When a medical student examined Lee Wattenberg’s infected hand, she suspected the worst. Thanks to her fast action—and the expertise of the University medical staff—the renowned cancer researcher survived a life-threatening encounter with flesh-eating bacteria.

By Peggy Rinard

It all started with a tiny crack in the skin on his right thumb, probably caused by the cold, dry January air, or perhaps it was a paper cut. Lee Wattenberg (M.D. ’50), the University of Minnesota Medical School professor well-known for discovering that eating broccoli helps prevent cancer, studied the cut briefly, decided it wasn’t worthy of a Band-Aid, and headed off to meet a friend for a game of tennis.

By the time he arrived at the tennis court, however, the cut hurt more than it should have. Wattenberg’s thumb began to swell and he felt some flu symptoms coming on, so he forfeited the game and returned home, where he sat at his dining-room table until his wife arrived home that evening. As he sat, Wattenberg felt his energy fade with the late winter afternoon light, and his thoughts scatter like pieces of a puzzle.

"When my wife came home, I told her, ‘I’ve got to get organized because my thumb really hurts,’" Wattenberg recalls. "Then I wondered what I was talking about."

Esther Wattenberg, a professor in the School of Social Work, knew immediately something was very wrong when she saw how weak and confused her husband was, but the only apparent problem was an infected cut on his thumb. At age 79, Lee Wattenberg continues to conduct research and remains physically and mentally vigorous. Esther called her daughter, Betsy Wattenberg, an associate professor in the School of Public Health, and together they talked Lee into a trip to Fairview-University Medical Center, just a few minutes from the Wattenbergs’ home.

The family arrived at the emergency room at about 8 p.m., and a doctor diagnosed Wattenberg with cellulitis, an inflammation of subcutaneous tissue that isn’t uncommon. The physician on duty prescribed antibiotics, then, as a precaution, decided to keep Wattenberg in the hospital overnight for observation to make sure he responded to therapy.

As the night wore on, Wattenberg’s condition worsened. Months later he says he doesn’t remember much of what happened after he was admitted to the hospital, but he does remember that shortly after he was settled in his room, a medical student named "Miss Olson" came in to get his medical history and examine his hand.

"She seemed very mature and knowledgeable for a medical student," Wattenberg says. "I was very impressed with her."

Wattenberg’s intuition was right. Kristine Olson, a third-year medical student who happened to be interning at Fairview-University Medical Center that night, has an impressive background. As an undergraduate, she worked in the laboratory of Ashley Haase, Regents Professor and head of the Medical School’s microbiology department. After graduation, Olson spent a couple of years as a Peace Corps volunteer in Africa, where she taught science and math to 10th graders. When she finishes medical school, Olson plans to apply for a joint residency in internal medicine and pediatrics and pursue further specialization in infectious diseases.

When Olson was asked to see Wattenberg, she knew he was a University researcher but had no idea he was a cancer researcher of some distinction. Wattenberg is widely known for discovering the antioxidant and cancer-preventive properties of broccoli and other vegetables. She didn’t learn that until later in the evening when she spoke with his wife and daughter.

Wattenberg didn’t appear very ill when Olson first saw him in the ER—just under the weather, she says. But when she visited him in his hospital room less than a half hour later, Wattenberg was sleepy and looked sicker.

"His thumb turned from pink to purple while I was standing there, and he began to shake with chills," Olson says. The fact that he was getting worse so quickly made her think it might be necrotizing fasciitis, or "flesh-eating" strep disease, and possibly streptococcal toxic shock syndrome (STSS), which has serious systemic effects.

"I’d never actually seen it before. But it’s one thing I wouldn’t want to miss," she says. The disease moves so rapidly and has such a high mortality rate that even a brief delay in treating it can mean the difference between life and death. Olson went to get Peter Melchert (M.D. ’98), the resident on duty. By the time they returned, Wattenberg’s thumb was deep purple and he had become more confused, a symptom of STSS. As Olson and Melchert examined him, his thumb turned blackish and the skin began to blister.

Olson and Melchert quickly put Wattenberg on intravenous antibiotics, then alerted Paul Bohjanen, the on-call expert in infectious diseases, and hand surgeon George Landis. They knew that, by this time, the stealthy strep bacteria would be progressing up through the tendon sheath in Wattenberg’s arm and out of reach of antibiotics in the bloodstream. Treating the infection would require surgery to drain fluids and remove infected tissue.

When Bohjanen arrived on the scene, Wattenberg was very sick, with a fever of 104 or 105. Because Wattenberg is allergic to penicillin, the preferable antibiotic for invasive strep disease, Bohjanen selected a broad spectrum of alternate antibiotics to do the same work.

"He had a very classic, very severe case of necrotizing fasciitis with systemic toxic shock, perhaps the most classic case I’ve seen," Bohjanen says. "There’s a very high mortality rate with severe disease, and given his age, he’s very lucky to be alive. If he hadn’t been in a setting where the progress of the disease could be observed, he may well have died. The outcome depends on what happens during the first 12 to 24 hours." Bohjanen adds that Wattenberg’s own good health also had a lot to do with his survival. "He’s an unusually healthy man. I mean, he’s nearly 80 years old and he was on his way to play tennis a few hours before he checked into the hospital."

