Jeff Hanneman, lead guitarist of the seminal thrash-metal group Slayer, died this week of liver failure. Without exception, the somber coverage of his death has included mention of the nearly fatal infection Hanneman had sustained in 2011 when he developed necrotizing fasciitis, a.k.a. flesh-eating bacteria, of his right arm. Even a representative of the band, which Hanneman had played in since its founding in 1981, suggested the bite that seemingly led to the devastating infection may have played a role in his early death.
The necrotizing fasciitis and the liver failure both are awful, but despite the tidiness of the narrative suggesting that the old necrotizing fasciitis caused the new liver failure, the story is exactly the opposite: people with severe underlying medical problems, such as chronic liver disease, are at increased risk for necrotizing fasciitis. So rather than the 2011 illness influencing his death, it is more likely that the very illness that killed him—liver failure—was the same condition that predisposed him to the near-death experience two years ago.
Necrotizing fasciitis is a very rare, altogether miserable disease that affects a hundred-plus people nationally each year. The condition gained national prominence a year ago when a young Georgian woman, Aimee Copeland, sustained a seemingly routine injury while zip-lining above a river and ended up with an overwhelming infection treated by amputations and a very prolonged hospitalization. The CDC tracks cases brought on by the most common bacterial cause, group A streptococci (the bug famous for strep throat), but a handful of other bacteria can cause the condition as well.
The clinical disease resulting from strep or any of the other organisms is more or less the same. Our arm and leg muscle groups are packed tightly together by a bloodless, tenacious “wrapping paper” of fibrous tissue—the fascia—to keep the arteries, nerves, and veins coursing through the spaces from jostling too much. It’s a wonderful, lightweight, low-energy solution except for one problem: an infection that touches the fascia has the run of the place. The absence of blood supply means that the fascia exists outside the reach of the immune system—no white blood cells, no antibodies, nothing. So a standard bacterial inoculum that, if present in say the tonsils, would be handled with routine, bored ease, can in the fascia take off like the proverbial lighted match to dry wood: the rapidity of the extension is truly startling. And the lack of blood supply also means that pouring antibiotics in might not do the trick; rather, that most barbaric of interventions—amputation—may be necessary to control the infection.
The real story of Hanneman’s death, though, is not the dramatic illness from two years ago or his heroic attempts to return to active touring, but rather the ongoing silent epidemic of chronic liver disease in the United States. We do not know the cause of Hanneman’s liver failure—though the most common cause in the U.S. is viral hepatitis. The alphabet soup of viral hepatitis—A, B, C, and E (don't ask)—at times seems like a deliberate attempt by the medical establishment to confound and confuse any non-hepatologist trying to make simple sense of the terrain. Here’s the Cliffs Notes version:
Each of the alphabetic diseases is caused by a distinct, genetically unrelated virus and two (A and B) are vaccine-preventable. Hepatitis A is the one that hits the headlines when a restaurant worker contracts the disease and spreads it to paying and unsuspecting customers. If you need info, there are lots of lawyers eager to help out. Hepatitis A also is responsible more than any other infection for the signs in all restaurant bathrooms that employees wash their hands. Why? The virus is present in high amounts in the feces of a newly infected person then is spread to the next poor soul by the “fecal-oral” route. I’ll leave the rest to your imagination. Hepatitis E shares many epidemiologic similarities with hepatitis A and is seen mostly in South Asia. Neither causes chronic hepatitis.
Hepatitis B and C both cause chronic hepatitis and are spread the way HIV is spread—sharing needles, mother-to-infant, and of course sexually. In addition, risks for hepatitis C include sharing straws (or rolled dollar bills) to snort cocaine or receiving a tattoo. The CDC has begun to turn a great deal of attention to hepatitis C, which affects 3 million to 4 million people in the U.S. and often is mild when first acquired. Because of its initial clinical subtlety, it may remain undiagnosed for decades, found only when a person has already developed advanced cirrhosis (late-stage scarring from infection), a condition that can be remedied only by a liver transplant. Therefore, the CDC now recommends broad testing of everyone born between 1945 and 1965. Hanneman was born in 1964.
Sadly, the coverage of Hanneman’s death distracts just as his work had distracted. His skill as a guitarist was obscured by the deliberate harshness and sharp edge that characterize heavy metal. And his death has become a reconsideration of the extremely rare infection, necrotizing fasciitis, that almost killed him rather than of the common, preventable and treatable condition, liver disease, that did. Perhaps in the days ahead, facts about both his musical gift and his medical history will emerge and provide his fans and the world of public health with something more than yet another unhappy tale of someone dying too young.