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A case of advanced bilateral pulmonary tuberculosis treated with streptomycin
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A Case of Advanced Bilateral Pulmonary Tuberculosis Treated with Streptomycin By B. R. SREENIVASAN, L.M.S. Case History.--A male Chinese, aged 25, was first seen by the writer w i t h a history of having been ill for tbur months with cough and fever. O n examination it was found that he w a s suffering from a d v a n c e d active bilateral pulm o n a r y tuberculosis w i t h laryngeal involvement. X - r a y films showed advanced active bilateral disease with cavitation. His Weight was 85 lb. There were numerous crepitations heard almost over the whole suifaee of the chest. T h e sputum was repeatedly positive for acid-fast bacilli and on each examination the smears showed numerous bacilli. His voice was hoarse and he looked v e r y toxic. Examination of the larynx showed redness and oedema of the vocal cords a n d arytenoids. T h e clinical impression was that this was an advanced case with a hopeless prognosis, and this opinion was confirmed by other doctors and shared to a great extent b y the patient's relatives. He was febrile at this stage with a temperature ranging between xoI ~ and to3 ~ F. His E.S.R. then was
(Singapore)
I33 ram. for the first hour (Westergren tech, nique.) Trealment.--He was started on streptomycin hydrochloride (Merck) on I4.8.47 and was given i grin. per day. T h e streptomycin was given as tbllows: i grm. was dissolved in 9 c.c. of distilled water to which was added I c.c. of 2 per cent solution of procaine so as to make a total of about ro c.c. At 6 a.m, the patient received 2 c,c. (0.2 grm.), at I 1.3) a.m. 2 e.e, (o'2 gzm),, at 5 p.m. 2 c.c. (0.2 grm.) and at Io p.m. 4 c.c. (o. 4 grin.) o f the solution. All the itljections were given intramuscularly. I t was considered that the injections should not be carried through the night becanse this would break rest. F r o m ~6.8.47 to 23.8.47 he was given 1.5 grm. of streptomycin daily, the dosage being as follows: At G a.m, 3 e.c. (o. 3 grin.), at i 1.3o a.m. 3 e.c. (o. 3 grm.), at 5 p.m. 3 c.c. (o. 3 grm.) and at Io p.m. 6 c.e. (0.6 grm.) of the solution. O n 23.8.47 the patient developed a profuse rash consisting o1'
June 1948
TUBERCLE
large purplish raised plaques. This was not itchy nor painful nor tender. The streptomycin was discontinued For onIy two days and an injection of calcium gluconate (~o c.c. of a ro per cent aolution) was given intravenously. On 26.8.47 streptomycin was started again at a dosage'of I. 5 grm. per day until 24.9.47. At this stage the patient complained of severe giddiness which was so pronounced that it caused nausea and prevented him from eating his food. The dosage was therefore cut down to grm. per day on -05.9.47. O n 6.Io.47 another effort was made to increase the dosage to z.5 grm. but the result was as before, i.e. the patient had severe vertigo with nausea. From 7.Io.47 to z4.z2.47 the patient had ~ grin. of streptomycin per day in divided doses as stated above. Within two weeks of treatment his temperature came down to normal, his voice became normal, his cough ceased and he regained his appetite which had been completely lost before. In fact he became symptomless. On 4.,o.47, an x-ray film taken showed some improvement. On 27.~o.47 his weight was 9~ lb. and his E.S.R. 75 ram. for the first hour. On t8.r x.4.7 a further x-ray film showed remarkable Improvement. The weight increased to 9.6 lb. and
129
the E.S.R. hecame reduced to 68 ram. for the first hour. Examination showed no physical signs of disease in the chest. His voice was normal and the appearance of the larynx was also normal. He felt very fit and was quite satisfied tbat he was cured and in this belief his relatives concurred. Repeated examinations of the sputum were negative for acid-fast bacilli. On 3~.1m47 his weight was lO5 lb., E.S.R. 24 ram. for the first hour and an'~x-ray film showed practically no evidence of disease. The first x-ray film ariel the last are shown.
