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Penicillin
PENICILLIN CASEREPORTOF
A PATIENT
HEMOLYTIC ROBERT
McN.
WHO RECOVERED STREPTOCOCCUS
MITCHELL,
M.D.
AND
Resident in Obstetrics and G,vnecology, Greenpoint Hospital
SANFORD Asso&tc
BROOKLYN,
NEW
A
report of a patient recovering from a puerpera1 sepsis compIicated by a hemolytic streptococcus (Iong chain variety) septicemia which faiIed to respond
FROM
PUERPERAL
KAMINESTER,
M.D.
Visiting Obstetrician and Gynecologist, Greenpoint Hospital
YORK
teen hours. Three hours term living female infant the right occipitoanterior cated third stage of labor
TABLE
SEPSIS
SEPTICEMIA
later a normal full was delivered from position. A compliwas anticipated since
I Sulfathiazole Trans_
~~~~~ Oral
4-I I-43 4- 12-43 4-13-43 4- 14-43 4-15-43 4- 16-43 4- 17-43 4- I 8-43 4- 19-43 4-20-43 4-2 I-43 4-22-43 4-23-43 4-24-43 4-25-43 4-26-43 4-27-43 4-28-43
2
!
2.2
7,600
1 9.5 , 65 ~. _.
3 4 5 6 s’
.,. _.
,......... 2.28 I.7
9 IO II 12
I.2
I3 ‘4 ‘5 I6
2.
10,800 6,200 5,620
I7.5 7.5 7 0
5’ 48
1:.._....
., I
5,500
8.0
54
.I I
13.2 3.8
5,200
g.0
61 no growth
I7 18
) ??
I ..‘.......
2.57
i
..I
taken
patient
I9
discharged
1.V.
.i
,........
~
~~
250 cc, . zoo cc.
start
start
stop
stop
200 cc.
I I I today
a history of two previous retained placentas, one fourteen years ago and one eight years ago, had been obtained. A bleeding third stage deveIoped. Posterior pituitary extract (I CC.) was given intramuscuIarIy but proved ineffectua1. Manual remova of the adherent placenta was completed under open drop ether anesthesia. Following this procedure the bIeeding was
to the suIfa drugs but did respond to peniciIIin is indeed a therapeutic triumph which cannot be ignored and merits a pIace in the Iiterature. CASE
REPORT
The patient, a thirty&e year old white female, at term, gravida VII, para VI, entered Greenpoint Hospital on the evening of ApriI 9, 1943, in active Iabor. At the time of admission the duration of parturition had extended four-
controlled, not, however, until approximately a Iiter of blood had been Iost. RepIacement therapy consisted of a liter of 5 per cent glucose 136
Is-
saline followed several hours later I)>- a titrated blood transfusion, the latter iinishing n ithout noticeable immediate reac-
in normal
granted on ApriI 28th after live afebrile 3a\s: the hospital stay lasted nineteen days. The patient was readmitted t\vo d:iv> later
FIG. I. OT, oral temperature; T, transfusion of citrwtvd whole blood; OS, oral sulfathiazole; IS, intravenous sulfathiazole; OSD, oral sulfathiazole discontinued; L, urtic:lri:i; OOB, out of bed; RC, bIood culture; c, chill.
The blood pressure was recorded at the pulse was slow and of good quality. On April I Ith, the second postpartum day, the patient had a severe chill with rise in tem(oral). Sulfathiazole was perature to I04’F. started orally at this time. On the following day, a generalized urticaria developed to confuse the picture. The question of whether the reaction was from ergotrate, transfusion or sulfa drug remained undetermined. The consulting dermatologist pronounced the skin medicamentosa and react ion a dermatitis itdvised withholding therapy except supportive and routine postpartum care. Deprived of the best therapeutic measures the postpartum c*ourse became tempestuous until, on the eighth postnatal day, when the temperature rose to I&‘F. (oral), it was decided to brave the consequences and once again institute the sulfa drug. The urticaria by this time had greatly diminished, hence, 5 Gm. of sodium sulfadiazine were intravenously and sulfathiazole was given started orally. Marked improvement in the patient’s condition followed during the course of the next six days, the temperature falling to normal. A thrombophlehitis was noted on the I‘ourteenth postpartum day in the left leg involving both the calf and thigh but appeared to be definitely subsiding. Discharge \vas tion.
