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Acute necrotizing ulcerative tonsillitis and gingivitis (Vincent's infections)
CASE REPORT
Acute Necrotizing Ulcerative Tonsillitis and Gingivitis (Vincent's Infections) David Kaplan, MD Providence, Rhode Island
The cases of two patients with acute necrotizing ulcerative infections are reported. One had involvement of the tonsil and the other, of the gingivae. In both cases a Gram stain revealed abundant fusiform rods and spirochetes. Both patients responded to treatment with oral penicillin, showing improvement and/or healing in three to six days. These two cases demonstrate the usefulness of the Gram stain in supporting a diagnosis which would otherwise rest solely on clinical grounds. Kaplan D: Acute necrotizing ulcerative tonsillitis, and gingivitis (Vincent's infections). Ann Emerg Mecl 10:593-595, November 1981. infection, acute necrotizing ulcerative; Vincent's infection INTRODUCTION Vincent's angina and Vincent's stomatitis refer to acute necrotizing ulcerative infections of the tonsil and of the gingivae. 1'2 Vincent's angina, the tonsillar form of infection, was differentiated from diphtheria in 1898 by J. H. Vincent, who noted characteristic fusiform and spirochetal organisms in stains prepared from tonsillopharyngeal ulcers? Although these infections are described in standard textbooks, 1'2'47 they have probably become less frequent in the antibiotic era. Two patients recently treated in the emergency department demonstrated the spectrum of Vincent's infections, thus prompting this report. CASE REPORTS Case Number One - - A 21-year-old woman complained of a four-day history of sore throat on the right side. She had had swollen glands in the neck for several days and complained of a bad taste in her mouth. There was no history of fever. Her temperature was 37.2 C orally; pulse, 92 beats per minute; respirations, 20/min; and blood pressure, 120/80 mm Hg. The oral cavity was clear. The superior pole of the right tonsil had an ulcer measuring 1 cm in diameter filled with gray necrotic debris. There were tender nodes, measuring-3 to 4 cm in diameter, in the jugulodigastric areas bilaterally. The ears, nose, nasopharynx, and larynx were normal. A Gram stain prepared from the ulcer (Figure) showed numerous gram-negative fusiform rods and numerous long gram-negative spiral organisms. She was treated with oral penicillin V potassium, 250 mg four times a day, and advised to complete a course of 10 days. The patient phoned the emergency department on the third day of treatment, concerned that the ulcer on the tonsil looked bigger to her. However, she said that her throat hurt less and that her glands were no longer tender. She From the Departments of Medicine and Surgery, Roger Williams General Hospital, and the Department of Medicine, Brown University Program in Medicine, Providence, Rhode island. Address for reprints: David Kaplan, MD, Department of Medicine, Roger Williams General Hospital, 825 Chalkstone Avenue, Providence, Rhode Island 02908
10:11 (November) 1981
Ann Emerg Med
593/73
was reexamined on the sixth day of treatment, at which time she said she felt ~100% better." Her adenopathy was much less prominent, and the tonsillar ulcer, although still present, was smaller. Case Number Two - - A 21-yearold woman c o m p l a i n e d of s l i g h t bleeding from the g u m s for two weeks. For two days she had noted intermittent pain in the right ear. She admitted to having a foul taste in her mouth. Her temperature was 36.5 C orally; pulse, 72 beats per minute; respirations, 18/min; and blood pressure, 90/50 mm Hg. The gingivae were inflamed. There was a tender node measuring 3 cm in diameter in the right jugulodigastric area; gentle palpation of this node caused pain to radiate to her right ear. A Gram stain of material removed from beneath the gingival margin showed a b u n d a n t gram-negative fusiform and spirochetal organisms. She was treated orally with penicillin V potassium, 250 mg four times a day, and advised to finish a course of 10 days. She was also advised to debride her g u m s by vigorously brushing her teeth four times a day. Because brushing would be painful, she was given prescriptions for acetaminophen with codeine to take orally, and for a viscous lidocaine preparation to swish around the mouth before brushing. The patient was contacted by phone on the third day of treatment. She said she felt greatly improved, and that her gums were not bleeding as much. Interestingly, she developed an asthma attack on the fourth day of t r e a t m e n t , for which she was admitted to the hospital. Penicillin therapy was not continued in the hospital. She was reexamined on the sixth day after her initial presentation in the emergency department. The gingivitis had cleared, and the originally enlarged and tender cervical node was no longer palpable.
