On November 16, 2001, a 94-year-old woman from Oxford, Conn, with fever,
fatigue, myalgias, dry cough, and shortness of breath of approximately 3 days'
duration was evaluated at her local hospital. During the preceding 2 months,
following the death of a close friend, she had experienced depressive symptoms,
including decreased appetite and increased general fatigue. On the day before
admission, family members noted that she was confused. There was no recent
history of headache, chills, sweats, sore throat, rhinorrhea, hemoptysis,
chest pain, abdominal pain, nausea, vomiting, or diarrhea. She had chronic
obstructive pulmonary disease. She had a 22-pack-year smoking history but
had not smoked in 30 years. She also had hypertension and chronic renal insufficiency.
Her medications included montelukast, irbesartan, loratadine, alprazolam,
inhaled salmeterol xinafoate/fluticasone propionate, and azelastine nasal
spray. Her only nonprescription medication was a multivitamin tablet, and
she rarely drank alcohol. Her diet was unremarkable. The patient had lived
alone since the death of her husband 22 years earlier. She had previously
worked as a legal secretary. She had no recent travel and had no pets. Additional
history obtained following admission revealed that she did not remember opening
any mail containing powder.