I 38/-4,
complaining of chills, fever, lower abdominal and pelvic pain. The impression was that of a severe pelvic thrombophIebitis. The patient’s course was notably stormy and response to therapy was nil. The organisms apparently had become sulfonamide fast. Oral and intravenous sulfa drugs were administered unti1 the \vhite
blood count reached became inadvisable
such a 101~ level that it to continue. Frequent
small tranfusions were given and convalescent (scarlet fever) was injected intraserum venously, but all to no advantage. The patient’s condition became steadily- worse until, in the opinion of those rendering therapy, little if an> hope existed for recovery. The patient seemed moribund and terminus was expected momentarily. Five positive bIood cultures were rcported on hlay 13, nlay 18, nlay 24, May 29 and .lune 2, 1943. The cultures showed a long chain variety of Streptococcus heniolyticus. A large tender, readily palpable spleen prcsented itself. Petechiae in skin and mucous membranes lvere absent. No evidence of endocarditis LVRS recognized. The lungs remained clear for the most part except for hypostatic riles in each base. The pulse was very rapid (132) and bounding; respirations (50) shallow and labored, the mental status befogged and speech delirious. Carphologin 1%~ present.
Anwican
138
Journal
Mitchell,
of Surgery
Through the advice of Dr. H. J. the administration of penicillin was
Kaminester-Penicillin Green, begun ;
38,800, seventh
TABLE
I
4-30-43 5- r-43 5- 2-43 5- 3-43 5- 4-43 5- 5-43 5- 6-43 5- 7-43 5- 8-43 5- 9-43 S-10-43 5-I I-43 5-I 2-43
Z9.3”” ..,
27 28
5-19-43 5-20-43 5-21-43 5-22-43 5-23-43 f-24-43 5-25-43 5-26-43 5-27-43 5-28-43 5-29-43 5-30-43 5-31-43 6- 1-43 6- z-43
29 3” 31 32 33 34 35 36 3i 38 39 4” 41 42 43 44 45 46 47 48 49 5” 51 52 53 54
6666-
55 56 57 58
S-13-43 5-14-43 T-15-43 5-16-43 5-I 7-43 j-18-43
66-
I
2.31
12
23 24 25 26
3-43 4-43 5-43 6-43
2.57
63 64 65 66
6-13-43 6-14-43 6-15-43 6-16-43 6-r--43 6-r 8-43
86
20 min.
“” ..
“’
‘I
7.5
5”
5”
1 j
min.
1””
~
i positive 1 i 2.56
‘.5
4.5””
54
46
:..:.::
~.
2.62 I.89
3.6””
7.5
sk
34
4.2”” 3.8””
‘.5 7.5
7’:
21
63
3-
i “““’
3.28
26
*oo
cc.
25”
cc.
:..::.:
1:::.
25” .’
cc.
ZjOCC.
/
2-s cc.
2
.,
2,800
~
:I,:_ pos,t,vc
. . . . . . .
2.8-
cc.
26
~
8.5
i 5oocc
positivr
.,.. 4.14
~ ~ ~
3955”
8.0
-7
23
4.65”
.rC:;
7”
28
3.7””
11.”
5,‘“”
IO.5 ~
neg.+Xhr.
2
neg.48 hk
over I
32
hr.
hr.
500cc. 550cc. $00cc.
neg. $3 hr. neg. - do.
67 68 69 -0 -1 72
6-19-43 6-20-43 6-21-43 6-22-43
5,900
-
9.5
54
neg. 7 da.
46
,..
‘3 -4 75 76
6-23-43 6-24-43
,
5.60”
i
~ ~
12.5
I
62
36
2
I hr.
r hr.
L
Oxford units were given during first twenty-four hours. This dosage was peated on the second day. On the third 40,600 Oxford units were injected, fourth
42,400
I
I
‘.
3.7””
:z 61 62
6- 9-43 6-10-43 6-11-43 6-12-43
II
.,
~ ~
2.69
7-43 8-43
8.5
1~4
fifth day 35,200, sixth day 35,200, day 26,400. The first 74,200 units 01
Differential
II
JAWANY.
the reday day
penicillin were conveyed by the medium of 5 per cent glucose in alternate soIutions of distilIed water and norma saIine. The remainder was administered either intramuscuIarIy or sub-
Ytw
SEIUES
VOL. LXIII,
No.
