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Treatment of Tuberculous Cervical Adenitis With Vitamin A and D Ointment
Treatment of Tuberculous Cervical Adenitis With Vitamin A and D Ointment WALTER RAAB, M.D.* Glen Gardner, New Jersey
Since no set rule for management of tuberculous cervical adenitis has been established,1 treatment may be either surgical or conservative. However, infected glands sometimes caseate, necessitating incision with drainage to prevent formation of spontaneous sinuses which commonly heal slowly and leave typical scar tissue. A case of tuberculous cervical adenitis in our hands began to caseate under conservative treatment and threatened to break down. Incision was made but failed to heal and despite conventional local therapy, pus drainage continued. Exposure to artificial sun lamp increased both drainage and inflammation and was therefore discontinued. Vitamin A and D Ointment** was applied around the incision. Results were so remarkable a report of the case is thought to be justified. Case—On August 11, 1943, a 5-year-old colored girl with primary pulmonary tuberculosis was admitted. Her family history revealed her father's having died of tuberculosis. X-ray of the chest showed involvement of right hilar glands. The Mantoux test was positive. Infected tonsils were removed (August 31st). Her stay in the hospital was uneventful until the beginning of October when, for the first time, a painless swelling on the right side of the neck was noted. The swelling increased in size and was accompanied by an elevation of evening temperature. Throat and mouth showed no signs of infection. White blood cell count (October 19th) was 16,200, (neutrophils 76 per cent, lymphocytes 21 per cent, monocytes 3 per cent). At this time both the local cervical swelling and the temperature elevation were maximal. On October 26th the white blood cell count was 10,400. The affected glands were still enlarged and temperature was normal. Treatment thus far had consisted of bed rest, cod liver oil by mouth, and local application of ichthyol ointment. No retrogression was noted. After consultation, the surgeon considered removal of the involved glands. However, before surgery could be scheduled some of the glands caseated and further conservative *New Jersey State Sanatorium, S. B. English, M.D., F.C.C.P., Superintendent.
**White's Vitamin A and D Ointment.
326
Volume X
TUBERCULOUS CERVICAL ADENITIS
327
therapy was advised. When the skin above the caseated glands threatened to break, incision with drainage was performed. Previously (Nov. 5 and 6) 3 cc. of pus had been aspirated from the swelling and was examined bacteriologically. Smears and cultures revealed no tubercle bacilli or other organisms. After the incision, the purulent discharge persisted. Three days after artificial sun lamp had been applied to the involved area, this treatment had to be discontinued because of a very marked local reaction with inflammation, swelling of the remaining non-caseated glands and increased purulent discharge. When the suppurative drainage continued without any sign of improvement from November 8th to December 6th, we considered our situation to be a rather hopeless one. At this point, locally applied Vitamin A and D Ointment proved most beneficial. In three days inflammation and swelling had disappeared. Suppuration was controlled and the incision healed. The effect of the application of the Vitamin A and D Ointment was so striking that it is difficult to describe our experience. After application of the ointment for some time, complete healing and a fine linear scar resulted. COMMENT Topical application of cod liver oil was first reported by Lohr in 1934.2 Since then, Brandaleone and Papper3 have shown that the absorption through the skin of the vitamins A and D of cod liver oil is more effective in healing wounds than oral intake of the oil. Getz4 and Hardin5 have stated that the active stimulating agent in the promotion of granulation and epithelization is chiefly the contained vitamins A and D in combination and in the same ratio as found in cod liver oil. Continued experimental and clinical investigations have established the topical application of vitamins A and D as a procedure of therapeutic value. A search of the literature, however, failed to reveal any reference to the application of vitamins A and D to the skin above tuberculous glands. Therefore, it is felt that this may be the flrst report on the effectiveness of treatment of tuberculous cervical adenitis with local applications of viamins A and D. Because such cases are very rare in our children's service, a comprehensive study is impossible. This report is submitted in the hope that it may encourage others, more advantageously situated, to undertake an investigation for the purpose of substantiating our observations. Even though biopsy was not done in the case reported, a diagnosis of tuberculous cervical adenitis was made, based upon the clinical course, sterility of aspirated pus and the absence of any infection in the mouth, teeth, nose or throat.
328
WALTER RAAB
July-Aug., 19M
SUMMARY
In a case of tuberculous cervical adenitis with caseation, the mass was incised. The incision drained for nearly four weeks. Exposure to artificial sun lamp aggravated the inflammation and increased the drainage. Local treatment with Vitamin A and D Ointment for three days accomplished complete healing, with formation of a fine linear scar. RESUMEN En un caso de adenitis cervical tuberculosa con caseacion se hizo una incisi6n en la masa. La incision supur6 por cerca de cuatro semanas. La exposici6n de la incisidn a la lampara solar artificial agrav6 la inflamacidn y aumento la supuraci6n. El tratamiento local con ungiiento de vitaminas A y D durante tres dias obtuvo la curacion completa con la formaci6n de una fina cicatriz lineal. REFERENCES 1 Romans, John: A Text Book of Surgery, C. C. Thomas, 1935. 2 Lohr, W.: "Die Behandlung von frischen und alten Hand—und Fussverletzungen mit Substanzverlusten mit dem Lebertran-Gipsverband," Chirurg., 6: 5, 1934. 3 Brandaleone, H., and Papper, E.: Ann. Surgery, 114: 791-798, (Oct.) 1941. 4 Getz, H. R.: "Cod Liver Oil Therapy in Experimental Tuberculosis," Proc. Soc. Exper. Biol. & Med., 38: 543, 1938. 5 Hardin, C.: "Cod Liver Oil Therapy of Wounds and Burns," South. Surgeon, 10: 301, (May) 1941.
