- Email: [email protected]
Epidemic pleurodynia
Comments
o n C u r r e n t Literature
EPIDEMIC PLEUROI)YNIA* URING the summer months of
single family: the first, a 14-year-old school girl who was stricken in the forenoon of August 10 (1951), her 16-yearpleurodynia occurred in a rural area old sister who became ill about 2 r.M. of east Texas. The pattern of this of the same day, and a 6-year-old Texas epidemic was similar to that de- brother who became ill on the morning scribed in connection with outbreaks in of August 12. In each of these cases other areas, in New England, in Great onset was the same; history and physBritain, and notably an epidemic in ical findings were considered typical of Scandinavia, concerning which Sylvest epidemic pleurodynia. published a classic monograph in The occurrence of such an epidemic 19332 Clinical features of the illness outbreak of this infectious disease in seem consistent, and have been sum- a rural locality afforded Huebner and marized as follows: onset character- his associates~, '~ of the National Microistically abrupt, with pain and fever biological Institute an unusual opporalmost invariably occurring together; tunity to cooperate with practicing headache and marked anorexia accom- physicians and the local health authoripanied by severe t)aroxysmal abdom- ties in a study of epidemic pleuroinal or chest pain, aggravated by respi- dynia that could be controlled by the ration. As a rule, the patient has little simultaneous observation of sick perwarning, and the abruptness and sons and equivalent healthy persons in severity of the symptoms may be alarm- the same community. While virus ing. However, there is sometimes a etiology in epidemic pleurodynia (and short prodromal period, from several Bornholm disease) has been suspected hours to a full day, of vague discom- for many years, and evidence sugfort with malaise and anorexia. Sore gesting an etiological relationship throat, nausea, and vomiting are not with the Coxsackie group of viruses common complaints. While recovery has been accumulating, until recently, may be interrupted by recurrences of controlled parallel studies of sick and pain and fever, prognosis is invariably well persons have not been possible. good. Complications of pleurodynia A preliminary report of these studies are relatively infrequent, but have inaccomplished during the Texas epichided pleurisy, pancreatitis, orehitis, and rarely, aseptic meningitis with ple- demic by ttuebner and his co-workers,'; appeared recently in the New England ocytosis of cerel)rospinal fluid2, ~, :~' 4 Journal of Medicine (Feb. 12, 1953). As has been described in previous Detailed investigations were carried epidemics, multiple cases occurred in out on a series of twenty-two patients certain families, three or four persons whose clinical manifestations were becoming ill ahnost simultaneously, in typically those of pleurodynia. Stool rapid succession, or at intervals of specimens from eighteen of the twentythree to five days. The occurrence of two patients yielded virus of the Coxthis outbreak in a rural area, more or saekie type, both type A and type B less defined, aided physicians in an at- Coxsaekie strains being isolated tempt to trace the spread of the infec- readily. These strains were identified tion. The pattern of family spread by careful laboratory analysis as Coxmay he illustrated by brief ease sum- sackie A-1 and Coxsaekie B-3 (Dailmaries of three members belonging ~o a dorf classification). Both types of virus were recovered from the stool * B o r n h o h n di.~oase, eoidenlie m y a | g i a . 770 1951, particularly June to SepD tember, an outbreak of epidemic
COMMENTS ON CURRENT LITERATURE
specimens of the same patients suffering from pleurodynia. However, antibody tests performed on blood samples obtained at intervals during the course of clinical recovery showed increasing titer of neutralizing antibody to the B-3 type of Coxsackie virus, giving good presumptive evidence that this im fectious agent was the cause of the clinical manifestations associated with the disease in question. These findings support the authors' summary: "The recovery of Coxsackie virus B-3 from the stools of sixteen of twenty-two persons with signs and symptoms of epidemic pleurodynia, together with evidence of antibody responses, provides a sound basis for the hypothesis that this virus represented the etiologic agent responsible for an outbreak of that disease in northeastern Texas." These results emphasize that mere isolation of a given strain of virus from a patient showing clinical evidence of infection does not mean necessarily that this is the agent responsible for the disease. Its presence in body fluids or excreta may be purely coincidental. In their studies Huebner and his associates have shown quite definitely that if 3-day-old suckling mice were used for virus isolation from stool specimens, Group A strains of Coxsackie could be recovered with ease, while if mice, one day of age, were used for virus isolation another type of virus, Coxsackie B-3, could be recovered. However, the demonstration in the patient's blood of increasing titer of neutralizing antibody to the strain of virus isolated from the patient, in this case, Coxsackie B-3, and to known strains of B-3, supports the conclusion that the clinical manifestations of the disease occurring epidemically at the time were the result of B-3 infection. The ubiquitous type A Coxsackie