I
MitchelI,
cutaneously in gradually decreasing dissolved in z cc. of normaI saline.
1021
acid
(0
;xid
I7
Kaminester--PeniciIlin the
amounts,
patient’s
A tota
of
TABLE
I I (Contim&)
3$3,$00 Oxford units of penicillin were given over the course of eIeven days. Within twenty-four hours following the inauguration of this therapeutic bombshell
proved.
American
condition
Juurnal
was
of Surgerv
decidedly
The fever began to subside,
’
39 im-
the mental
status brightened, urinary and fecal incontl. nence became controlled, and pulse and respiration improved. The temperature was normal in forty-eight hours. Together n-ith these
140
American
changes, recovery thirty-six and 180
Journal
of Surgery MitcheII,
Kaminester-PeniciIIin
too good to be true, hope for her revived. Each blood culture drawm hours, eighty-four hours, 132 hours hours aft& onset of treatment with
.JANUAI
she was allowed up in a wheel chair and on June 24th she was up and about anxiously awaiting discharge from the hospital which was granted on June 26th. The patient had been at
FIG. 2. T, transfusion of titrated whole blood; OS, oral sulfathiazole or sulfadiazine; OSD, oral sulfa drug discontinued; RT, rectal temperature; OT, oral temperature; c, chiIl; DC, bIood culture taken; IS, intravenous sulfadiazinc; PB, positive blood cuIture; ND, negative bIood culture; CS, convaIescent serum; PV, penicillin intravenously; PM, penicillin intramuscuIarl,y; WC, patient sitting in whcrlchair; OOB, out of bed.
penicillin
was reported
negative
subsequent
to
forty-eight hours’ incubation and also foIlo\ving a seven-day period of incubation. The patient The covery. norma for the On June ITth,
progressed steadily toward retemperature curve remained remainder of her hospita1 stay. she was permitted to dangIe her
legs over the edge of the bed; three
days later
the hospita1 fifty-seven days. Graphic representation of fever curve, therapy and laboratory iindings are sho\vn in Figures I and 2. We wish to express our appreciation to Dr. T. S. WeIton, Director of Obstetrics and Gynecology at Greenpoint Hospital, Brooklyn, N. Y. for granting permission to publish this case.
A PATIENT
HEMOLYTIC ROBERT
McN.
WHO RECOVERED STREPTOCOCCUS
MITCHELL,
M.D.
AND
Resident in Obstetrics and G,vnecology, Greenpoint Hospital
SANFORD Asso&tc
BROOKLYN,
NEW
A
report of a patient recovering from a puerpera1 sepsis compIicated by a hemolytic streptococcus (Iong chain variety) septicemia which faiIed to respond
FROM
PUERPERAL
KAMINESTER,
M.D.
Visiting Obstetrician and Gynecologist, Greenpoint Hospital
YORK
teen hours. Three hours term living female infant the right occipitoanterior cated third stage of labor
TABLE
SEPSIS
SEPTICEMIA
later a normal full was delivered from position. A compliwas anticipated since
I Sulfathiazole Trans_
~~~~~ Oral
4-I I-43 4- 12-43 4-13-43 4- 14-43 4-15-43 4- 16-43 4- 17-43 4- I 8-43 4- 19-43 4-20-43 4-2 I-43 4-22-43 4-23-43 4-24-43 4-25-43 4-26-43 4-27-43 4-28-43
2
!
2.2
7,600
1 9.5 , 65 ~. _.
3 4 5 6 s’
.,. _.
,......... 2.28 I.7
9 IO II 12
I.2
I3 ‘4 ‘5 I6
2.
10,800 6,200 5,620
I7.5 7.5 7 0
5’ 48
1:.._....
., I
5,500
8.0
54
.I I
13.2 3.8
5,200
g.0
61 no growth
I7 18
) ??
I ..‘.......
2.57
i
..I
taken
patient
I9
discharged
1.V.
.i
,........
~
~~
250 cc, . zoo cc.
start
start
stop
stop
200 cc.