Since no set rule for management of tuberculous cervical adenitis has been established,1 treatment may be either surgical or conservative. However, infected glands sometimes caseate, necessitating incision with drainage to prevent formation of spontaneous sinuses which commonly heal slowly and leave typical scar tissue. A case of tuberculous cervical adenitis in our hands began to caseate under conservative treatment and threatened to break down. Incision was made but failed to heal and despite conventional local therapy, pus drainage continued. Exposure to artificial sun lamp increased both drainage and inflammation and was therefore discontinued. Vitamin A and D Ointment** was applied around the incision. Results were so remarkable a report of the case is thought to be justified. Case—On August 11, 1943, a 5-year-old colored girl with primary pulmonary tuberculosis was admitted. Her family history revealed her father's having died of tuberculosis. X-ray of the chest showed involvement of right hilar glands. The Mantoux test was positive. Infected tonsils were removed (August 31st). Her stay in the hospital was uneventful until the beginning of October when, for the first time, a painless swelling on the right side of the neck was noted. The swelling increased in size and was accompanied by an elevation of evening temperature. Throat and mouth showed no signs of infection. White blood cell count (October 19th) was 16,200, (neutrophils 76 per cent, lymphocytes 21 per cent, monocytes 3 per cent). At this time both the local cervical swelling and the temperature elevation were maximal. On October 26th the white blood cell count was 10,400. The affected glands were still enlarged and temperature was normal. Treatment thus far had consisted of bed rest, cod liver oil by mouth, and local application of ichthyol ointment. No retrogression was noted. After consultation, the surgeon considered removal of the involved glands. However, before surgery could be scheduled some of the glands caseated and further conservative *New Jersey State Sanatorium, S. B. English, M.D., F.C.C.P., Superintendent.
**White's Vitamin A and D Ointment.
326
Volume X
TUBERCULOUS CERVICAL ADENITIS
327
therapy was advised. When the skin above the caseated glands threatened to break, incision with drainage was performed. Previously (Nov. 5 and 6) 3 cc. of pus had been aspirated from the swelling and was examined bacteriologically. Smears and cultures revealed no tubercle bacilli or other organisms. After the incision, the purulent discharge persisted. Three days after artificial sun lamp had been applied to the involved area, this treatment had to be discontinued because of a very marked local reaction with inflammation, swelling of the remaining non-caseated glands and increased purulent discharge. When the suppurative drainage continued without any sign of improvement from November 8th to December 6th, we considered our situation to be a rather hopeless one. At this point, locally applied Vitamin A and D Ointment proved most beneficial. In three days inflammation and swelling had disappeared. Suppuration was controlled and the incision healed. The effect of the application of the Vitamin A and D Ointment was so striking that it is difficult to describe our experience. After application of the ointment for some time, complete healing and a fine linear scar resulted. COMMENT Topical application of cod liver oil was first reported by Lohr in 1934.2 Since then, Brandaleone and Papper3 have shown that the absorption through the skin of the vitamins A and D of cod liver oil is more effective in healing wounds than oral intake of the oil. Getz4 and Hardin5 have stated that the active stimulating agent in the promotion of granulation and epithelization is chiefly the contained vitamins A and D in combination and in the same ratio as found in cod liver oil. Continued experimental and clinical investigations have established the topical application of vitamins A and D as a procedure of therapeutic value. A search of the literature, however, failed to reveal any reference to the application of vitamins A and D to the skin above tuberculous glands. Therefore, it is felt that this may be the flrst report on the effectiveness of treatment of tuberculous cervical adenitis with local applications of viamins A and D. Because such cases are very rare in our children's service, a comprehensive study is impossible. This report is submitted in the hope that it may encourage others, more advantageously situated, to undertake an investigation for the purpose of substantiating our observations. Even though biopsy was not done in the case reported, a diagnosis of tuberculous cervical adenitis was made, based upon the clinical course, sterility of aspirated pus and the absence of any infection in the mouth, teeth, nose or throat.
328
WALTER RAAB
July-Aug., 19M
SUMMARY
In a case of tuberculous cervical adenitis with caseation, the mass was incised. The incision drained for nearly four weeks. Exposure to artificial sun lamp aggravated the inflammation and increased the drainage. Local treatment with Vitamin A and D Ointment for three days accomplished complete healing, with formation of a fine linear scar. RESUMEN En un caso de adenitis cervical tuberculosa con caseacion se hizo una incisi6n en la masa. La incision supur6 por cerca de cuatro semanas. La exposici6n de la incisidn a la lampara solar artificial agrav6 la inflamacidn y aumento la supuraci6n. El tratamiento local con ungiiento de vitaminas A y D durante tres dias obtuvo la curacion completa con la formaci6n de una fina cicatriz lineal. REFERENCES 1 Romans, John: A Text Book of Surgery, C. C. Thomas, 1935. 2 Lohr, W.: "Die Behandlung von frischen und alten Hand—und Fussverletzungen mit Substanzverlusten mit dem Lebertran-Gipsverband," Chirurg., 6: 5, 1934. 3 Brandaleone, H., and Papper, E.: Ann. Surgery, 114: 791-798, (Oct.) 1941. 4 Getz, H. R.: "Cod Liver Oil Therapy in Experimental Tuberculosis," Proc. Soc. Exper. Biol. & Med., 38: 543, 1938. 5 Hardin, C.: "Cod Liver Oil Therapy of Wounds and Burns," South. Surgeon, 10: 301, (May) 1941.