771
virus, in this case A-1 type, was present in the stool specimens of these patients incidentally, but had no etiological significance in this particular outbreak of epidemic disease. These authors are fully aware of the difficulties and false leads which may be inherent in such etiological studies, and of the need for con~parable control groups. They are extending their investigations with a view to verification. A further report concerning the epidemiologic pattern of the outbreak in east Texas is to be published shortly. RUSSELL J . BLATTNER. REFEREI~CES ]. Sylvest, E. : Den Bornholmske syge. Myalgia epidemiea, Levin, KOber~havn, 1933, Ejnar Nunksgaards Forlag. English Translation: Epidemic Myalgia : ]~ornholm Disease, Milford, Humphry, LoadQ~! 1934, Oxford University Press. 2. Morrison, R. J. G., and Baird, J. I~.~ Orchitis in Bornholm Disease, Brit. M. J. 1: 198, 1952. 3. Th~lin, F., and Wirth, J.: La My~16! ~ Epidemique (Mat~tio d~e Bornhot~;'~ Isolement d'une Virus a~ Cours d'l~0 Epid6mie R~cente, Rev. m~d, ~ i s s e RmRa~ 71: 44, 1951. 4. Weller, Thos. H.: Recent Clinical $~d Laberaimry Observations on t h e ' C o x s a ~ Virus, ~ull. N~w England M:ed. Centa~ 13: 62, 1951. Galpine, J. F., and Macrae, A. D.: Aa Outbreak of Benign Meningo-Encephalitis : Isolation Of Coxsackie u (B), Lancet 1: 372, 1953. 5. ttuebner, Robert J., Beeman, Ed. A., Cole, Roger M., Beigelman, Paul ~I., and Bell, Jos. A.: The Importance of Coxsachie Viruses in Human Disegse, lsa~ticularly Herpangina and E p ~ Pleuradynia, New England J. Med. 249, 285, 1952. 6. Huebner, Robert J., Risser, Joe A., Jos. A., Beeman, Ed. A., Beigelman, Paul M., and Strong, James C.: Epidemic Pleurodynia in Texas: A Study of Twenty-two Cases, New England J. Med. 248: 267, 1953.
o n C u r r e n t Literature
EPIDEMIC PLEUROI)YNIA* URING the summer months of
single family: the first, a 14-year-old school girl who was stricken in the forenoon of August 10 (1951), her 16-yearpleurodynia occurred in a rural area old sister who became ill about 2 r.M. of east Texas. The pattern of this of the same day, and a 6-year-old Texas epidemic was similar to that de- brother who became ill on the morning scribed in connection with outbreaks in of August 12. In each of these cases other areas, in New England, in Great onset was the same; history and physBritain, and notably an epidemic in ical findings were considered typical of Scandinavia, concerning which Sylvest epidemic pleurodynia. published a classic monograph in The occurrence of such an epidemic 19332 Clinical features of the illness outbreak of this infectious disease in seem consistent, and have been sum- a rural locality afforded Huebner and marized as follows: onset character- his associates~, '~ of the National Microistically abrupt, with pain and fever biological Institute an unusual opporalmost invariably occurring together; tunity to cooperate with practicing headache and marked anorexia accom- physicians and the local health authoripanied by severe t)aroxysmal abdom- ties in a study of epidemic pleuroinal or chest pain, aggravated by respi- dynia that could be controlled by the ration. As a rule, the patient has little simultaneous observation of sick perwarning, and the abruptness and sons and equivalent healthy persons in severity of the symptoms may be alarm- the same community. While virus ing. However, there is sometimes a etiology in epidemic pleurodynia (and short prodromal period, from several Bornholm disease) has been suspected hours to a full day, of vague discom- for many years, and evidence sugfort with malaise and anorexia. Sore gesting an etiological relationship throat, nausea, and vomiting are not with the Coxsackie group of viruses common complaints. While recovery has been accumulating, until recently, may be interrupted by recurrences of controlled parallel studies of sick and pain and fever, prognosis is invariably well persons have not been possible. good. Complications of pleurodynia A preliminary report of these studies are relatively infrequent, but have inaccomplished during the Texas epichided pleurisy, pancreatitis, orehitis, and