I I I today
a history of two previous retained placentas, one fourteen years ago and one eight years ago, had been obtained. A bleeding third stage deveIoped. Posterior pituitary extract (I CC.) was given intramuscuIarIy but proved ineffectua1. Manual remova of the adherent placenta was completed under open drop ether anesthesia. Following this procedure the bIeeding was
to the suIfa drugs but did respond to peniciIIin is indeed a therapeutic triumph which cannot be ignored and merits a pIace in the Iiterature. CASE
REPORT
The patient, a thirty&e year old white female, at term, gravida VII, para VI, entered Greenpoint Hospital on the evening of ApriI 9, 1943, in active Iabor. At the time of admission the duration of parturition had extended four-
controlled, not, however, until approximately a Iiter of blood had been Iost. RepIacement therapy consisted of a liter of 5 per cent glucose 136
Is-
saline followed several hours later I)>- a titrated blood transfusion, the latter iinishing n ithout noticeable immediate reac-
in normal
granted on ApriI 28th after live afebrile 3a\s: the hospital stay lasted nineteen days. The patient was readmitted t\vo d:iv> later
FIG. I. OT, oral temperature; T, transfusion of citrwtvd whole blood; OS, oral sulfathiazole; IS, intravenous sulfathiazole; OSD, oral sulfathiazole discontinued; L, urtic:lri:i; OOB, out of bed; RC, bIood culture; c, chill.
The blood pressure was recorded at the pulse was slow and of good quality. On April I Ith, the second postpartum day, the patient had a severe chill with rise in tem(oral). Sulfathiazole was perature to I04’F. started orally at this time. On the following day, a generalized urticaria developed to confuse the picture. The question of whether the reaction was from ergotrate, transfusion or sulfa drug remained undetermined. The consulting dermatologist pronounced the skin medicamentosa and react ion a dermatitis itdvised withholding therapy except supportive and routine postpartum care. Deprived of the best therapeutic measures the postpartum c*ourse became tempestuous until, on the eighth postnatal day, when the temperature rose to I&‘F. (oral), it was decided to brave the consequences and once again institute the sulfa drug. The urticaria by this time had greatly diminished, hence, 5 Gm. of sodium sulfadiazine were intravenously and sulfathiazole was given started orally. Marked improvement in the patient’s condition followed during the course of the next six days, the temperature falling to normal. A thrombophlehitis was noted on the I‘ourteenth postpartum day in the left leg involving both the calf and thigh but appeared to be definitely subsiding. Discharge \vas tion.
I 38/-4,
complaining of chills, fever, lower abdominal and pelvic pain. The impression was that of a severe pelvic thrombophIebitis. The patient’s course was notably stormy and response to therapy was nil. The organisms apparently had become sulfonamide fast. Oral and intravenous sulfa drugs were administered unti1 the \vhite
blood count reached became inadvisable
such a 101~ level that it to continue. Frequent
small tranfusions were given and convalescent (scarlet fever) was injected intraserum venously, but all to no advantage. The patient’s condition became steadily- worse until, in the opinion of those rendering therapy, little if an> hope existed for recovery. The patient seemed moribund and terminus was expected momentarily. Five positive bIood cultures were rcported on hlay 13, nlay 18, nlay 24, May 29 and .lune 2, 1943. The cultures showed a long chain variety of Streptococcus heniolyticus. A large tender, readily palpable spleen prcsented itself. Petechiae in skin and mucous membranes lvere absent. No evidence of endocarditis LVRS recognized. The lungs remained clear for the most part except for hypostatic riles in each base. The pulse was very rapid (132) and bounding; respirations (50) shallow and labored, the mental status befogged and speech delirious. Carphologin 1%~ present.
Anwican
138
Journal
Mitchell,
of Surgery
Through the advice of Dr. H. J. the administration of penicillin was
Kaminester-Penicillin Green, begun ;
38,800, seventh
TABLE
I
4-30-43 5- r-43 5- 2-43 5- 3-43 5- 4-43 5- 5-43 5- 6-43 5- 7-43 5- 8-43 5- 9-43 S-10-43 5-I I-43 5-I 2-43
Z9.3”” ..,
27 28
5-19-43 5-20-43 5-21-43 5-22-43 5-23-43 f-24-43 5-25-43 5-26-43 5-27-43 5-28-43 5-29-43 5-30-43 5-31-43 6- 1-43 6- z-43
29 3” 31 32 33 34 35 36 3i 38 39 4” 41 42 43 44 45 46 47 48 49 5” 51 52 53 54
6666-
55 56 57 58
S-13-43 5-14-43 T-15-43 5-16-43 5-I 7-43 j-18-43
66-
I
2.31
12
23 24 25 26
3-43 4-43 5-43 6-43
2.57
63 64 65 66
6-13-43 6-14-43 6-15-43 6-16-43 6-r--43 6-r 8-43
86
20 min.