DISCUSSION Vincent's angina and Vincent's stomatitis refer to acute necrotizing ulcerative lesions of the tonsil and of the gingivae. 1'2 In the past, these were referred to as fusospirochetal infections because of the abundance of fusiform and spirochetal organisms noted on stained smears prepared from infected sites, as first recognized by Vincent. ~ However, current views 4 suggest t h a t it is
74/594
Fig. Gram stain from Case Number One. Arrows indicate gram-negative fusiform rods and spiral organisms. more proper to refer to these infections as mixed anaerobic infections, for spirochetes are not pathogenic and m a n y other bacterial species have been isolated from infected sites. The o r g a n i s m s i n v o l v e d are probably normal inhabitants of the gingivae and oral cavity. 4 The exact inciting influence which allows them to become invasive and cause disease is not known. Because the fusiform and spirochetal organisms are not the causative agents, current nomenclature, as presented by Uohara and Knapp, s has focused on descriptive terminology instead of the less accurate ~fusospirochetal infection," the historical ~Vincent's infection," or the s o m e w h a t pejorative " t r e n c h mouth." They proposed use of "acute necrotizing ulcerative gingivitis," ~acute necrotizing ulcerative mucositis," ~gangrenous stomatitis," and ~agranulocytic ulcer." These descriptive t e r m s cover the spectrum of acute necrotizing ulcerative lesions of the oral cavity and pharynx. Acute necrotizing ulcerative tonsillitis and gingivitis are said to be most common in young adults. 4'6 Because the organisms involved are normal inhabitants of the oral cavity, the infections are not exogenously acquired. ~,4 In healthy young people, such host factors as stress and s m o k i n g 9 and poor oral hygiene I° have been cited as etiologic factors. A recent report tl describes an epidemic of Vincent's angina on an Air Force base. The authors suspected that the inciting factor was not case-to-case spread, but rather
Ann Emerg Med
the stressful training situation, a factor to which the entire population was equally exposed. This stress factor could account for the presumed increased incidence in the trenches during World War I, hence the description ~trench mouth. ''3 Standard descriptions of the tonsillar form of this disease include a young adult, possibly under stress, with poor oral hygiene. He complains of throat pain and foul breath. 6 Regional lymphadenopathy is variable and fever is not usual. The tonsil is ulcerated. When the film over the ulcer is removed, the ulcer base bleeds. Descriptions of the gingival form of this disease likewise include a young adult, possibly under stress, with poor oral hygiene. He complains of foul breath and painful bleeding gums. t2 A g a i n , r e g i o n a l lymphadenopathy is variable, and fever is unusual. Examination discloses necrotizing ulceration with formation of pseudomembrane, most prominently at the interdental papillae. The diagnosis of acute necrotizing infection of the gingivae or tonsil is g e n e r a l l y made on clinical grounds: the clinical findings are said to be characteristic. 6 These are both mixed anaerobic infections; routine cultures will not recover anaerobes. Because the organisms involved are normal inhabitants o f the oral cavity, their recovery even after anaerobic culture will not be helpful in diagnosis. T h o u g h the fusiform and the spirochete are not causative agents, nonetheless , there is a correlation between the presence of these organisms in large number
10:11 (November) 1981
