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Diphtheria of the uterine cervix
DIPBi'BEltl.A. OF THE U'.l'1!L'It.1D ODVIX* W.
P.A.C.S., AND MAURICE NEW ORLEANS, LA.
D. BEACHA.'vf, M.D.,
RICE, M.D.
t
(From the Departments of GyneooZagy and Obstetrios, TulaM Umvemty Scfhool of
Medicitn.e, and Charity Hospital of LtYUisifl;na, and: the Deparlment8 of Pnti«Jk;oy ooil Baoterioloff!J, LtYUisiana State Uni.t,ersity School of Medicine, and Charity Hogpittil of Liftt.isiana:)
1932 Eigen reviewed the literature of vaginal diphtheria and rean additional ease. His studies revealed a total of 115 eases, IofNported which only 72 had been confirmed by bacteriologic investigation. 1
The youngest in the series was 5 months of age, death being due to toxic myocarditis. The eldest was 55 years. This also was fatal. Since then cases of diphtheritic vaginitis have been reported in English by Lee and Van Saun, 2 who mention six cases which were not included in Eigen's study, viz., Bisdorn's observations of three sisters (1927), Mason's case (1927), and the case of Vasile (1924); Wallfteld and Litvak8 ; Cantrell4 ; Grant 5 • 6 ; StouF; and Parks. 3 The majority of the cases described were of the secondary rather than the primary type. Furthermore, our study of the literature has failed to reveal an instance in which the manifestations of the disease were confined to the cervix uteri. We are, therefore, presenting data regarding a case in which the clinical diagnosis was diphtheria. of the uterine cert·i:r.
Case Report Mrs. I<'. T. M. (T-42-39594), aged 23 years, resident of New Orleans, was admitted to the Charity Hospital April 23, 1942, presenting a chief complaint of "whitish vaginal discharge." Menstrual index was 15 by 28 by 6-7. She gave a history of having had two pregnancies. The first terminated spo~taneously at approximately two months .almost three years prior to the present admission. The second resulted in a normal delivery ofa 7-pound 1-ounce living, well-formed male, eighteen months ago. Slight dysmenorrhea has been experienced for many years, manifesting itself as cramps and backache. Headaches and breast pain are also frequently associated with the onset of the menstrual flow, the amount and character of which have not changed recently. The vaginal discharge, of which the patient complained, was not sufficient to cause her to seek medical advice. As a matter of fact, the only reason that she came to the hospital was that a health examination was compulsory for continuation of her job as a waitress. The person referring her for admittance recorded a diagnosis of "tumor of the cervix." Historieal review by systems disclosed no positive facts of note. Thorough interrogation failed to elicit any evidence of luetic or Neisserian infections. Past history included tonsillectomy and adenoidectomy in 1936 as the only surgical procedures. Measles and pertussis, uncomplicated occurred during childhood. There had been no serious illnesses or injuries. •Presented before a joint meetin~r of the New Orleans Gynecological and Obstetri· c:al Society and the Orleans Parish Medical Society, May 24, 1943. tNow on mllltary leave of absence.
417
418
AMJ<;iHCL\N jOURNAL OF OBSTETRics AND GY1\g
At 20 years she married for the first time. During this marriage the two gestations mentioned previously occurred. ~\fter a divorce, she married again on :February 1, 1942. Physical examination disclosed a well-developed and nourished ambulatory white female apparently not ill. Blood pressure, temperature, pulse, and respiratory rates were well within physiologic limits. The general physical examination was negative. Perineum was relaxed, but not lacerated. Skene's and Bartholin 's glands showed no infection. The vaginal mucous membrane presented a healthy color. The nonirritating discharge was of a mucoid character. The cervix uteri exhibited an extenSive frosty-white membrane which was firmly adherent to both anterior and posterior cervical lips. Attempts to remove portions of the membrane resulted in bleeding. The appearance was such as to cause the examiner to record the impression that it was diphtheritic in type. (At that time the patient was questioned fully regarding any treatments which might have been undergone during recent months to rule out the possibility of therapeutic traumatic cervicitis.) The very slightly enlarged uterus was in a state of third degree retroversion and beginning prolapse. It could be moved without difficulty and there were no abnormal adnexal masses. The rectal findings were irrelevant.
Fig. 1.-Frosty-white densely adherent membrane on anterior and posterior lips o! cervix uteri, as seen at the time of admission to hospital.
