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PALLIATIVE CHEMOTHERAPY FOR RELIEF OF SUBOCCLUSIVE SYMPTOMS
578 TOXIC SHOCK SYNDROME AND STAPHYLOCOCCAL PNEUMONIA
SjR,—Staphylococcal toxic shock syndrome (TSS) is most commonly seen in menstruating women, although it has also been reported after other staphylococcal infections.! Wilkins and colleagues2 reported a case of partial TSS with staphylococcal pneumonia. We describe here a case of full TSS in staphylococcal pneumonia. A 15-year-old boy presented with fever, hypotension, and confusion, preceded by a 9-day influenza-like illness with coryza, headache, and vomiting. On the 7th day he had had diarrhoea, pleuritic chest pain, and a cough productive of white sputum. He admitted 48 h later, after a sudden alteration in his mental state. He was cyanosed, tachypnoeic, and dehydrated. Body temperature 39"4OC, pulse 110/min, systolic blood pressure 60 mm Hg. Initial treatment was with gentamicin, flucloxacillin, erythromycin, and ceftazidime. On the following day he remained confused and had moderate neck stiffness with a positive Kernig’s sign. A lumbar puncture was normal. He had, however, a generalised confluent erythema (fig 1) and conjunctivitis. Since blood cultures were sterile TSS was considered. Erythromycin was withdrawn, an atypical pneumonia having been excluded. was
Fig 1—Generalised erythema. The white cell count was 15-5x109/1 with a shift to the left. Blood 27-3 rnmol/1, serum creatinine 297 imol/1, adjusted serum calcium 2-01 mmol/1, alkaline phosphatase 394 IU/1, and aspartate aminotransferase 55 IU/1. Clotting was normal but fibrinogen degradation products were raised (16 ng/1). The 24 h urine contained blood and protein (2-3 g) and microscopy revealed an excess of epithelial cells, though culture was sterile. Sputum culture after the start of antibiotics was negative but pus cells were seen on microscopy. Chest X-ray was initially normal but 3 days later the left lower lobe was collapsed and there was dullness to percussion at the left base, reduced breath sounds, and a pleuropericardial rub. A loculated pleural effusion subsequently developed (protein 39 g/l, occasional pus cells, culture sterile). His creatinine kinase rose to a peak of 19 056 IU/1 after 1 week. Other possible infective causes were excluded by serology. Since the diagnostic criteria for TSS were fulfilled, ceftazidime was replaced with fucidin. urea was
normal chest X-ray. 2 days after starting antibiotics there was clinical and radiographic evidence of pneumonia. This suggests that toxin production preceded consolidation, which then developed despite intravenous antistaphylococcal chemotherapy. We thank Dr J. M. Medlock for allowing us to report this case and for his help in preparing this report.
B. MARCHANT J. BROWN
Rush Green Hospital, Romford, Essex RM7 0YA
Dan BB, Shands KN, Strickland BY, Broome CV. Nonmenstrual toxic shock syndrome: a review of 130 cases. Ann Intern Med 1982; 96: 871-74. 2. Wilkins EGL, Nye F, Roberts C, de Saxe M. Probable toxic shock syndrome with primary staphylococcal pneumonia. J Infect Dis 1985; 11: 231-32. 3. Shands KN, Schmid GP, Dan BB, et al. Toxic-shock syndrome in menstruating women: Association with tampon use and Staphylococcal aureus and the clinical features in 52 cases. N Engl J Med 1980; 303: 1436-52. 1.
Reingold L, Hargrett NT,
PALLIATIVE CHEMOTHERAPY FOR RELIEF OF SUBOCCLUSIVE SYMPTOMS
SIR,-Baines et all suggested the possibility of relieving subocclusive symptoms in patients with abdominal or pelvic malignant disease by treatment other than cytostatic drugs. Intestinal colic, vomiting, and diarrhoea were effectively controlled. We have used palliative chemotherapy with cytostatic drugs in patients with advanced abdominal and/or pelvic metastatic colorectal cancer. We chose a chemotherapy schedule with the aim of delaying as long as possible the use of palliative tools such as nasogastric suction or alleviative surgery, and of avoiding prolonged medical management which may be less comfortable for patients. We treated 30 sequential patients with a performance status of 3-4 on the ECOG sealer who had relapsed after radical surgery but had not previously received any kind of adjuvant chemotherapy. There were 20 in subocclusive status and 10 with periodic symptoms of early subocclusive status. Our treatment schedule was: 5-fluorouracil combined with folate (375 and 200 mg/m2, respectively) for 5 consecutive days every 3 weeks.3 No major side-effects, except mucositis (grade 3)4 in 16% of patients, were recorded. 28 patients (93 %) had remarkable relief of sub-occlusive symptoms after one to three courses of therapy (3-9 weeks) (figure).
