Complications of Measles
In Table LXIV the complications developing in the measles patients under observation at Camp Pike are tabulated. In the division of the complications developing in “carriers” and “noncarriers” of the hemolytic streptococci, reference is made only to the records of the throat cultures. The division is therefore not dependent upon the bacteriology of the complications. For example, only 9 of the 12 cases of pneumonia developing in “carriers” were streptococcus pneumonias. On the other hand, the cases of mastoiditis following otitis media were almost invariably due to hemolytic streptococci. Of the 10 otitis cases occurring in “noncarriers,” 4 developed mastoiditis and 3 of these showed hemolytic streptococci on culture from the mastoid cells at operation. Missed cases of identification of S. hemolyticus by throat culture in cases which develop S. hemolyticus complications may arise from a number of causes. It is desired here only to direct attention to these discrepancies.
Pneumonia Following Measles.—Fifty-six cases of pneumonia following measles occurred during the period of observation in this group of 867 cases of measles. Of these, 9 were streptococcus pneumonias. This gives an incidence for streptococcus pneumonias of 1.04 per cent, while that for all the pneumonia is 6.4 per cent. There were 8 cases of lobar and 48 cases of bronchopneumonia. Seventeen fatal cases occurred giving a mortality rate of 30.4 per cent for the group. Five of these fatal cases occurred among the 9 streptococcus pneumonias. The mortality rate for the streptococcus pneumonia thus was 55.5 per cent; that for the nonstreptococcus group was 25.5 per cent. All 9 cases of streptococcus pneumonia developed empyema. In 7 cases it was diagnosed clinically; in 2 at autopsy only. No cases of empyema developed in the group of nonstreptococcus pneumonias.
| Table LXIV | |||||||
|---|---|---|---|---|---|---|---|
| Complications Developing in 867 Cases of Measles at Camp Pike. Distribution of Complications Between 242 “Carriers” and 625 “Noncarriers” of Hemolytic Streptococci from September 15 to December 15, 1918 | |||||||
| NAME OF COMPLICATION | NUMBER OCCURRING IN | TOTAL NUMBER | PER CENT IN | ||||
| “CARRIERS” OF HEM. STREP. | “NONCARRIERS” OF HEM. STREP. | CASES WITH INCOMPLETE RECORD OF THROAT CULTURES | ALL CASES | HEM. STREP. “CARRIERS” | “NONCARRIERS” OF HEM. STREP. | ||
| Pneumonia | 12 | 44 | 0 | 56 | 6.4 | 5.0 | 7.0 |
| Otitis media | 31 | 11 | 6 | 48 | 5.5 | 12.8 | 1.8 |
| Mastoiditis (following otitis media) | 15 | 4 | 4 | 23 | 2.6 | 6.2 | 0.6 |
| Local meningitis (extension from mastoid) | 2 | 0 | 0 | 2 | |||
| Frontal sinusitis | 1 | 0 | 0 | 1 | |||
| Ethmoidal sinusitis | 0 | 1 | 0 | 1 | |||
| Suppurative arthritis | 1 | 0 | 0 | 1 | |||
| Cervical adenitis | 1 | 0 | 0 | 1 | |||
| Acute bronchitis | 4 | 2 | 0 | 6 | |||
| Acute tonsillitis | 4 | 1 | 0 | 5 | |||
| Acute laryngitis and aphonia | 1 | 0 | 0 | 1 | |||
| Acute pleurisy | 2 | 1 | 0 | 3 | |||
| Erysipelas of face | 0 | 1 | 0 | 1 | |||
| Epidemic meningitis | 0 | 1 | 0 | 1 | |||
| Note.—The percentages of incidence of pneumonia and otitis media in the “carrier” and “noncarrier” groups are at direct variance. It would appear from these findings that streptococci very readily invade the middle ear from the throat and set up grave disorders. The invasion of the lung from the throat occurs with less frequency. Hemolytic streptococci perhaps never initiate the pneumonic processes and can be regarded as more or less accidental secondary invaders. | |||||||
The relation of these pneumonias following measles, to the influenza epidemic has been discussed. The time relations between the onsets of measles and that of the subsequent pneumonia vary widely. There appears to be nothing constant in the length of time between the onset of measles and that of the pneumonia. In 30 of the cases this period is less than ten days; in the remaining 26 cases, it ranges from ten to thirty-two days (Chart 4).
In the ward treatment of these cases of pneumonia, they were divided into three groups according to their clinical characters and according to the results of throat and sputum cultures.
| (a) | Streptococcus pneumonias | 9 cases |
| (b) | Pneumonia with hemolytic streptococci in the throat without symptoms referable to the streptococcus | 13 cases |
| (c) | Pneumococcus pneumonias not carrying hemolytic streptococci | 34 cases |
The streptococcus-free cases were treated in a separate ward. Cases were admitted to this ward directly from the “clean” measles wards, but only after a throat culture taken prior to their transfer had been negative for the hemolytic streptococcus.
