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Poldark’s Putrid Throat!

29/4/2015

 
Picture
The patient for this week is a lady in her mid-twenties who had recently been caring for a family struck down with a severe upper respiratory tract infection. Now she too had a severe sore throat and a high fever and was finding it increasingly difficult to swallow. She became delirious and started to hallucinate. Her young daughter also had the same types of symptoms, but if anything was more unwell. The doctor had been called, he diagnosed “putrid throat” and said there was nothing more he could do to save the lives of Demelza and her daughter Julia… the situation looked bleak for the Poldark’s…

Poldark is the hit BBC TV drama, but what is putrid throat? Is this condition just a dramatic fantasy of the BBC scriptwriters?! I think it is real! It is very likely that the Poldark’s had the condition diphtheria. This is an acute bacterial infection of the upper respiratory tract caused by the bacterium Corynebacterium diphtheriae. Back in the 18th Century they did not know the cause and the only treatment was leeching or honey in hot water. The reason it was so feared is that it was one of the most common causes of death and killed almost all of the children it affected.

Since the introduction of a vaccine in 1942, diphtheria has become very uncommon in the UK. Today, all children born in the UK are offered the vaccine as part of their primary childhood immunisations (it is the “D” of the DTP+Hib vaccine). The few cases seen in the UK now are in non-immunised patients who usually acquire their infection in Eastern Europe and the former Soviet Union as vaccination there is no longer routine practice.

Clinical Features
Diphtheria most commonly affects the upper respiratory tract but it can affect any mucous membrane including the conjunctivae, vagina or ear. Diphtheria can also cause skin infections. Asymptomatic colonisation is more common than infection.

The respiratory features of the classical presentation of diphtheria are:
  • Severe sore throat
  • Painful cervical lymphadenopathy
  • Swelling of the neck leading to a “bull neck” appearance
  • Asymmetrical adherent greyish white membranes (pharyngeal membranes), with surrounding inflammation, which may extend into the trachea and cause airway obstruction (diphtheria looks more like opaque Clingfilm or plastic food wrap whereas in tonsillitis there is pus on the tonsils and no membrane, see image below)

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“Old moania”, double pneumonia...what’s wrong with just plain pneumonia?

22/4/2015

 
There are lots of “coughs and colds” around at the moment and I’m sure that clinics are full of patients who are convinced they have pneumonia. My wife moans all the time that her throat infection has gone onto her chest; I diagnosed “old moania” and she got better quite quickly! So what criteria can be used to distinguish those patients with pneumonia from those with upper respiratory tract infections or exacerbations of chronic obstructive pulmonary disease (COPD)? Should antibiotics be started and if so which ones and should a sputum sample be sent to the microbiology laboratory?

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Maybe exercise isn’t always good for you!

8/4/2015

 
A twenty five year old woman presented to the Emergency Department with severe pain in her hip. The pain was so bad she could barely put any weight through her leg. On examination she had a fever of 40oC and pain on flexion of her hip. Blood cultures were taken and she was referred to the orthopaedic surgeons for the management of a presumed septic arthritis of the hip.  

The following day the blood cultures were positive for a Staphylococcus aureus so the Microbiologist went to review the patient on the ward. In the notes was the result of the ultrasound scan of the hip which was normal with no effusion. Speaking to the patient she had taken out a new gym membership and started exercising in order to lose weight. The patient remembered “pulling a leg muscle” a week ago. The clinical team had been planning to stop her antibiotics and send her home with analgesia for a musculoskeletal pain but the Microbiologist was not so sure it was this simple, it’s that Staphylococcus aureus blood culture result you see... 

So what was going on? Why was the patient in pain despite a normal hip? Was it just a minor musculoskeletal injury or was the Staphylococcus aureus relevant?

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Ouch that really hurts, is that a red warning flag sticking in me?

8/4/2015

 
For me the “red warning flags” are:
  • Pain out of proportion to the clinical signs, extreme tenderness but little swelling or erythema does not fit for something common like cellulitis so I would be concerned that cellulitis is not the diagnosis
  • Fever and tachycardia, I’m not reassured by the normal blood pressure as young patients can maintain their blood pressure even when unwell
  • Sore throat, tonsillitis and skin and soft tissue infections can be caused by the same bacteria, in particular the Beta-haemolytic Streptococci Groups A, C and G, and the bacteria from a tonsillitis could easily spread to the skin via the blood stream

These are all warning signs for the life-threatening skin and soft tissue infection, necrotising fasciitis. Would you have spotted them?

An hour later the patient becomes hypotensive and the thigh now appears grey and mottled, and is more swollen with a “peau d’orange” appearance (like the skin of an orange, caused by cutaneous oedema). His blood tests come back showing a raised white blood cell (WBC) count and C-reactive protein (CRP) as well as an international normalised ratio (INR) of 1.6. 

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    Blog Author:

    David Garner
    Consultant Microbiologist
    Surrey, UK

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