Severity of subocclusive state before and after chemotherapy. Severity scale (x-axis) is that of Baines et al:l 0 = absent, 1 = mild, 2
=
moderate, 3
=
severe, and 4
=
fatal.
(7 %) died as a result of progression of the disease. 20 % of patients are still alive 1 year after the start of treatment. Our data indicate that palliative cytostatic treatment may be useful even in selected patients with advanced disease. Whether this 2 patients our
effect
was
related
to
5-fluorouracil
or
folate
or
both needs further
assessment.
Fig 2-Desquamation. On the second week of his admission there was desquamation of the skin around his fingers and toes and from the soles of his feet (fig 2). After 5 weeks he was discharged. This case fulfils criteria for TSS.’ Isolation of S aureus is not necessary for the diagnosis, although most cases do have an identifiable source of infection. The anti-staphylococcal haemolysin level was very high in this case but the result was not available until after the patient had been discharged. At the time of presentation with TSS this patient had a 48 h history of pleuritic chest pain but a
Institute of Medical Semeiotics, Division of Clinical Oncology, and 1st and 2nd Institutes of General Surgery, University of Siena, 53100 Siena, Italy 1. Baines
GUIDO FRANCINI LUCIANO LORENZINI SALVATORE ARMENIO CARLO GENNARI
M, Oliver DJ, Carter RL. Medical management
of intestinal obstruction
patients with advanced malignant disease: a clinical and pathological study
in
Lancet
1985; ii: 990-93. 2. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982, 5: 649-55. 3 Machover D, Schwarzenberg L, Goldschmidt E, et al. Treatment of advanced colorectal and gastric adenocarcinoma with 5-F.U. combined with high-dose folinic acid: a pilot study. Cancer Treat Rep 1982; 66: 1803-07. 4. Miller AB, Hoogstraten B, Staquet M, Winkler A Reporting results of cancer treatment. Cancer 1981; 47: 207-14.
SjR,—Staphylococcal toxic shock syndrome (TSS) is most commonly seen in menstruating women, although it has also been reported after other staphylococcal infections.! Wilkins and colleagues2 reported a case of partial TSS with staphylococcal pneumonia. We describe here a case of full TSS in staphylococcal pneumonia. A 15-year-old boy presented with fever, hypotension, and confusion, preceded by a 9-day influenza-like illness with coryza, headache, and vomiting. On the 7th day he had had diarrhoea, pleuritic chest pain, and a cough productive of white sputum. He admitted 48 h later, after a sudden alteration in his mental state. He was cyanosed, tachypnoeic, and dehydrated. Body temperature 39"4OC, pulse 110/min, systolic blood pressure 60 mm Hg. Initial treatment was with gentamicin, flucloxacillin, erythromycin, and ceftazidime. On the following day he remained confused and had moderate neck stiffness with a positive Kernig’s sign. A lumbar puncture was normal. He had, however, a generalised confluent erythema (fig 1) and conjunctivitis. Since blood cultures were sterile TSS was considered. Erythromycin was withdrawn, an atypical pneumonia having been excluded. was
Fig 1—Generalised erythema. The white cell count was 15-5x109/1 with a shift to the left. Blood 27-3 rnmol/1, serum creatinine 297 imol/1, adjusted serum calcium 2-01 mmol/1, alkaline phosphatase 394 IU/1, and aspartate aminotransferase 55 IU/1. Clotting was normal but fibrinogen degradation products were raised (16 ng/1). The 24 h urine contained blood and protein (2-3 g) and microscopy revealed an excess of epithelial cells, though culture was sterile. Sputum culture after the start of antibiotics was negative but pus cells were seen on microscopy. Chest X-ray was initially normal but 3 days later the left lower lobe was collapsed and there was dullness to percussion at the left base, reduced breath sounds, and a pleuropericardial rub. A loculated pleural effusion subsequently developed (protein 39 g/l, occasional pus cells, culture sterile). His creatinine kinase rose to a peak of 19 056 IU/1 after 1 week. Other possible infective causes were excluded by serology. Since the diagnostic criteria for TSS were fulfilled, ceftazidime was replaced with fucidin. urea was
normal chest X-ray. 2 days after starting antibiotics there was clinical and radiographic evidence of pneumonia. This suggests that toxin production preceded consolidation, which then developed despite intravenous antistaphylococcal chemotherapy. We thank Dr J. M. Medlock for allowing us to report this case and for his help in preparing this report.