“” ..
“’
‘I
7.5
5”
5”
1 j
min.
1””
~
i positive 1 i 2.56
‘.5
4.5””
54
46
:..:.::
~.
2.62 I.89
3.6””
7.5
sk
34
4.2”” 3.8””
‘.5 7.5
7’:
21
63
3-
i “““’
3.28
26
*oo
cc.
25”
cc.
:..::.:
1:::.
25” .’
cc.
ZjOCC.
/
2-s cc.
2
.,
2,800
~
:I,:_ pos,t,vc
. . . . . . .
2.8-
cc.
26
~
8.5
i 5oocc
positivr
.,.. 4.14
~ ~ ~
3955”
8.0
-7
23
4.65”
.rC:;
7”
28
3.7””
11.”
5,‘“”
IO.5 ~
neg.+Xhr.
2
neg.48 hk
over I
32
hr.
hr.
500cc. 550cc. $00cc.
neg. $3 hr. neg. - do.
67 68 69 -0 -1 72
6-19-43 6-20-43 6-21-43 6-22-43
5,900
-
9.5
54
neg. 7 da.
46
,..
‘3 -4 75 76
6-23-43 6-24-43
,
5.60”
i
~ ~
12.5
I
62
36
2
I hr.
r hr.
L
Oxford units were given during first twenty-four hours. This dosage was peated on the second day. On the third 40,600 Oxford units were injected, fourth
42,400
I
I
‘.
3.7””
:z 61 62
6- 9-43 6-10-43 6-11-43 6-12-43
II
.,
~ ~
2.69
7-43 8-43
8.5
1~4
fifth day 35,200, sixth day 35,200, day 26,400. The first 74,200 units 01
Differential
II
JAWANY.
the reday day
penicillin were conveyed by the medium of 5 per cent glucose in alternate soIutions of distilIed water and norma saIine. The remainder was administered either intramuscuIarIy or sub-
Ytw
SEIUES
VOL. LXIII,
No.
I
MitchelI,
cutaneously in gradually decreasing dissolved in z cc. of normaI saline.
1021
acid
(0
;xid
I7
Kaminester--PeniciIlin the
amounts,
patient’s
A tota
of
TABLE
I I (Contim&)
3$3,$00 Oxford units of penicillin were given over the course of eIeven days. Within twenty-four hours following the inauguration of this therapeutic bombshell
proved.
American
condition
Juurnal
was
of Surgerv
decidedly
The fever began to subside,
’
39 im-
the mental
status brightened, urinary and fecal incontl. nence became controlled, and pulse and respiration improved. The temperature was normal in forty-eight hours. Together n-ith these
140
American
changes, recovery thirty-six and 180
Journal
of Surgery MitcheII,
Kaminester-PeniciIIin
too good to be true, hope for her revived. Each blood culture drawm hours, eighty-four hours, 132 hours hours aft& onset of treatment with
.JANUAI
she was allowed up in a wheel chair and on June 24th she was up and about anxiously awaiting discharge from the hospital which was granted on June 26th. The patient had been at
FIG. 2. T, transfusion of titrated whole blood; OS, oral sulfathiazole or sulfadiazine; OSD, oral sulfa drug discontinued; RT, rectal temperature; OT, oral temperature; c, chiIl; DC, bIood culture taken; IS, intravenous sulfadiazinc; PB, positive blood cuIture; ND, negative bIood culture; CS, convaIescent serum; PV, penicillin intravenously; PM, penicillin intramuscuIarl,y; WC, patient sitting in whcrlchair; OOB, out of bed.
penicillin
was reported
negative
subsequent
to
forty-eight hours’ incubation and also foIlo\ving a seven-day period of incubation. The patient The covery. norma for the On June ITth,
progressed steadily toward retemperature curve remained remainder of her hospita1 stay. she was permitted to dangIe her
legs over the edge of the bed; three
days later
the hospita1 fifty-seven days. Graphic representation of fever curve, therapy and laboratory iindings are sho\vn in Figures I and 2. We wish to express our appreciation to Dr. T. S. WeIton, Director of Obstetrics and Gynecology at Greenpoint Hospital, Brooklyn, N. Y. for granting permission to publish this case.