and a clinical diagnosis of Vincent's angina and Vincent's stomatitis. Their d e m o n s t r a t i o n in a p p r o p r i a t e l y collected G r a m - s t a i n e d m a t e r i a l is accepted as s u p p o r t i n g evidence of the diagnosis3a14 The t r e a t m e n t r e c o m m e n d e d for these a c u t e n e c r o t i z i n g u l c e r a t i v e mixed a n a e r o b i c i n f e c t i o n s is oral penicillin. ~'15 W h e n penicillin cannot be used, t e t r a c y c l i n e 14 and erythromycin 7 have been suggested. Metronidazole h a s b e e n u s e d to t r e a t a wide range of anaerobic infections, 16 i n c l u d i n g a c u t e n e c r o t i z i n g ulcerative gingivitis. 17 However, it is not approved for this i n d i c a t i o n by the Food and Drug A d m i n i s t r a t i o n . In addition to antibiotics, the patient w i t h g i n g i v i t i s n e e d s a d v i c e concerning oral hygiene and d e n t a l follow-up, and should be i n s t r u c t e d to d e b r i d e t h e g i n g i v a e by r i n s i n g the mouth w i t h h a l f - s t r e n g t h hydrogen p e r o x i d e , b y r e m o v i n g d e b r i s with a hydrogen-peroxide-soaked cotton-tipped applicator, 7 or by brushing the teeth. Because some of these m a n e u v e r s will be painful, he may need a systematic analgesic and/or a topical local anesthetic. He should have r o u t i n e d e n t a l follow-up if the gingivitis seems to clear well, and u r g e n t d e n t a l care if it does not. Because diagnosis will be made on c l i n i c a l g r o u n d s , p e r h a p s w i t h support from a G r a m stain, a modest differential diagnosis should be entertained. If the p a t i e n t is an older adult, the history is not clearly of an acute process, or t h e l e s i o n is exophytic or i n d u r a t e d , squamous cell c a r c i n o m a should be considered. If the a d e n o p a t h y is b i l a t e r a l and involves t h e p o s t e r i o r cervical t r i a n gles, the possibility of mononucleosis should be e n t e r t a i n e d . 1~ This could be an agranulocytic ulcer s associated with a g r a n u l o c y t o s i s of a n y cause, such as l e u k e m i a or cytotoxic d r u g therapy. If the lesion is not clearly painful, p r i m a r y o r s e c o n d a r y s y p h i l i s must be considered, and a complete physical e x a m i n a t i o n , a VDRL, and a darkfield e x a m i n a t i o n 19 (recognizing t h a t m a t e r i a l from a n i n t r a o r a l lesion m a y be difficult to i n t e r p r e t on
10:11 (November) 1981
d a r k f i e l d e x a m i n a t i o n ) , s h o u l d be done. F i n a l l y , a group A b e t a - h e m o lytic streptococcal infection produci n g a n a s y m m e t r i c a l e x u d a t i v e lesion of the tonsil m i g h t be confused w i t h t h e debris-filled u l c e r of Vincent's angina. Because the usual t r e a t m e n t for V i n c e n t ' s i n f e c t i o n w i t h 10 days of oral p e n i c i l l i n will provide adequate treatment for strep, is the cost of a t h r o a t culture for strep m i g h t not be justified. However, if the p a t i e n t were to be t r e a t e d as V i n c e n t ' s a n g i n a w i t h o u t G r a m stain confirmation, and a shorter course of t r e a t m e n t or an antibiotic not reliably effective against the s t r e p t o c o c c u s w e r e chosen, t h e n a culture for strep would be useful.
CONCLUSIONS The two cases p r e s e n t e d demons t r a t e t h a t Vincent's infections still occur. A l t h o u g h diagnosis is m a d e on c l i n i c a l g r o u n d s , a G r a m s t a i n of e a s i l y o b t a i n a b l e m a t e r i a l showing abundant gram-negative fusiform and spirochetal o r g a n i s m s can rapidly and inexpensively support the diagnosis.
The author thanks Hendrik Bogaars, MD, and Marian Holzinger, MD, for their help in preparing the photomicrograph.
REFERENCES 1. Owaltney JM Jr: Pharyngitis, in Mandel GL, Douglas RG, Bennett JE (eds): Principles and Practice of Infectious Diseases. New York, John Wiley and Sons, 1979, vol 1, p 438. 2. Meyers BR, Lawson W: Infections of • the oral cavity, in Mandel GL, Douglas RG, Bennett JE (eds): Principles and Practice of Infectious Diseases. New York, John Wiley & Sons, 1979, vol 1, p 468. 3. Pickard HM: Historical aspects of Vincent's disease. Proc Roy Soc Med 66:695-698, 1973. 4. P e l l e t i e r LL Jr: Infections due to mixed anaerobic organisms, in Isselbacher KJ, Adams RD, Braunwald E, et al (eds): Harrison's Principles of Internal Medicine, ed 9. New York, McGraw-Hill Book Company, 1980, pp 694-700.
