the hospital.”
    â€œThat’s exactly what my case apparently is,” Laurie said, even more impressed.
    â€œThe strain is called community-acquired MRSA, or CA-MRSA, to distinguish it from the usual nosocomial, hospital-acquired MRSA, or HA-MRSA.”
    â€œI remember reading about it,” Laurie said. “Someone had a case five or six months ago, of a football player who picked it up in the locker room and had an infection that ate away a lot of his thigh.”
    â€œThat was Kevin’s case,” Arnold said. Kevin Southgate was another senior ME who’d joined the OCME only a year after Arnold had. As the old guard, Arnold and Kevin stuck together like a team, although opposites in their politics. Both were infamous around the office for constantly conspiring to take as few cases as possible. It was like they were working half-time full-time.
    â€œI remember when he presented the case at Thursday conference,” Laurie said. Other than the informal but effective give-and-take in the autopsy room, the formal Thursday conference with its required attendance was the only other opportunity for all of the city’s nineteen MEs to share their experiences. Laurie, for one, lamented this situation because it hampered the OCME’s ability to recognize trends. She had complained about it, but without coming up with a solution, the issue had died. With the OCME doing more than ten thousand cases a year, there wasn’t time for more interaction, and there were no funds to hire more forensic pathologists than the one they had hired that year.
    â€œThe CA-MRSA bug is scary, as this case of yours aptly demonstrates,” Arnold said. “It’s been a mini-epidemic outside the hospital, like Kevin’s football player and even, tragically enough, some young, healthy children getting scrapes on the playground. Now it seems to be going back into the hospital. That’s the bad side. The good side is that it is sensitive to more antibiotics, but the antibiotics have to be started immediately because, believe it or not, being more sensitive to antibiotics has given the strain added virulence. Not making the complete line of defensive molecules for antibiotics like the HA-MRSA strains, these community-acquired strains are able to spend more time and effort making a soup of powerful toxins to enhance their virulence. One of them is called PVL, which I’m sure has played a role in your case here. PVL toxin chews up the patient’s cellular defenses, particularly in the lungs, and initiates an overwhelming and perverse release of cytokines, which normally help the body fight infection. Do you realize that as much as one-half of the destruction you are seeing in the lung sections you are holding comes from the victim’s own completely overstimulated immune system?”
    â€œYou mean like the cytokine storm they are seeing with people dying from H5N1 bird flu?” Laurie asked. The thought went through her mind that she would have to suggest to Jack that he might need to adjust the opinion he had of Besserman. He was embarrassing her by how much more he knew about MRSA than she.
    â€œExactly,” Arnold said.
    â€œI’m afraid I’m going to have to do some serious reading about all this,” Laurie admitted. “Thanks for all the information. How is it that you are such an expert?”
    Arnold laughed. “You’re giving me too much credit. But a month or so ago, Kevin and I got interested in the issue because of several cases we each had. We kinda challenged each other to learn about it. It’s a good example of the genetic versatility of bacteria and how quickly they can evolve.”
    Laurie struggled to rein in her mind, which