rarely, aseptic meningitis with ple- demic by ttuebner and his co-workers,'; appeared recently in the New England ocytosis of cerel)rospinal fluid2, ~, :~' 4 Journal of Medicine (Feb. 12, 1953). As has been described in previous Detailed investigations were carried epidemics, multiple cases occurred in out on a series of twenty-two patients certain families, three or four persons whose clinical manifestations were becoming ill ahnost simultaneously, in typically those of pleurodynia. Stool rapid succession, or at intervals of specimens from eighteen of the twentythree to five days. The occurrence of two patients yielded virus of the Coxthis outbreak in a rural area, more or saekie type, both type A and type B less defined, aided physicians in an at- Coxsaekie strains being isolated tempt to trace the spread of the infec- readily. These strains were identified tion. The pattern of family spread by careful laboratory analysis as Coxmay he illustrated by brief ease sum- sackie A-1 and Coxsaekie B-3 (Dailmaries of three members belonging ~o a dorf classification). Both types of virus were recovered from the stool * B o r n h o h n di.~oase, eoidenlie m y a | g i a . 770 1951, particularly June to SepD tember, an outbreak of epidemic
COMMENTS ON CURRENT LITERATURE
specimens of the same patients suffering from pleurodynia. However, antibody tests performed on blood samples obtained at intervals during the course of clinical recovery showed increasing titer of neutralizing antibody to the B-3 type of Coxsackie virus, giving good presumptive evidence that this im fectious agent was the cause of the clinical manifestations associated with the disease in question. These findings support the authors' summary: "The recovery of Coxsackie virus B-3 from the stools of sixteen of twenty-two persons with signs and symptoms of epidemic pleurodynia, together with evidence of antibody responses, provides a sound basis for the hypothesis that this virus represented the etiologic agent responsible for an outbreak of that disease in northeastern Texas." These results emphasize that mere isolation of a given strain of virus from a patient showing clinical evidence of infection does not mean necessarily that this is the agent responsible for the disease. Its presence in body fluids or excreta may be purely coincidental. In their studies Huebner and his associates have shown quite definitely that if 3-day-old suckling mice were used for virus isolation from stool specimens, Group A strains of Coxsackie could be recovered with ease, while if mice, one day of age, were used for virus isolation another type of virus, Coxsackie B-3, could be recovered. However, the demonstration in the patient's blood of increasing titer of neutralizing antibody to the strain of virus isolated from the patient, in this case, Coxsackie B-3, and to known strains of B-3, supports the conclusion that the clinical manifestations of the disease occurring epidemically at the time were the result of B-3 infection. The ubiquitous type A Coxsackie
771
virus, in this case A-1 type, was present in the stool specimens of these patients incidentally, but had no etiological significance in this particular outbreak of epidemic disease. These authors are fully aware of the difficulties and false leads which may be inherent in such etiological studies, and of the need for con~parable control groups. They are extending their investigations with a view to verification. A further report concerning the epidemiologic pattern of the outbreak in east Texas is to be published shortly. RUSSELL J . BLATTNER. REFEREI~CES ]. Sylvest, E. : Den Bornholmske syge. Myalgia epidemiea, Levin, KOber~havn, 1933, Ejnar Nunksgaards Forlag. English Translation: Epidemic Myalgia : ]~ornholm Disease, Milford, Humphry, LoadQ~! 1934, Oxford University Press. 2. Morrison, R. J. G., and Baird, J. I~.~ Orchitis in Bornholm Disease, Brit. M. J. 1: 198, 1952. 3. Th~lin, F., and Wirth, J.: La My~16! ~ Epidemique (Mat~tio d~e Bornhot~;'~ Isolement d'une Virus a~ Cours d'l~0 Epid6mie R~cente, Rev. m~d, ~ i s s e RmRa~ 71: 44, 1951. 4. Weller, Thos. H.: Recent Clinical $~d Laberaimry Observations on t h e ' C o x s a ~ Virus, ~ull. N~w England M:ed. Centa~ 13: 62, 1951. Galpine, J. F., and Macrae, A. D.: Aa Outbreak of Benign Meningo-Encephalitis : Isolation Of Coxsackie u (B), Lancet 1: 372, 1953. 5. ttuebner, Robert J., Beeman, Ed. A., Cole, Roger M., Beigelman, Paul ~I., and Bell, Jos. A.: The Importance of Coxsachie Viruses in Human Disegse, lsa~ticularly Herpangina and E p ~ Pleuradynia, New England J. Med. 249, 285, 1952. 6. Huebner, Robert J., Risser, Joe A., Jos. A., Beeman, Ed. A., Beigelman, Paul M., and Strong, James C.: Epidemic Pleurodynia in Texas: A Study of Twenty-two Cases, New England J. Med. 248: 267, 1953.