Ann Emerg Med
5.. Parkins FM, Barbero GJ: The oral cavity, in Vaughn VC, McKay RJ (ects): Nelson's Textbook of Pediatrics, ed 10. Philadelphia, WB Saunders Co, 1975, p 799. 6. Everts EC, Echevarria J: The pharynx and deep neck infections, in Paparella MM, Shumrick DA (eds): Otolaryngology Philadelphia, WB Saunders Co, 1973, vol 3, p 325. 7. Franklin JD: Disorders of the mouth (benign), in Conn HF (ed): Current Therapy. philadelphia, WB Saunders Co, 1980, p 643. 8. Uohara GI, Knapp MJ: Oral fusospirochetosis and associated lesions, Oral Surg 24:113-123, 1967. 9. Shields WD: Acute necrotizing ulcerative gingivitis. J Periodontol 48:346-349, 1977. 10. Barnes GP, Bowles WF, Carter HG: Acute necrotizing ulcerative gingivitis: A survey of 218 cases. J Periodontol 44:3542, 1973. 11. James L, McCaskey DL, Goris GB: An outbreak of tonsillar Vincent's angina among students at Lowry Air Force Base. Milit Med 143:279-280, 1978. 12. Young WG: Diseases of the teeth and gingivae, in English GM (ed): Otolaryngology. Hagerstown, Maryland, Harper and Row, 1979, vol 3, pp 7-8. 13. MacFarlane TW, Ross CA, Cohen BJ: Oral ulceration and infective agents, (letter). Br Med J 1:643, 1974. 14. Kelly RT: Spirochetes and spiral bacteria, in Henry JB (ed): Todd, Sanford, and Davidsohn's Clinical Diagnosis and Management by Laboratory Methods, ed 16. Philadelphia, WB Saunders Co, 1979, vol 2, p 1659. 15. Gwaltney JM, Jr: Pharyngitis, in Mandel GL, Douglas RG, Bennett JE (eds): Principles and Practice of Infectious Diseases. New York, John Wiley & Sons, 1979, vol 1, p 440. 16. Tally FP, Sutter VL, Finegold SM: Metronidazole versus anaerobes - - in vitro data and initial clinical observations. California Medicine 117:22-26, 1972. 17. Fletcher JP, Plant CG: An assessment of metronidazole in the treatment of acute ulcerative pseudomembranous gingivitis (Vincent's disease). Oral Surg 22:729-736, 1966. 18. Komaroff AL: A management strategy for sore throat. JAMA 239:1429-1432, 1978. 19. Lee TJ, Sparling PF: Syphilis: An algorithm. JAMA 242:1187-1189, 1979.
595/75
Acute Necrotizing Ulcerative Tonsillitis and Gingivitis (Vincent's Infections) David Kaplan, MD Providence, Rhode Island
The cases of two patients with acute necrotizing ulcerative infections are reported. One had involvement of the tonsil and the other, of the gingivae. In both cases a Gram stain revealed abundant fusiform rods and spirochetes. Both patients responded to treatment with oral penicillin, showing improvement and/or healing in three to six days. These two cases demonstrate the usefulness of the Gram stain in supporting a diagnosis which would otherwise rest solely on clinical grounds. Kaplan D: Acute necrotizing ulcerative tonsillitis, and gingivitis (Vincent's infections). Ann Emerg Mecl 10:593-595, November 1981. infection, acute necrotizing ulcerative; Vincent's infection INTRODUCTION Vincent's angina and Vincent's stomatitis refer to acute necrotizing ulcerative infections of the tonsil and of the gingivae. 1'2 Vincent's angina, the tonsillar form of infection, was differentiated from diphtheria in 1898 by J. H. Vincent, who noted characteristic fusiform and spirochetal organisms in stains prepared from tonsillopharyngeal ulcers? Although these infections are described in standard textbooks, 1'2'47 they have probably become less frequent in the antibiotic era. Two patients recently treated in the emergency department demonstrated the spectrum of Vincent's infections, thus prompting this report. CASE REPORTS Case Number One - - A 21-year-old woman complained of a four-day history of sore throat on the right side. She had had swollen glands in the neck for several days and complained of a bad taste in her mouth. There was no history of fever. Her temperature was 37.2 C orally; pulse, 92 beats per minute; respirations, 20/min; and blood pressure, 120/80 mm Hg. The oral cavity was clear. The superior pole of the right tonsil had an ulcer measuring 1 cm in diameter filled with gray necrotic debris. There were tender nodes, measuring-3 to 4 cm in diameter, in the jugulodigastric areas bilaterally. The ears, nose, nasopharynx, and larynx were normal. A Gram stain prepared from the ulcer (Figure) showed numerous gram-negative fusiform rods and numerous long gram-negative spiral organisms. She was treated with oral penicillin V potassium, 250 mg four times a day, and advised to complete a course of 10 days. The patient phoned the emergency department on the third day of treatment, concerned that the ulcer on the tonsil looked bigger to her. However, she said that her throat hurt less and that her glands were no longer tender. She From the Departments of Medicine and Surgery, Roger Williams General Hospital, and the Department of Medicine, Brown University Program in Medicine, Providence, Rhode island. Address for reprints: David Kaplan, MD, Department of Medicine, Roger Williams General Hospital, 825 Chalkstone Avenue, Providence, Rhode Island 02908
