Flu Drug Worsened Hepatitis

November 9, 2003
By Karen Roebuck, Tribune-Review

The first person to die in the Beaver County hepatitis A outbreak took an over-the-counter medication containing acetaminophen that worsened the disease. He received a liver transplant the day he died.

Jeffrey Cook, 38, of West Aliquippa, a stay-at-home father, died Friday night of liver failure, Beaver County Coroner Wayne Tatalovich said Saturday.

Cook, his wife and two daughters, ages 8 and 10, had eaten at the Chi-Chi's Mexican Restaurant in the Beaver Valley Mall in early October, said his widow, Christine Cook, 35, an emergency room nurse at Sewickley Valley Hospital. Cassie Cook, 10, also contracted the disease, but is recovering and did not need to be hospitalized, Christine Cook said.

The family never connected that meal to the low-grade fevers and mild flu-like symptoms Jeffrey Cook developed in mid-October. As the symptoms waxed and waned through the rest of the month, he took Tylenol, which contains acetaminophen, a fever- and pain-reducer, his wife said.

Richard McGarvey, state health department spokesman, said people with hepatitis A or other liver diseases should not take medications with acetaminophen or drink alcohol, as both can exacerbate liver problems. Anyone at risk for getting hepatitis A who gets sick with flu-like symptoms should see a doctor, he advised.

But Jeffrey Cook seemed to just have a mild case of the flu.

"Nothing that made me think it was (the) liver. I thought it was the flu," his wife said.

Jeffrey Cook fell more seriously ill Oct. 29. Four days later, his wife took him to the Sewickley Valley Hospital emergency room, where he was diagnosed with hepatitis A and sent home. The rest of the family was tested the next day as news of the Chi-Chi's outbreak first broke. Cassie tested positive while Christine and Courtney, 8, tested negative.

Her husband took the news of the outbreak well and was not angry at the restaurant, Christine Cook said. "We're pretty laid back people. ... At that time, we thought we survived worse -- who knew all this was going to happen.

"By Tuesday, he just got really sick. That's why I had to take him back to the emergency room. He was confused," she said.

From the Sewickley hospital, he was taken to UPMC Presbyterian hospital in Oakland, where he spent much of the time in a drug-induced coma, she said. Doctors there did everything they could to save him, getting him to the top of the liver transplant list.

But he was too sick. He died in the intensive care unit Friday, following transplant surgery earlier that day, never knowing he had had the surgery, she said.

Coroner Tatalovich said, "We want to take a look at what the old liver was like and see if there was any previous condition" that contributed to his death. He said he is waiting for Cook's medical records from UPMC Presbyterian.

The Pennsylvania Department of Health, which is investigating the outbreak, said Cook had a pre-existing, liver-related medical condition. His wife said they were not aware of any liver problems.

Confirmed cases of hepatitis A linked to the outbreak stood at 185 for the second day, because state health officials did not release any results of blood tests yesterday.

One victim, a 46-year-old man, is in intensive care and being evaluated for a liver and pancreas transplant. He is on dialysis after his kidneys shut down.

He is among four hepatitis A patients hospitalized at UPMC Presbyterian because of the outbreak: two in critical condition, and two in fair condition, according to University of Pittsburgh Medical Center spokeswoman Susan Manko. Some other hospitals, including the Medical Center, Beaver -- the largest hospital in Beaver County -- repeatedly have refused to say if they have patients related to the outbreak.

About 11,000 people could have been exposed to the disease after eating at the Chi-Chi's between Oct. 1 and Nov. 2, when the restaurant voluntarily shut down, McGarvey said. Six employees tested positive for the virus, Chi-Chi's said in a written statement yesterday.

Through yesterday, 7,546 people received immune globulin shots the state health department is giving in Beaver County to help stave off the disease. That's more than double the estimated 3,400 people who ate at Chi-Chi's between Oct. 22 and Nov. 2, the span for which health department officials recommended the shots.

More than 60 people also received shots at the Allegheny County Health Department's Oakland clinic, and nurses will be on hand Monday to continue giving shots.

In the meantime, officials are bracing for more cases through second-hand infection.

"There may definitely be emerging cases on the way," said department spokesman Guillermo Cole.

"You could have more cases from the initial outbreak, because there's such a long incubation period, and you could have more cases from secondary infection that could extend that timeframe further," he said,

The shots are recommended for people living with those who are confirmed to have the disease -- but not those who came in contact with people only exposed to it.

Those who said they ate at the restaurant before Oct. 22 are not being given the shots, because public health officials said the injections won't help them. The shots help only when given within two weeks of exposure, and then they are 80 percent to 90 percent effective in preventing the disease for about three months, health officials said.

Standard medical care calls for immune globulin inoculations for family members of people infected with hepatitis A, regardless of how they contracted it, McGarvey said. The disease is transmitted by infected fecal matter, usually in such small amounts it cannot be seen, so even families trying to practice good hygiene cannot eliminate the risk to those with whom they live, he said.

Hepatitis A patients who develop jaundice, which most adults will, are contagious for two weeks before and one week after the onset of jaundice, which causes the skin and whites of the eyes to turn yellow. Those who do not develop jaundice are contagious for one week before and two weeks after the first symptoms appear.

Symptoms resemble the flu, including fever, abdominal pain, diarrhea, headaches, weakness, extreme fatigue, nausea and loss of appetite.

The Beaver County outbreak is expected to exacerbate an already chronic shortage of livers, said Pat Kornick, spokeswoman for the Center for Organ Recovery and Education, a nonprofit that distributes organs, tissues and corneas to hospitals nationwide.

In response, CORE has stepped up its outreach to schools, unions and corporations. Nationwide, two people die every day awaiting a liver transplant that never comes.

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