Later that night, Wattenberg was wheeled into the operating room, where Landis drained fluid and removed infected tissue. Called debridement, it’s a tricky procedure because it’s difficult to tell where the advancing edge of the infection stops. Landis had to take care to remove a large enough margin of tissue to make sure that no infection remained.

Then the wait began to learn if Wattenberg would survive. The first 24 hours after the surgery were the most critical. Although doctors controlled the local infection, Wattenberg’s body continued to struggle with its systemic effects. His fate was unclear for the next several days as he remained unconscious. He remembers waking up and being surprised when he saw his hand. "It’s really hard to describe how terrible it looked," he says. "I barely recognized it. The skin and much of the underlying tissue were gone."

The tissue was so damaged that Landis considered amputating the thumb and was unsure whether Wattenberg would regain use of his hand. But Wattenberg, who is right-handed and needs the use of his hand for working, not to mention playing tennis, was willing to try anything. And as it turned out, Landis’s creativity as a reconstructive surgeon was fully put to use.

The first skin graft failed, so the next time Landis sutured Wattenberg’s thumb to his abdomen for two weeks so healthy blood vessels could feed the graft. This time the graft took, but to strengthen it Landis wrote an unusual prescription—for medicinal leeches to stimulate circulation. Used many years ago for medicinal bloodletting, leeches have recently made a comeback in the clinic, primarily to support skin grafts on burn patients and reattach severed fingers and toes.

Placed on the skin, the leeches promote the growth of capillaries by sucking blood through tissue. Landis says he uses them a couple of times a year for reattaching fingers but had never before used them for this purpose. Wattenberg was skeptical, but Landis assured him that these were not just any old leeches scooped up out of a nearby pond—they are cultured in a laboratory to meet Food and Drug Administration standards and available by prescription only.

Although he didn’t enjoy the experience at the time, Wattenberg now finds some humor in it. Applied four times a day, the leeches, which are prone to sleeping on the job, required professional supervision. If they were hungry and alert, the treatment would go quickly; if not, it would drag on.

"Whenever a leech fell asleep, we would groan, especially if it was during the middle of the night," Wattenberg says. "Then we would try to wake the leech up by poking it." One nurse was particularly good at spotting the energetic ones and screening out the laggards. The leeches also needed to be monitored because when they are full, they detach and may wander off. Wattenberg was told that there have been cases in double rooms where leeches have been placed on one patient and later turned up on another.

After five weeks in the hospital, Wattenberg finally returned home. One of the first things he did when he felt better was track down Kristine Olson so that he could personally thank her. She had stopped in a couple of times during his long hospitalization, and he regretted that he hadn’t gotten her full name and address so that he could contact her.

"It’s very reassuring to me that there are students like Miss Olson to carry on the legacy that my colleagues and I have worked long and hard to establish," he says.

Although he feels particularly touched by the role Olson played, Wattenberg also attributes his survival to "a series of virtuoso performances" by George Landis, Paul Bohjanen, his hand therapists, whom he calls the "uncompromising perfectionists," and everyone else involved in his care.

And while he might be pressing his luck, he adds, he’s still hoping to grip a tennis racquet again and reschedule that game he forfeited back in January.

Peggy Rinard is publications manager at the University’s Academic Health Center.

Facts about "flesh-eating" strep

Patrick Schlievert, professor of microbiology at the University of Minnesota, first described necrotizing fasciitis, or "flesh-eating" strep disease, with Larry Cohn in a 1987 issue of the New England Journal of Medicine. The information below was provided by Schlievert and the Minnesota Department of Health.

Flesh-eating strep disease is a serious, invasive infection caused by Group A streptococcus, the same bug that causes strep throat and impetigo. There are 80 known strains of Group A strep, but only a few are deadly. Even so, they are harmless unless they get into the bloodstream through a cut or other opening such as a chicken pox lesion—a serious threat in children. Deadly strains of strep disappear and reappear in cycles of about 35 to 50 years. They caused serious infections such as scarlet fever and rheumatic fever between 1900 and 1950, disappeared, then reappeared in the mid-1980s because the population was no longer immune to them.

Once in the body, virulent strep bacteria settle in a spot where circulation is sluggish, such as a bruise, where they multiply and produce deadly toxins. The toxins kill surrounding cells, turning them into liquid "food" to fuel their destructive spree—hence the name "flesh-eating." The toxins may also cause streptococcal toxic shock syndrome (STSS), a massive inflammatory response that causes low blood pressure, shock, and injury to internal organs. Lee Wattenberg had both conditions.

According to the Minnesota Department of Health, there were nine cases of necrotizing fasciitis in Minnesota in 2000 and 17 cases in 1999. The state had eight reported cases of STSS in 2000 and four in 1999. And there were only two reported cases of people with both conditions in 2000, none in 1999.

Either necrotizing fasciitis or septic shock can be deadly. When they are combined, the fatality rate is about 70 percent. A treatment developed by Schlievert, giving immunoglobulin intravenously, helps to neutralize the toxins and save lives. If the infection goes beyond the subcutaneous tissue into muscle, it is almost always fatal. That’s why early treatment is so important.

Early symptoms of necrotizing fasciitis include fever and severe pain, swelling, and redness at the wound site. Early symptoms of STSS include fever, dizziness, confusion, a diffuse red rash, and abdominal pain. Anyone with these symptoms should seek medical attention immediately.