Blood sedimentation rate proved to be 18 mm. in 3 hours, Linzenmeier method. Kline and Kolmer blood tests were negative. There was evidence of slight anemia, with a leucocyte count of 7,000, 84 per cent polymorphonuclear neutrophiles. Urinary and hemoohemical findings were within normal limits. Urethral, vaginal and cervical smears were negative for gonococci, trichomonads, and yeast. Cultures of material from the cervix proved to be as follows: unsatisfactory, 4/ 30/ 42; positive for Corynebaderium dipht'Mriae, 5/5, 5/8, 5/11, 5/ 18, 5/26, and 5/28/42. On 6/ 1/ 42, they were negative and continued to be. :Fig. 2 is a photomicrograph of culture from the cervix showing the typical palisade arrangement of C. diphtheriae with characteristic metachromatic granules, dub-shaped forms, a few barred forms, and an occasional solid staining form. Subcutaneous virulence test employing pure culture of organisms obtained on 5/ 5/ 42 showed nontoxin producer. Intracutaneous virulence test employing pure culture of
BEACHAM AND RICE :
DIPHTHERIA OF UTF..RINE CERVIX
4] ~)
organisms obtained 5/18/42, using a modification of the technique described by Fraser and Weld (1926) also demonstrated a nontoxin producer. Nose and throat cultures were negative for C. dipldheriae ou 5/8/42, 5/11, and 5/13. Microscopic study of tissue obtained from the (jervix on two oocasions exhibited the picture of chronic cervicitis. Nose and throat cultures from the husband of the patient were positive for C. diphtheriae on 5/8/42, 5/11, and 5/18. Similar cultures from the little son were negative. Intracutaneous virulence test (Fraser-Weld modification) employing pure culture organisms obtained from nose and throat of patient's husband on 5/18 revealed a non toxin producer. On 5/10/42, after the patient had been proved not to be hypersensitive to diphtheria antitoxin, she was given 10,000 units intramuscularly. No local therapy was administered. A week later the membrane continued to grow, regenerating at the sites of removal; consequently, normal saline douches were given once daily. On 5/21/42, an additional 10,000 units of antitoxin were injected into the gluteal region, following desensitization procedure. Soon thereafter the membrane began to disappear, being completely gone four days later and leaving a cervix which presented erosions and eversion. Cultural studies proving to be negative, the patient was anesthetized with pentothal sodium and the areas of cervicitis destroyed by means of electrodesiccation. The patient was discharged from the hospital on the following day. Subsequent follow-up studies have revealed entirely satisfactory :findings.
Fig. 2.-Photomlcrograph of organisms cultured from the cervix, showing the typical palisade arrangement of Corynebacterium diphtheriae with characteristic metachromatic granules, club-shaped forms, a few barred forms and an occasional solid staining form.
Authors9 - 17 of the current textbooks on pediatrics, obstetrics, and gynecology have little to say regarding diphtheria of the genital tract. They evidently concur in the belief that such infections are very rare. There are no data indicating that the infection can be transferred to the fetus in utero. And it should probably have no immunity; therefore, such an infant should be isolated and given the benefit of antitoxin. Negative Schick tests indicate that approximately 90 per cent of newborn babies have an immunity to the disease, but this protection is lost in most instances during the first year of life. Before the introduction of aseptic methods in the practice of obstetrics, puerperal ulcers are said to have been very common. As a result of necrosis their appearance was such as to often cause them to be desig-
420
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLO
nated as ''diphtheritic'' although they had nothing else in common with diphtheria.
Summary
The case of a 23-year-old white female who presented a frosty-white markedly adherent uterine cervical membrane is reported. The organisms cultured were morphologically Coryneba.cterinm diphtheria-e. Although virulence tests proved the organisms to be nontoxin producers, the administration of diphtheria antitoxin to the patient resulted in the disappearance of the cervical lesion. Study of the literature confirms the opinion that female genital diphtheria is rare. Not a single case of diphtheria confined to the cervix uteri was found. Every case of diphtheria should be given the benefit of careful study of the genitalia. Such studies in the past would have undoubtedly revealed some secondary infections which were overlooked.
