Sources of Information: Primarily Dr. Cirilo Lawson, the General Director of Health of Panama's Ministry of Health. I also spoke briefly with Dr. Jorge Motta, the Director of the Gorgas Institute. Apart from the official response I spoke to a long list of doctors in Panama about this syndrome and the situation. In short, there is an emerging situation that is not yet clearly defined. Everyone is working hard to figure it out. Official sources are limiting themselves to presenting what is known and what is unknown and are working to manage an emerging situation. Non-official sources are more willing to speculate.

What's Causing This? Still unknown. Tissue samples have been sent to the Center for Disease Control in Atlanta. While I was in the Ministry of Health this afternoon Dr. Jorge Motta was waiting to receive an email with details of the results of the analysis. As of right now they still do not know if this is being caused by a virus, bacteria, or something else. They are working hard to identify the cause and source.

Is It Contagious? Unknown. What is known that patients who have presented with this syndrome have not followed any kind of infectious disease control protocols and they have not infected family members or health care workers. Or actually it would be more accurate to say that people who have been exposed to patients have not presented symptoms.

When Did This Start: There has been a current outbreak of cases that started on 20 September 2006. Doctors working in the Social Security hospital recognized the pattern and began to track, diagnose, and report cases internally to the hospital. On Friday 28 September the Social Security health care system reported the situation to the Ministry of Health, which has been coordinating a national response.

How Many Cases Have There Been? So far there have been 22 cases that have been related to this syndrome. Of those, 12 have died of their illness. There are other deaths that have occurred but have not yet been related to the syndrome. There was one case in July of 2006, none in August, and then this current outbreak in the end of September.

What Are the Symptoms? So far all patients have presented with the same set of symptoms. For the most part the symptoms present basically in order and with a short period of onset. In other words, you get very sick, very quickly. Patients are presenting with the same symptoms every time, making it easier to both diagnose new cases and to go back through the files and to search for old cases that were potentially related to this outbreak. The syndrome presents basically as follows:

• Nausea
• Vomiting
• High Fever
• Diarrhea
• Severe Headache
• Kidney Failure
• Paralysis, especially around the face
• Difficulty Walking and Physical Coordination
• Eventually, death if the patient does not receive dialysis.

"Sounds Like a Virus" This part is not from the Ministry of Health. According to several pathologists I spoke with today, the syndrome is presenting like a virus.

Is There A Cure? The patients that have survived this infection have all received dialysis. The suspicion is that the infection is producing some kind of toxins which are causing the renal failure and paralysis. The dialysis cleans the blood and allows the body time to recover from the infection.

Elements In Common: Patients have had several things in common, such as high blood pressure, diabetes, or some kind of kidney disease. Most of the patients have been more than 60 years of age. According to Dr. Cirilo Lawson there is a possibility that patients are taking some kind of pills vitamins or home remedies that might be causing this syndrome, and health officials are recommending that people only take those medications that are prescribed by a doctor.

Arriving Sick: One thing is clear, patients who are arriving at the hospital are already very ill. They are presenting with Acute Renal Failure, and their production of urine basically shuts down. Eventually toxins build up in the blood and the patient is basically poisoned from the inside, out. In other words patients are not catching it in the hospital. On the evening news today there are reports of another person dying in the capital. There is also a case of one man presenting with acute renal failure in Veraguas but that case has not been identified as linked to this syndrome.

Prevention Measures: Obviously, increase your alert level. Increase personal hygiene procedures. Be aware of the symptoms and go immediately to the ER if you present one or more of the symptoms related to this syndrome. Spread the word, and make sure that everyone knows what's going on. Do not panic. There are more than 3 million people in Panama and there have been less than two dozen cases. As one experienced doctor told me today, sometimes these types of things come and go and the exact cause is never identified with precision.

Insects? The vector is unknown. It might be a virus, and transmission via insect is a possibility that can not be ruled out.

Person to Person? Unknown. It does not appear to be passed from one infected person to another but no one knows what is causing these patients to become ill. So again, there's no need to panic or over-react, but at the same time nothing can be ruled out.

Don't Self Medicate: One of the primary messages the doctors from the Ministry of Health want to get out is for people not to try to self-medicate. If you do have this syndrome, self-medicating will on mask symptoms and might make you feel a little better for awhile but you won't get well. Go to the ER and let them take care of you.

It Might Just be Gas: It is possible to present one or more of the symptoms and not have this syndrome. Every case of diarrhea in Panama is not going to end in death. Don't over react, just go to the doctor. The people who have gotten very sick have waited until the last minute.

Developing Situation: This situation will most certainly gain the attention of the international health community. Interested or responding health professionals should coordinate their efforts through Panama's Ministry of Health.