Comments This case is reported as showing remarkable improvemeat possibly amounting to a cure in a case that appeared hopeless. In fact at the time he started treatment the writer was quite sure in his own mind that this patient would not live for three weeks and this opinion was confirmed b~" other doctors who saw him. The dosage of streptomycin used in this case is extremely small compared to the dosage used in U.S.A. Actually for most of the time this patient received only i ~rm. per day and the total dosage was z38 grm. Another point of interest is that the rash disappeared and did not reappear with the exhibition of streptomycin
130
June 1948
TUBERCLE
again. This case was shown at a clinical meeting of the Alumni Association of King Edward VII College of Medicine and the meeting agreed not only that it was a remarkable case but that to all intents and purposes the patient appeared cured. This patient was treated in Singapore in his own house and although he was not working during the period of treatment he was not at complete rest in spite of repeated advice on this matter.
Summary A case of advanced bilateral pulmonary tuberculosis treated with streptomycinhydrochloride (Merck) is reported. The dosage was more or less a gram per day. The total duration of treatment was I2~ days and the total dosage of streptomycin was I38 grm. X - r a y films taken before and after treatment are reproduced. I wish to thank my wife for the invaluable help she gave me in the management of this case.
Reviews TUBERKULOSE REINFEKTION BEIM R I N D E U N D I H R E I N F L U S S AUF DIE R E S I S T E N Z (Tuberculous Reinfection in Cattle and its Influence on Resistance). By E. Graub, P.D., Bernl With 41 illustrations and charts. I947. Basel. S. Karger. New York. Price I~ Swiss francs. This monograph describes studies covering thirteen years and deals largely with the properties of a relatively avirulent strain (P-strain) of the bovine tubercle bacillus. In rabbits 0'25 mg. inoculated intravenously produced no ill-effect and the animals were healthy one year later when killed. G u i n e a - p i g s inoculated subcutaneousIy developed a primary complex and some died within a few months, others lived for one or more years and showed no lesions when killed. Calves were given 0.005 grin. subcutaneously and larger animals twice this dose. A local lesion, but not an abscess, was produced; the regional lymph node became enlarged, but there was no further spread of the disease. T h e immunizing power of the P-strain was compared in guinea-pigs with that of killed tubercle bacilli, B.C.G. and another relatively avirulent strain. All 'the control animals were dead three months after the inoculation of a virulent strain and 65 per cent of those inoculated with B.C.G. After four months all those vaccinated with B.C.G. were dead, but none of those vaccinated with the P-strain had died of tuberculosis. This appears to be a more striking superiority over B.C.G. than any which has been demonstrated with the vole acid-fast bacillus and it would appear that this greater immunizing power was due to greater virulence. T h e P-strain produced a much more persistent lesion at the site of inoculation in the guinea-pig than B. C.G. and in contrast to ]3. C.G. produced a moderate enlargement of the regionallymph node. Reinjection of the P-straln in calves caused a post-primary complex (i.e. the regional lymph nodes were not involved); it is recommended
that this reinoculation should be done in a fi'esh site, which maintains immunity although living bacilli can be recovered from the inoculation site for two to three years. It is stated t h a t following vaccination the P-strain did not a p p e a r in the milk and that allergy disappeared w i t h i n one year. Rcvaccinated animals remained tuberculin negative and a positive reaction could be taken as evidence of active infection with tuberculosis. Vaccination was shown to produce a good immunity in cattle against infection by subcutaneous inoculation or natural exposure. There can be little doubt that the P-strain has good immunizing properties but it w o u l d obviously require much work before its c o m plete safety and reliability for inoculation of dairy stock could be accepted. It would seem that under certain conditions vaccinatior~ of man against tuberculosis is of real value b u t its value for the control and eradication of tuberculosis in cattle has never been conclusively demonstrated on any large scale.* DISEASES OF T H E NOSE, T H R O A T A N D EAR. By I. Simson Hall, M.B., Ch.B., F.R.C.P.E., F.R.C.S.E. Fourth Edition. Many illustrations, eight in colour. E. & S. Livingstone, Ltd. Price I5S. This concise book of 463 pages is the most u p to date and readable book for students and busy practitioners. In addition, the student nurse and theatre sister will find much useful knowledge therein. The general arrangement of the book having proved its success in previous editions, has b e e n retained. The Introduction deals with examination, equipment and methods o f use of instruments. Mr Russell Howard, a great teacher, used to say, 'More mistakes in diagnoses a r e *The whole subject of vaccination has been discussed in 'Bovine Tuberculosis,' Francis, J., I947. Staples Press Ltd.