10:11 (November) 1981
Ann Emerg Med
593/73
was reexamined on the sixth day of treatment, at which time she said she felt ~100% better." Her adenopathy was much less prominent, and the tonsillar ulcer, although still present, was smaller. Case Number Two - - A 21-yearold woman c o m p l a i n e d of s l i g h t bleeding from the g u m s for two weeks. For two days she had noted intermittent pain in the right ear. She admitted to having a foul taste in her mouth. Her temperature was 36.5 C orally; pulse, 72 beats per minute; respirations, 18/min; and blood pressure, 90/50 mm Hg. The gingivae were inflamed. There was a tender node measuring 3 cm in diameter in the right jugulodigastric area; gentle palpation of this node caused pain to radiate to her right ear. A Gram stain of material removed from beneath the gingival margin showed a b u n d a n t gram-negative fusiform and spirochetal organisms. She was treated orally with penicillin V potassium, 250 mg four times a day, and advised to finish a course of 10 days. She was also advised to debride her g u m s by vigorously brushing her teeth four times a day. Because brushing would be painful, she was given prescriptions for acetaminophen with codeine to take orally, and for a viscous lidocaine preparation to swish around the mouth before brushing. The patient was contacted by phone on the third day of treatment. She said she felt greatly improved, and that her gums were not bleeding as much. Interestingly, she developed an asthma attack on the fourth day of t r e a t m e n t , for which she was admitted to the hospital. Penicillin therapy was not continued in the hospital. She was reexamined on the sixth day after her initial presentation in the emergency department. The gingivitis had cleared, and the originally enlarged and tender cervical node was no longer palpable.
DISCUSSION Vincent's angina and Vincent's stomatitis refer to acute necrotizing ulcerative lesions of the tonsil and of the gingivae. 1'2 In the past, these were referred to as fusospirochetal infections because of the abundance of fusiform and spirochetal organisms noted on stained smears prepared from infected sites, as first recognized by Vincent. ~ However, current views 4 suggest t h a t it is
74/594
Fig. Gram stain from Case Number One. Arrows indicate gram-negative fusiform rods and spiral organisms. more proper to refer to these infections as mixed anaerobic infections, for spirochetes are not pathogenic and m a n y other bacterial species have been isolated from infected sites. The o r g a n i s m s i n v o l v e d are probably normal inhabitants of the gingivae and oral cavity. 4 The exact inciting influence which allows them to become invasive and cause disease is not known. Because the fusiform and spirochetal organisms are not the causative agents, current nomenclature, as presented by Uohara and Knapp, s has focused on descriptive terminology instead of the less accurate ~fusospirochetal infection," the historical ~Vincent's infection," or the s o m e w h a t pejorative " t r e n c h mouth." They proposed use of "acute necrotizing ulcerative gingivitis," ~acute necrotizing ulcerative mucositis," ~gangrenous stomatitis," and ~agranulocytic ulcer." These descriptive t e r m s cover the spectrum of acute necrotizing ulcerative lesions of the oral cavity and pharynx. Acute necrotizing ulcerative tonsillitis and gingivitis are said to be most common in young adults. 4'6 Because the organisms involved are normal inhabitants of the oral cavity, the infections are not exogenously acquired. ~,4 In healthy young people, such host factors as stress and s m o k i n g 9 and poor oral hygiene I° have been cited as etiologic factors. A recent report tl describes an epidemic of Vincent's angina on an Air Force base. The authors suspected that the inciting factor was not case-to-case spread, but rather
Ann Emerg Med