References 1. Eigen, L. A.: Vaginal Diphtheria-Review of the Literature to Date and Report of a Case, J. M. Soc. New Jersey 29: 778, 1932. 2. Lee, E. P., and Saun, A. I.: Primary Diphtheritic Vaginitis in Children, J. M. Soc. New Jersey 29: 477, 1932. 3. Walltield, M. J., and Litvak, A. M.: Vulvovaginal Diphtheria, .J. Pe.diat. 3: 756, 1933. 4. Cantrell, R. H.: Diphtheritic Vulvovaginitis and Diphtheria of the Skin, Mouth and Throat, J. A. M. A. 201: 1295, 1934. 5. Grant, J.: An Unusual Case of Diphtheria, Brit. M. J. 1: 1074, 1934. 6. Ibid: Vulvovaginal Diphtheria, Brit. M. J. 1: 1101, 19;38. 7. Stout, S. L.: Vaginal Diphtheria, J. Kansas M. Soc. 42: 56, 1941. 8. Parks, J.: Diphtheritic Vaginitis in the Adult, AM. J. OBST. & GYNEC. 41: 714, 1941. 9. Stander, H. J.: Williams Obstetrics, 8 ed., New York, 1941, D. Appleton-Century Co., pp. 1268 and, 1336. 10. Beck, A. C.: Obstetrical Practice, 3 ~d., Baltimore, 1942, Williams & Wilkins Co., p. 742. 11. DeLee, J. B., and Greenhill, J. P.: Principles and Practice of Obstetrics, 8 ed., Philadelphia, 1943, W. B. Saunders Co., p. 493. 12. Crossen, H. S., and Crossen, R. J.: Diseases of Women, 9 ed., St. Louis, 1941, The C. V. Mosby Co., p. 283. 13. Adair, F. L.: Obstetrics and Gynecology, Philadelphia, 1940 2: 497 and 515, Lea & Febiger. 14. Kerr, J. M. M.: Combined Textbook of Obstetrics and Gynecology, Baltimore, 1939, Williams & Wilkins Co., pp. 867 and 880. 15. Taussig, F. J.: Practice of Pediatrics, edited by Brennemann, J. Hagerstown, Md., 1942, W. F. Prior Co. 2: 31, p. 24. 16. Griffith, J. P. C., and Mitehell, A. G.: 'rextbook of Pediatrics, Philadelphia, 1941, W. B. Saunders Co., p. 709. 17. Holt, L. E., Jr., and Mcintosh, R.: Holt's Diseases of Infancy and Childhood, New York, 1940, D. Appleton-Century Co., p. 823.
P.A.C.S., AND MAURICE NEW ORLEANS, LA.
D. BEACHA.'vf, M.D.,
RICE, M.D.
t
(From the Departments of GyneooZagy and Obstetrios, TulaM Umvemty Scfhool of
Medicitn.e, and Charity Hospital of LtYUisifl;na, and: the Deparlment8 of Pnti«Jk;oy ooil Baoterioloff!J, LtYUisiana State Uni.t,ersity School of Medicine, and Charity Hogpittil of Liftt.isiana:)
1932 Eigen reviewed the literature of vaginal diphtheria and rean additional ease. His studies revealed a total of 115 eases, IofNported which only 72 had been confirmed by bacteriologic investigation. 1
The youngest in the series was 5 months of age, death being due to toxic myocarditis. The eldest was 55 years. This also was fatal. Since then cases of diphtheritic vaginitis have been reported in English by Lee and Van Saun, 2 who mention six cases which were not included in Eigen's study, viz., Bisdorn's observations of three sisters (1927), Mason's case (1927), and the case of Vasile (1924); Wallfteld and Litvak8 ; Cantrell4 ; Grant 5 • 6 ; StouF; and Parks. 3 The majority of the cases described were of the secondary rather than the primary type. Furthermore, our study of the literature has failed to reveal an instance in which the manifestations of the disease were confined to the cervix uteri. We are, therefore, presenting data regarding a case in which the clinical diagnosis was diphtheria. of the uterine cert·i:r.
