A 94-year-old woman who lived alone in rural Connecticut died yesterday of inhalation anthrax as baffled investigators searched for clues as to how she might have become infected.
Investigators were interviewing friends, relatives and neighbors to learn more about her activities, and were sampling her home and two local post offices for traces of anthrax.
Ottilie W. Lundgren, who lived in a small town 35 miles southwest of Hartford, died at 10:32 a.m., five days after being admitted to Griffin Hospital in nearby Derby.
She was the 11th person diagnosed with inhalation anthrax since early October - and the fifth fatality - but only the second victim who did not have an obvious connection to the U.S. Postal Service or known contact with contaminated mail.
"There are many questions," said Dr. Donald A. Henderson, who heads an office of public health preparedness in the U.S. Department of Health and Human Services. "One does find in many outbreaks an unusual case that is really a puzzle, and the work done to solve that puzzle can usually be revealing."
The only other case quite so mystifying is that of Kathy Nguyen, a 61-year-old Vietnamese immigrant who lived alone and worked in the storage room of a New York City hospital. Investigators have not found anthrax in her home, office or clothing or along her daily travel route.
Nguyen died Oct. 31.
Lundgren lived in a modest home in Oxford, a town of fewer than 10,000 people, one bank and no hotel.
Neighbors described Lundgren, the widow of a local judge who died in 1977, as a sharp and kindly woman who had been in good health for her age.
"My kids used to visit her all the time, take her flowers from our garden," said Aaron Smith, who lives across Edgewood Road from Lundgren's house. "She was sort of a surrogate grandparent."
Smith said he was astonished to hear that anthrax was blamed for the death of the friendly woman who liked to sit on her porch and watch neighborhood children play.
"It's completely baffling," he said. "It's a sad and scary time."
Dr. Jeffrey Koplan, director of the U.S. Centers for Disease Control and Prevention, said he is open to the possibility that Lundgren contracted anthrax through a natural source, such as spores in garden soil. But he said the chances of that were remote, and he was leaning heavily toward the view that Lundgren was the victim of a criminal act.
"The initial reading is that this 94-year-old woman had no occupational exposure, did not associate in pastimes associated with anthrax - tanning hides, sorting wool, being a veterinarian, a farmer," Koplan said.
Federal officials consider the previous anthrax cases to be acts of bioterrorism but acknowledge that they have no idea who is responsible.
Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said Lundgren's advanced age might have made her susceptible to a very small amount of anthrax spores. The dose required to infect an average person is estimated at 8,000 to 10,000 spores, but scientists say the infective dose for the most vulnerable people might be fewer than 100 spores.
Though Lundgren was believed to be in good health, Fauci said anyone who has lived as long as she lacks the natural defenses against airborne bacteria that a younger person would have.
That opens the possibility, though it remains to be proved, that she might have been infected by a letter that was "cross-contaminated" by other mail as it passed through the postal system.
Doctors at Griffin Hospital said she had been sick for two days before she was admitted Friday with fever, weakness and fatigue. Her initial chest X-rays showed no indication of inhalation anthrax, the hallmark of which is a widening in the area between the lungs.
Doctors initially suspected pneumonia, and began treating her with antibiotics Saturday. Five tests subsequently showed the presence of anthrax bacteria.
Yesterday, Koplan said her case is almost certainly anthrax, though the CDC is awaiting results of a blood culture that would confirm the diagnosis.
Investigators were hampered by the fact that Lundgren had a breathing tube that made it impossible for her to talk. Any clues to how she became infected will have to come from environmental sampling and interviews with people who knew her.
"Our preliminary understanding is that either a friend or relative picked mail up for her from her post box and brought it to her," Koplan said, adding that she apparently opened the mail herself.
Mail to Oxford passes through a processing center in Wallingford, Conn., said Postal Service spokesman Jim Cari. The center was tested recently and showed no sign of anthrax, he said.
Two smaller post offices in Connecticut were being tested for anthrax, said HHS Secretary Tommy G. Thompson. As a precaution, workers at the two facilities were placed on antibiotics.
Judith Daddio, who lives near Lundgren, said neighbors were not panicking and had not been warned to take special precautions. But she said she is discarding mail from strangers and washing her hands after handling letters.
"I am concerned over it," she said. "I have a couple of grandchildren here in Oxford."
While anthrax in animals occurs regularly in the western United States, the World Health Organization has not reported the disease in the East in recent years.
A Tufts University veterinarian who works with cattle in Connecticut said the chance that Lundgren had contracted anthrax from a natural source was "infinitesimally small."
"I've practiced in Connecticut since 1978, and I never saw a case of anthrax," said Dr. George Saperstein, chairman of environmental and population health at the Tufts vet school in North Grafton, Mass., which maintains a practice in Woodstock, Conn. He said he could remember hearing about anthrax in the state only once, from a farmer who recalled a cattle outbreak in the 1960s in the northeastern part of the state.
Moreover, he said, farmers who handle infected animal carcasses usually get the skin form of anthrax, not the more serious inhalation type.
Saperstein said anthrax spores survive best in alkaline soil and would not be likely to live long in Connecticut's acidic soil.
The first anthrax case was reported Oct. 4 in a photo editor for a tabloid newspaper in Florida. Since then, authorities have found anthrax-laced letters addressed to NBC News anchor Tom Brokaw, Senate Majority Leader Tom Daschle, the New York Post and, most recently, Sen. Patrick J. Leahy of Vermont.