the stressful training situation, a factor to which the entire population was equally exposed. This stress factor could account for the presumed increased incidence in the trenches during World War I, hence the description ~trench mouth. ''3 Standard descriptions of the tonsillar form of this disease include a young adult, possibly under stress, with poor oral hygiene. He complains of throat pain and foul breath. 6 Regional lymphadenopathy is variable and fever is not usual. The tonsil is ulcerated. When the film over the ulcer is removed, the ulcer base bleeds. Descriptions of the gingival form of this disease likewise include a young adult, possibly under stress, with poor oral hygiene. He complains of foul breath and painful bleeding gums. t2 A g a i n , r e g i o n a l lymphadenopathy is variable, and fever is unusual. Examination discloses necrotizing ulceration with formation of pseudomembrane, most prominently at the interdental papillae. The diagnosis of acute necrotizing infection of the gingivae or tonsil is g e n e r a l l y made on clinical grounds: the clinical findings are said to be characteristic. 6 These are both mixed anaerobic infections; routine cultures will not recover anaerobes. Because the organisms involved are normal inhabitants o f the oral cavity, their recovery even after anaerobic culture will not be helpful in diagnosis. T h o u g h the fusiform and the spirochete are not causative agents, nonetheless , there is a correlation between the presence of these organisms in large number
10:11 (November) 1981
and a clinical diagnosis of Vincent's angina and Vincent's stomatitis. Their d e m o n s t r a t i o n in a p p r o p r i a t e l y collected G r a m - s t a i n e d m a t e r i a l is accepted as s u p p o r t i n g evidence of the diagnosis3a14 The t r e a t m e n t r e c o m m e n d e d for these a c u t e n e c r o t i z i n g u l c e r a t i v e mixed a n a e r o b i c i n f e c t i o n s is oral penicillin. ~'15 W h e n penicillin cannot be used, t e t r a c y c l i n e 14 and erythromycin 7 have been suggested. Metronidazole h a s b e e n u s e d to t r e a t a wide range of anaerobic infections, 16 i n c l u d i n g a c u t e n e c r o t i z i n g ulcerative gingivitis. 17 However, it is not approved for this i n d i c a t i o n by the Food and Drug A d m i n i s t r a t i o n . In addition to antibiotics, the patient w i t h g i n g i v i t i s n e e d s a d v i c e concerning oral hygiene and d e n t a l follow-up, and should be i n s t r u c t e d to d e b r i d e t h e g i n g i v a e by r i n s i n g the mouth w i t h h a l f - s t r e n g t h hydrogen p e r o x i d e , b y r e m o v i n g d e b r i s with a hydrogen-peroxide-soaked cotton-tipped applicator, 7 or by brushing the teeth. Because some of these m a n e u v e r s will be painful, he may need a systematic analgesic and/or a topical local anesthetic. He should have r o u t i n e d e n t a l follow-up if the gingivitis seems to clear well, and u r g e n t d e n t a l care if it does not. Because diagnosis will be made on c l i n i c a l g r o u n d s , p e r h a p s w i t h support from a G r a m stain, a modest differential diagnosis should be entertained. If the p a t i e n t is an older adult, the history is not clearly of an acute process, or t h e l e s i o n is exophytic or i n d u r a t e d , squamous cell c a r c i n o m a should be considered. If the a d e n o p a t h y is b i l a t e r a l and involves t h e p o s t e r i o r cervical t r i a n gles, the possibility of mononucleosis should be e n t e r t a i n e d . 1~ This could be an agranulocytic ulcer s associated with a g r a n u l o c y t o s i s of a n y cause, such as l e u k e m i a or cytotoxic d r u g therapy. If the lesion is not clearly painful, p r i m a r y o r s e c o n d a r y s y p h i l i s must be considered, and a complete physical e x a m i n a t i o n , a VDRL, and a darkfield e x a m i n a t i o n 19 (recognizing t h a t m a t e r i a l from a n i n t r a o r a l lesion m a y be difficult to i n t e r p r e t on
10:11 (November) 1981
d a r k f i e l d e x a m i n a t i o n ) , s h o u l d be done. F i n a l l y , a group A b e t a - h e m o lytic streptococcal infection produci n g a n a s y m m e t r i c a l e x u d a t i v e lesion of the tonsil m i g h t be confused w i t h t h e debris-filled u l c e r of Vincent's angina. Because the usual t r e a t m e n t for V i n c e n t ' s i n f e c t i o n w i t h 10 days of oral p e n i c i l l i n will provide adequate treatment for strep, is the cost of a t h r o a t culture for strep m i g h t not be justified. However, if the p a t i e n t were to be t r e a t e d as V i n c e n t ' s a n g i n a w i t h o u t G r a m stain confirmation, and a shorter course of t r e a t m e n t or an antibiotic not reliably effective against the s t r e p t o c o c c u s w e r e chosen, t h e n a culture for strep would be useful.