Case Report Mrs. I<'. T. M. (T-42-39594), aged 23 years, resident of New Orleans, was admitted to the Charity Hospital April 23, 1942, presenting a chief complaint of "whitish vaginal discharge." Menstrual index was 15 by 28 by 6-7. She gave a history of having had two pregnancies. The first terminated spo~taneously at approximately two months .almost three years prior to the present admission. The second resulted in a normal delivery ofa 7-pound 1-ounce living, well-formed male, eighteen months ago. Slight dysmenorrhea has been experienced for many years, manifesting itself as cramps and backache. Headaches and breast pain are also frequently associated with the onset of the menstrual flow, the amount and character of which have not changed recently. The vaginal discharge, of which the patient complained, was not sufficient to cause her to seek medical advice. As a matter of fact, the only reason that she came to the hospital was that a health examination was compulsory for continuation of her job as a waitress. The person referring her for admittance recorded a diagnosis of "tumor of the cervix." Historieal review by systems disclosed no positive facts of note. Thorough interrogation failed to elicit any evidence of luetic or Neisserian infections. Past history included tonsillectomy and adenoidectomy in 1936 as the only surgical procedures. Measles and pertussis, uncomplicated occurred during childhood. There had been no serious illnesses or injuries. •Presented before a joint meetin~r of the New Orleans Gynecological and Obstetri· c:al Society and the Orleans Parish Medical Society, May 24, 1943. tNow on mllltary leave of absence.
417
418
AMJ<;iHCL\N jOURNAL OF OBSTETRics AND GY1\g
At 20 years she married for the first time. During this marriage the two gestations mentioned previously occurred. ~\fter a divorce, she married again on :February 1, 1942. Physical examination disclosed a well-developed and nourished ambulatory white female apparently not ill. Blood pressure, temperature, pulse, and respiratory rates were well within physiologic limits. The general physical examination was negative. Perineum was relaxed, but not lacerated. Skene's and Bartholin 's glands showed no infection. The vaginal mucous membrane presented a healthy color. The nonirritating discharge was of a mucoid character. The cervix uteri exhibited an extenSive frosty-white membrane which was firmly adherent to both anterior and posterior cervical lips. Attempts to remove portions of the membrane resulted in bleeding. The appearance was such as to cause the examiner to record the impression that it was diphtheritic in type. (At that time the patient was questioned fully regarding any treatments which might have been undergone during recent months to rule out the possibility of therapeutic traumatic cervicitis.) The very slightly enlarged uterus was in a state of third degree retroversion and beginning prolapse. It could be moved without difficulty and there were no abnormal adnexal masses. The rectal findings were irrelevant.
Fig. 1.-Frosty-white densely adherent membrane on anterior and posterior lips o! cervix uteri, as seen at the time of admission to hospital.
Blood sedimentation rate proved to be 18 mm. in 3 hours, Linzenmeier method. Kline and Kolmer blood tests were negative. There was evidence of slight anemia, with a leucocyte count of 7,000, 84 per cent polymorphonuclear neutrophiles. Urinary and hemoohemical findings were within normal limits. Urethral, vaginal and cervical smears were negative for gonococci, trichomonads, and yeast. Cultures of material from the cervix proved to be as follows: unsatisfactory, 4/ 30/ 42; positive for Corynebaderium dipht'Mriae, 5/5, 5/8, 5/11, 5/ 18, 5/26, and 5/28/42. On 6/ 1/ 42, they were negative and continued to be. :Fig. 2 is a photomicrograph of culture from the cervix showing the typical palisade arrangement of C. diphtheriae with characteristic metachromatic granules, dub-shaped forms, a few barred forms, and an occasional solid staining form. Subcutaneous virulence test employing pure culture of organisms obtained on 5/ 5/ 42 showed nontoxin producer. Intracutaneous virulence test employing pure culture of
BEACHAM AND RICE :
DIPHTHERIA OF UTF..RINE CERVIX
4] ~)
organisms obtained 5/18/42, using a modification of the technique described by Fraser and Weld (1926) also demonstrated a nontoxin producer. Nose and throat cultures were negative for C. dipldheriae ou 5/8/42, 5/11, and 5/13. Microscopic study of tissue obtained from the (jervix on two oocasions exhibited the picture of chronic cervicitis. Nose and throat cultures from the husband of the patient were positive for C. diphtheriae on 5/8/42, 5/11, and 5/18. Similar cultures from the little son were negative. Intracutaneous virulence test (Fraser-Weld modification) employing pure culture organisms obtained from nose and throat of patient's husband on 5/18 revealed a non toxin producer. On 5/10/42, after the patient had been proved not to be hypersensitive to diphtheria antitoxin, she was given 10,000 units intramuscularly. No local therapy was administered. A week later the membrane continued to grow, regenerating at the sites of removal; consequently, normal saline douches were given once daily. On 5/21/42, an additional 10,000 units of antitoxin were injected into the gluteal region, following desensitization procedure. Soon thereafter the membrane began to disappear, being completely gone four days later and leaving a cervix which presented erosions and eversion. Cultural studies proving to be negative, the patient was anesthetized with pentothal sodium and the areas of cervicitis destroyed by means of electrodesiccation. The patient was discharged from the hospital on the following day. Subsequent follow-up studies have revealed entirely satisfactory :findings.