B. MARCHANT J. BROWN
Rush Green Hospital, Romford, Essex RM7 0YA
Dan BB, Shands KN, Strickland BY, Broome CV. Nonmenstrual toxic shock syndrome: a review of 130 cases. Ann Intern Med 1982; 96: 871-74. 2. Wilkins EGL, Nye F, Roberts C, de Saxe M. Probable toxic shock syndrome with primary staphylococcal pneumonia. J Infect Dis 1985; 11: 231-32. 3. Shands KN, Schmid GP, Dan BB, et al. Toxic-shock syndrome in menstruating women: Association with tampon use and Staphylococcal aureus and the clinical features in 52 cases. N Engl J Med 1980; 303: 1436-52. 1.
Reingold L, Hargrett NT,
PALLIATIVE CHEMOTHERAPY FOR RELIEF OF SUBOCCLUSIVE SYMPTOMS
SIR,-Baines et all suggested the possibility of relieving subocclusive symptoms in patients with abdominal or pelvic malignant disease by treatment other than cytostatic drugs. Intestinal colic, vomiting, and diarrhoea were effectively controlled. We have used palliative chemotherapy with cytostatic drugs in patients with advanced abdominal and/or pelvic metastatic colorectal cancer. We chose a chemotherapy schedule with the aim of delaying as long as possible the use of palliative tools such as nasogastric suction or alleviative surgery, and of avoiding prolonged medical management which may be less comfortable for patients. We treated 30 sequential patients with a performance status of 3-4 on the ECOG sealer who had relapsed after radical surgery but had not previously received any kind of adjuvant chemotherapy. There were 20 in subocclusive status and 10 with periodic symptoms of early subocclusive status. Our treatment schedule was: 5-fluorouracil combined with folate (375 and 200 mg/m2, respectively) for 5 consecutive days every 3 weeks.3 No major side-effects, except mucositis (grade 3)4 in 16% of patients, were recorded. 28 patients (93 %) had remarkable relief of sub-occlusive symptoms after one to three courses of therapy (3-9 weeks) (figure).
Severity of subocclusive state before and after chemotherapy. Severity scale (x-axis) is that of Baines et al:l 0 = absent, 1 = mild, 2
=
moderate, 3
=
severe, and 4
=
fatal.
(7 %) died as a result of progression of the disease. 20 % of patients are still alive 1 year after the start of treatment. Our data indicate that palliative cytostatic treatment may be useful even in selected patients with advanced disease. Whether this 2 patients our
effect
was
related
to
5-fluorouracil
or
folate
or
both needs further
assessment.
Fig 2-Desquamation. On the second week of his admission there was desquamation of the skin around his fingers and toes and from the soles of his feet (fig 2). After 5 weeks he was discharged. This case fulfils criteria for TSS.’ Isolation of S aureus is not necessary for the diagnosis, although most cases do have an identifiable source of infection. The anti-staphylococcal haemolysin level was very high in this case but the result was not available until after the patient had been discharged. At the time of presentation with TSS this patient had a 48 h history of pleuritic chest pain but a
Institute of Medical Semeiotics, Division of Clinical Oncology, and 1st and 2nd Institutes of General Surgery, University of Siena, 53100 Siena, Italy 1. Baines
GUIDO FRANCINI LUCIANO LORENZINI SALVATORE ARMENIO CARLO GENNARI
M, Oliver DJ, Carter RL. Medical management
of intestinal obstruction
patients with advanced malignant disease: a clinical and pathological study
in
Lancet
1985; ii: 990-93. 2. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982, 5: 649-55. 3 Machover D, Schwarzenberg L, Goldschmidt E, et al. Treatment of advanced colorectal and gastric adenocarcinoma with 5-F.U. combined with high-dose folinic acid: a pilot study. Cancer Treat Rep 1982; 66: 1803-07. 4. Miller AB, Hoogstraten B, Staquet M, Winkler A Reporting results of cancer treatment. Cancer 1981; 47: 207-14.