The other two groups were treated together in another ward, but in strictly separate compartments of it. This precaution was carried out on the assumption that patients with an acute streptococcus pneumonia were real sources of danger in the ward because of a heightened virulence of the organism causing the grave symptoms. The pneumonias subsequently developing hemolytic streptococci in their throats, without their presence modifying the course of the pneumonia, came to be regarded as being in the same class with uncomplicated cases of measles carrying hemolytic streptococci, in so far as their being potential sources of danger in a ward is concerned.
Chart 4.—Shows the time interval between the onset of measles and the onset of the subsequent pneumonia in the 56 cases of pneumonia following measles at Camp Pike. Each case is represented by one of the small blocks measured along the ordinate. The onset of measles in all cases is represented by the line at the extreme left of the chart. The onset of pneumonia in each case is indicated by the limit of the block marked off in days to the right of this line.
(a) Streptococcus Pneumonias.—Nine cases of streptococcus pneumonia developed. Of the 867 cases of measles studied, 242 showed throat cultures positive for the hemolytic streptococci at some period of their stay in the hospital. It appears then that 3.7 per cent of the patients carrying hemolytic streptococci in their throats developed streptococcus pneumonia. Thirty-seven cases had positive throat cultures when first observed on admission to the measles wards. It is significant to note that not a single case of pneumonia of any kind developed among these cases.
MEASLES PNEUMONIA; STREPTOCOCCUS GROUP
Case 98, O. McN. Onset of measles, Sep. 19; admitted to hospital Sep. 21; onset of bronchopneumonia, Oct. 21; of empyema, Oct. 23. Recovered from pneumonia; convalescent in empyema ward.
Bacteriology.—1. Throat culture for: (a) S. hem.: Sep. 21, −; 28, −; Oct. 9, −; 20, −; 23, +; Nov. 2, −; 9, −; 15, −; (b) B. influenzæ: Sep. 21, +; 28, −; Oct. 9, +. 2. Pleural fluid (culture) S. hem. Oct. 23, +.
Case 141, J. G. G. Autopsy No. 438. Onset of measles, Sep. 28; admitted to hospital, Oct. 1; onset of bronchopneumonia, Oct. 6; of otitis media (bilateral), Oct. 12; died, Oct. 18.
Bacteriology.—1. Throat culture for: (a) S. hem., Oct. 2, −; 6, −; 8, −; (b) B. influenzæ, Oct. 2, −; 6, +; 8, +. 2. Autopsy cultures: Heart blood, negative; left lung, Pneumococcus II atypical, B. influenzæ and S. viridans; right lung, S. hem. and B. influenzæ; right bronchus, S. hem. and B. influenzæ.
Case 147, S. W. Autopsy No. 442. Onset of measles, Oct. 1; admitted to hospital, Oct. 2; onset of bronchopneumonia, Oct. 17, with chill and rapid development; died, Oct. 18.
Bacteriology.—1. Throat culture for: (a) S. hem., Oct 2, −; 9 −; 15, −; 18, +; (b) B. influenzæ, Oct. 2, −; 9, −; 15, −; 18, −. 2. Autopsy cultures: Heart blood, S. hem.; right main bronchus, S. hem. and B. influenzæ.
Case 281, T. M. Onset of measles, Oct. 6; admitted to hospital Oct. 9; onset of bronchopneumonia, Oct. 21; of empyema, Oct. 23; recovered from pneumonia; convalescent in empyema ward.
Bacteriology.—1. Throat culture for: (a) S. hem., Oct. 10, −; 20, −; 24, +; Nov. 2, +; 9, +; 15, +; (b) B. influenzæ, Oct. 10, −; 20, +. 2. Culture from pleural fluid, Oct. 23, S. hem.
Case 285, J. H. Onset of measles, Oct. 4; admitted to hospital, Oct 9; onset of lobar pneumonia, Oct. 29; of empyema, Nov. 9; convalescent in empyema ward.
Bacteriology.—1. Throat cultures for: (a) S. hem., Oct. 11, −; 20, −; 24, +; 29, −; Nov. 2, −; 9, −; (b) B. influenzæ, Oct. 11, −. 2. Cultures from pleural fluid, Nov. 9 and 13, S. hem.
Case 714, W. H. Onset of measles, Oct. 26; admitted to hospital, Oct. 28; otitis media, Nov. 8; onset of bronchopneumonia, Nov. 9; of empyema, Nov. 17; convalescent in pneumonia ward.
Bacteriology.—1. Throat cultures for: S. hem., Oct. 28, −; Nov. 4, −; 12, +; 23, +; 30, +; Dec. 7, +; 12, −. 2. Sputum: Nov. 10, Pneumococcus II atypical, S. hem. and B. influenzæ.
Case 730, W. S. Autopsy No. 491. Onset of measles, Oct. 26; admitted to hospital, Oct. 29; onset of bronchopneumonia, Nov. 10; of empyema, Nov. 11; of cervical adenitis, Nov. 5; died, Nov. 15.