Fig. 2.-Photomlcrograph of organisms cultured from the cervix, showing the typical palisade arrangement of Corynebacterium diphtheriae with characteristic metachromatic granules, club-shaped forms, a few barred forms and an occasional solid staining form.
Authors9 - 17 of the current textbooks on pediatrics, obstetrics, and gynecology have little to say regarding diphtheria of the genital tract. They evidently concur in the belief that such infections are very rare. There are no data indicating that the infection can be transferred to the fetus in utero. And it should probably have no immunity; therefore, such an infant should be isolated and given the benefit of antitoxin. Negative Schick tests indicate that approximately 90 per cent of newborn babies have an immunity to the disease, but this protection is lost in most instances during the first year of life. Before the introduction of aseptic methods in the practice of obstetrics, puerperal ulcers are said to have been very common. As a result of necrosis their appearance was such as to often cause them to be desig-
420
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLO
nated as ''diphtheritic'' although they had nothing else in common with diphtheria.
Summary
The case of a 23-year-old white female who presented a frosty-white markedly adherent uterine cervical membrane is reported. The organisms cultured were morphologically Coryneba.cterinm diphtheria-e. Although virulence tests proved the organisms to be nontoxin producers, the administration of diphtheria antitoxin to the patient resulted in the disappearance of the cervical lesion. Study of the literature confirms the opinion that female genital diphtheria is rare. Not a single case of diphtheria confined to the cervix uteri was found. Every case of diphtheria should be given the benefit of careful study of the genitalia. Such studies in the past would have undoubtedly revealed some secondary infections which were overlooked.
References 1. Eigen, L. A.: Vaginal Diphtheria-Review of the Literature to Date and Report of a Case, J. M. Soc. New Jersey 29: 778, 1932. 2. Lee, E. P., and Saun, A. I.: Primary Diphtheritic Vaginitis in Children, J. M. Soc. New Jersey 29: 477, 1932. 3. Walltield, M. J., and Litvak, A. M.: Vulvovaginal Diphtheria, .J. Pe.diat. 3: 756, 1933. 4. Cantrell, R. H.: Diphtheritic Vulvovaginitis and Diphtheria of the Skin, Mouth and Throat, J. A. M. A. 201: 1295, 1934. 5. Grant, J.: An Unusual Case of Diphtheria, Brit. M. J. 1: 1074, 1934. 6. Ibid: Vulvovaginal Diphtheria, Brit. M. J. 1: 1101, 19;38. 7. Stout, S. L.: Vaginal Diphtheria, J. Kansas M. Soc. 42: 56, 1941. 8. Parks, J.: Diphtheritic Vaginitis in the Adult, AM. J. OBST. & GYNEC. 41: 714, 1941. 9. Stander, H. J.: Williams Obstetrics, 8 ed., New York, 1941, D. Appleton-Century Co., pp. 1268 and, 1336. 10. Beck, A. C.: Obstetrical Practice, 3 ~d., Baltimore, 1942, Williams & Wilkins Co., p. 742. 11. DeLee, J. B., and Greenhill, J. P.: Principles and Practice of Obstetrics, 8 ed., Philadelphia, 1943, W. B. Saunders Co., p. 493. 12. Crossen, H. S., and Crossen, R. J.: Diseases of Women, 9 ed., St. Louis, 1941, The C. V. Mosby Co., p. 283. 13. Adair, F. L.: Obstetrics and Gynecology, Philadelphia, 1940 2: 497 and 515, Lea & Febiger. 14. Kerr, J. M. M.: Combined Textbook of Obstetrics and Gynecology, Baltimore, 1939, Williams & Wilkins Co., pp. 867 and 880. 15. Taussig, F. J.: Practice of Pediatrics, edited by Brennemann, J. Hagerstown, Md., 1942, W. F. Prior Co. 2: 31, p. 24. 16. Griffith, J. P. C., and Mitehell, A. G.: 'rextbook of Pediatrics, Philadelphia, 1941, W. B. Saunders Co., p. 709. 17. Holt, L. E., Jr., and Mcintosh, R.: Holt's Diseases of Infancy and Childhood, New York, 1940, D. Appleton-Century Co., p. 823.