A Case of Advanced Bilateral Pulmonary Tuberculosis Treated with Streptomycin By B. R. SREENIVASAN, L.M.S. Case History.--A male Chinese, aged 25, was first seen by the writer w i t h a history of having been ill for tbur months with cough and fever. O n examination it was found that he w a s suffering from a d v a n c e d active bilateral pulm o n a r y tuberculosis w i t h laryngeal involvement. X - r a y films showed advanced active bilateral disease with cavitation. His Weight was 85 lb. There were numerous crepitations heard almost over the whole suifaee of the chest. T h e sputum was repeatedly positive for acid-fast bacilli and on each examination the smears showed numerous bacilli. His voice was hoarse and he looked v e r y toxic. Examination of the larynx showed redness and oedema of the vocal cords a n d arytenoids. T h e clinical impression was that this was an advanced case with a hopeless prognosis, and this opinion was confirmed by other doctors and shared to a great extent b y the patient's relatives. He was febrile at this stage with a temperature ranging between xoI ~ and to3 ~ F. His E.S.R. then was
(Singapore)
I33 ram. for the first hour (Westergren tech, nique.) Trealment.--He was started on streptomycin hydrochloride (Merck) on I4.8.47 and was given i grin. per day. T h e streptomycin was given as tbllows: i grm. was dissolved in 9 c.c. of distilled water to which was added I c.c. of 2 per cent solution of procaine so as to make a total of about ro c.c. At 6 a.m, the patient received 2 c,c. (0.2 grm.), at I 1.3) a.m. 2 e.e, (o'2 gzm),, at 5 p.m. 2 c.c. (0.2 grm.) and at Io p.m. 4 c.c. (o. 4 grin.) o f the solution. All the itljections were given intramuscularly. I t was considered that the injections should not be carried through the night becanse this would break rest. F r o m ~6.8.47 to 23.8.47 he was given 1.5 grm. of streptomycin daily, the dosage being as follows: At G a.m, 3 e.c. (o. 3 grin.), at i 1.3o a.m. 3 e.c. (o. 3 grm.), at 5 p.m. 3 c.c. (o. 3 grm.) and at Io p.m. 6 c.e. (0.6 grm.) of the solution. O n 23.8.47 the patient developed a profuse rash consisting o1'
June 1948
TUBERCLE
large purplish raised plaques. This was not itchy nor painful nor tender. The streptomycin was discontinued For onIy two days and an injection of calcium gluconate (~o c.c. of a ro per cent aolution) was given intravenously. On 26.8.47 streptomycin was started again at a dosage'of I. 5 grm. per day until 24.9.47. At this stage the patient complained of severe giddiness which was so pronounced that it caused nausea and prevented him from eating his food. The dosage was therefore cut down to grm. per day on -05.9.47. O n 6.Io.47 another effort was made to increase the dosage to z.5 grm. but the result was as before, i.e. the patient had severe vertigo with nausea. From 7.Io.47 to z4.z2.47 the patient had ~ grin. of streptomycin per day in divided doses as stated above. Within two weeks of treatment his temperature came down to normal, his voice became normal, his cough ceased and he regained his appetite which had been completely lost before. In fact he became symptomless. On 4.,o.47, an x-ray film taken showed some improvement. On 27.~o.47 his weight was 9~ lb. and his E.S.R. 75 ram. for the first hour. On t8.r x.4.7 a further x-ray film showed remarkable Improvement. The weight increased to 9.6 lb. and
129
the E.S.R. hecame reduced to 68 ram. for the first hour. Examination showed no physical signs of disease in the chest. His voice was normal and the appearance of the larynx was also normal. He felt very fit and was quite satisfied tbat he was cured and in this belief his relatives concurred. Repeated examinations of the sputum were negative for acid-fast bacilli. On 3~.1m47 his weight was lO5 lb., E.S.R. 24 ram. for the first hour and an'~x-ray film showed practically no evidence of disease. The first x-ray film ariel the last are shown.