CONCLUSIONS The two cases p r e s e n t e d demons t r a t e t h a t Vincent's infections still occur. A l t h o u g h diagnosis is m a d e on c l i n i c a l g r o u n d s , a G r a m s t a i n of e a s i l y o b t a i n a b l e m a t e r i a l showing abundant gram-negative fusiform and spirochetal o r g a n i s m s can rapidly and inexpensively support the diagnosis.
The author thanks Hendrik Bogaars, MD, and Marian Holzinger, MD, for their help in preparing the photomicrograph.
REFERENCES 1. Owaltney JM Jr: Pharyngitis, in Mandel GL, Douglas RG, Bennett JE (eds): Principles and Practice of Infectious Diseases. New York, John Wiley and Sons, 1979, vol 1, p 438. 2. Meyers BR, Lawson W: Infections of • the oral cavity, in Mandel GL, Douglas RG, Bennett JE (eds): Principles and Practice of Infectious Diseases. New York, John Wiley & Sons, 1979, vol 1, p 468. 3. Pickard HM: Historical aspects of Vincent's disease. Proc Roy Soc Med 66:695-698, 1973. 4. P e l l e t i e r LL Jr: Infections due to mixed anaerobic organisms, in Isselbacher KJ, Adams RD, Braunwald E, et al (eds): Harrison's Principles of Internal Medicine, ed 9. New York, McGraw-Hill Book Company, 1980, pp 694-700.
Ann Emerg Med
5.. Parkins FM, Barbero GJ: The oral cavity, in Vaughn VC, McKay RJ (ects): Nelson's Textbook of Pediatrics, ed 10. Philadelphia, WB Saunders Co, 1975, p 799. 6. Everts EC, Echevarria J: The pharynx and deep neck infections, in Paparella MM, Shumrick DA (eds): Otolaryngology Philadelphia, WB Saunders Co, 1973, vol 3, p 325. 7. Franklin JD: Disorders of the mouth (benign), in Conn HF (ed): Current Therapy. philadelphia, WB Saunders Co, 1980, p 643. 8. Uohara GI, Knapp MJ: Oral fusospirochetosis and associated lesions, Oral Surg 24:113-123, 1967. 9. Shields WD: Acute necrotizing ulcerative gingivitis. J Periodontol 48:346-349, 1977. 10. Barnes GP, Bowles WF, Carter HG: Acute necrotizing ulcerative gingivitis: A survey of 218 cases. J Periodontol 44:3542, 1973. 11. James L, McCaskey DL, Goris GB: An outbreak of tonsillar Vincent's angina among students at Lowry Air Force Base. Milit Med 143:279-280, 1978. 12. Young WG: Diseases of the teeth and gingivae, in English GM (ed): Otolaryngology. Hagerstown, Maryland, Harper and Row, 1979, vol 3, pp 7-8. 13. MacFarlane TW, Ross CA, Cohen BJ: Oral ulceration and infective agents, (letter). Br Med J 1:643, 1974. 14. Kelly RT: Spirochetes and spiral bacteria, in Henry JB (ed): Todd, Sanford, and Davidsohn's Clinical Diagnosis and Management by Laboratory Methods, ed 16. Philadelphia, WB Saunders Co, 1979, vol 2, p 1659. 15. Gwaltney JM, Jr: Pharyngitis, in Mandel GL, Douglas RG, Bennett JE (eds): Principles and Practice of Infectious Diseases. New York, John Wiley & Sons, 1979, vol 1, p 440. 16. Tally FP, Sutter VL, Finegold SM: Metronidazole versus anaerobes - - in vitro data and initial clinical observations. California Medicine 117:22-26, 1972. 17. Fletcher JP, Plant CG: An assessment of metronidazole in the treatment of acute ulcerative pseudomembranous gingivitis (Vincent's disease). Oral Surg 22:729-736, 1966. 18. Komaroff AL: A management strategy for sore throat. JAMA 239:1429-1432, 1978. 19. Lee TJ, Sparling PF: Syphilis: An algorithm. JAMA 242:1187-1189, 1979.
595/75