Comments This case is reported as showing remarkable improvemeat possibly amounting to a cure in a case that appeared hopeless. In fact at the time he started treatment the writer was quite sure in his own mind that this patient would not live for three weeks and this opinion was confirmed b~" other doctors who saw him. The dosage of streptomycin used in this case is extremely small compared to the dosage used in U.S.A. Actually for most of the time this patient received only i ~rm. per day and the total dosage was z38 grm. Another point of interest is that the rash disappeared and did not reappear with the exhibition of streptomycin
130
June 1948
TUBERCLE
again. This case was shown at a clinical meeting of the Alumni Association of King Edward VII College of Medicine and the meeting agreed not only that it was a remarkable case but that to all intents and purposes the patient appeared cured. This patient was treated in Singapore in his own house and although he was not working during the period of treatment he was not at complete rest in spite of repeated advice on this matter.
Summary A case of advanced bilateral pulmonary tuberculosis treated with streptomycinhydrochloride (Merck) is reported. The dosage was more or less a gram per day. The total duration of treatment was I2~ days and the total dosage of streptomycin was I38 grm. X - r a y films taken before and after treatment are reproduced. I wish to thank my wife for the invaluable help she gave me in the management of this case.
Reviews TUBERKULOSE REINFEKTION BEIM R I N D E U N D I H R E I N F L U S S AUF DIE R E S I S T E N Z (Tuberculous Reinfection in Cattle and its Influence on Resistance). By E. Graub, P.D., Bernl With 41 illustrations and charts. I947. Basel. S. Karger. New York. Price I~ Swiss francs. This monograph describes studies covering thirteen years and deals largely with the properties of a relatively avirulent strain (P-strain) of the bovine tubercle bacillus. In rabbits 0'25 mg. inoculated intravenously produced no ill-effect and the animals were healthy one year later when killed. G u i n e a - p i g s inoculated subcutaneousIy developed a primary complex and some died within a few months, others lived for one or more years and showed no lesions when killed. Calves were given 0.005 grin. subcutaneously and larger animals twice this dose. A local lesion, but not an abscess, was produced; the regional lymph node became enlarged, but there was no further spread of the disease. T h e immunizing power of the P-strain was compared in guinea-pigs with that of killed tubercle bacilli, B.C.G. and another relatively avirulent strain. All 'the control animals were dead three months after the inoculation of a virulent strain and 65 per cent of those inoculated with B.C.G. After four months all those vaccinated with B.C.G. were dead, but none of those vaccinated with the P-strain had died of tuberculosis. This appears to be a more striking superiority over B.C.G. than any which has been demonstrated with the vole acid-fast bacillus and it would appear that this greater immunizing power was due to greater virulence. T h e P-strain produced a much more persistent lesion at the site of inoculation in the guinea-pig than B. C.G. and in contrast to ]3. C.G. produced a moderate enlargement of the regionallymph node. Reinjection of the P-straln in calves caused a post-primary complex (i.e. the regional lymph nodes were not involved); it is recommended
that this reinoculation should be done in a fi'esh site, which maintains immunity although living bacilli can be recovered from the inoculation site for two to three years. It is stated t h a t following vaccination the P-strain did not a p p e a r in the milk and that allergy disappeared w i t h i n one year. Rcvaccinated animals remained tuberculin negative and a positive reaction could be taken as evidence of active infection with tuberculosis. Vaccination was shown to produce a good immunity in cattle against infection by subcutaneous inoculation or natural exposure. There can be little doubt that the P-strain has good immunizing properties but it w o u l d obviously require much work before its c o m plete safety and reliability for inoculation of dairy stock could be accepted. It would seem that under certain conditions vaccinatior~ of man against tuberculosis is of real value b u t its value for the control and eradication of tuberculosis in cattle has never been conclusively demonstrated on any large scale.* DISEASES OF T H E NOSE, T H R O A T A N D EAR. By I. Simson Hall, M.B., Ch.B., F.R.C.P.E., F.R.C.S.E. Fourth Edition. Many illustrations, eight in colour. E. & S. Livingstone, Ltd. Price I5S. This concise book of 463 pages is the most u p to date and readable book for students and busy practitioners. In addition, the student nurse and theatre sister will find much useful knowledge therein. The general arrangement of the book having proved its success in previous editions, has b e e n retained. The Introduction deals with examination, equipment and methods o f use of instruments. Mr Russell Howard, a great teacher, used to say, 'More mistakes in diagnoses a r e *The whole subject of vaccination has been discussed in 'Bovine Tuberculosis,' Francis, J., I947. Staples Press Ltd.