Bacteriology.—1. Throat culture for: S. hem., Oct. 30, −; Nov. 4, +. 2. Sputum: Nov. 10, S. hem. 3. Pleural fluid: Nov. 11, S. hem. Autopsy bacteriology: Heart blood, S. hem.; right main bronchus, B. influenzæ, B. coli; right lung, S. hem. and B. influenzæ; right pleura, S. hem.; peritoneum, S. hem.
Case 751, P. B. Autopsy No. 492. Entered hospital, Oct. 19; onset of measles, Oct. 30; of bronchopneumonia, Nov. 5; of right empyema, Nov. 12; died, Nov. 16.
Bacteriology.—1. Throat cultures for: S. hem., Nov. 1, −; 4, +; 15, +. 2. Sputum: Nov. 13, B. influenzæ and S. hem. 3. Autopsy cultures: Heart blood, S. hem.; right lung, S. hem., Pneumococcus IV, B. influenzæ, B. coli; pericardium, negative; right pleura, S. hem.; peritoneum, S. hem.
Case 880, B. McN. Autopsy No. 507. Onset of measles, Nov. 30; entered hospital, Dec. 3; onset of bronchopneumonia, Dec. 11; of empyema, Dec. 14; died, Dec. 14.
Bacteriology.—1. Throat cultures for: S. hem., Dec. 3, −; 5, −; 12, +. 2. Cultures from pleural fluid, Dec. 14, S. hem. 3. Autopsy cultures: Heart blood, S. hem.; right main bronchus, S. hem., B. influenzæ, staphylococcus (a few); left lung, S. hem.; left pleura, S. hem.
The average period in the hospital before the development of the streptococcus pneumonia is about two weeks. Cases 98 and 285 were in the hospital thirty and twenty days respectively before the onset of pneumonia. There is a record of from one to four negative throat cultures on each case before streptococcus was found in the throat. This enables us to fix the onset of the pneumonia with reference to the appearance of the streptococcus in the throat.
Case 141 stands alone as representing a class in which S. hemolyticus was implanted upon a pneumococcus pneumonia during its course. In this instance two throat cultures on alternate days after the onset of the pneumonia were negative for hemolytic streptococci. Unfortunately the last record of a throat culture is for one taken ten days before the fatal termination of the case, and it can only be stated that the S. hemolyticus infection was implanted within the last ten days of the course of the pneumonia, perhaps on or about October 12 when bilateral otitis media developed.
In Cases 285 and 730 hemolytic streptococci were found in the throats five and six days respectively before the onset of pneumonia. They represent the 2 cases of pneumonia which developed in patients isolated in the streptococcus “carrier” ward. Case 285 is of particular interest for several reasons. It is the only case of lobar pneumonia in the group and happens also to be the only case from which B. influenzæ was not obtained. S. hemolyticus was found only once on throat culture, i.e., five days before the onset of the pneumonia. Three throat cultures after the onset of the pneumonia were negative. The case ran the course of a lobar pneumonia. Eleven days after the onset (November 9) a small amount of pleural fluid was diagnosed. Aspirated fluid on this date and again four days later showed many streptococci in smears and pure cultures of S. hemolyticus.
The remaining 6 cases belong to a group in which hemolytic streptococci were first identified in the throats after the cases had been reported to the laboratory as pneumonia suspects to be examined by culture before transfer from the measles ward. In all these cases the culture taken at this time was positive while all cultures taken before were negative. In some cases, e. g., Cases 98, 147, and 281, throat cultures taken only one or two days before the onset of the pneumonia were negative. In these cases the onset of the pneumonia and the appearance of the streptococcus in the throats appear to be simultaneous.
It should be noted that the period between the appearance of the hemolytic streptococci in the throat and the development of the pneumonia is very short in all cases. In this small group of cases S. hemolyticus infection which has complicated pneumonia has been acquired at or near the time of onset of the pneumonia.
(b) Pneumonia with Hemolytic Streptococci in the Throat without Symptoms Referable to the Streptococcus.—Thirteen cases of pneumonia associated with measles developed into S. hemolyticus “carriers” without having the course of the disease affected by the presence of the organism in the throat. Cases 705, 872, and 188 are of interest in that hemolytic streptococci were identified in the throats from one to six days prior to the onset of the pneumonia. In spite of their presence, the symptoms, course and outcome of the pneumonia were apparently unaffected. One of these cases (Case 872) died. Autopsy showed lobar pneumonia with no signs of invasion of the lung by hemolytic streptococci. Cultures at autopsy showed that pneumonia was due to a pneumococcus, Type II atypical. A few hemolytic streptococci were found in culture from the right main bronchus.
Of the remaining 10 cases 1 developed S. hemolyticus in a throat culture at the end of the first week of the pneumonia; 3 during the second week; 1 during the third week, and 5 further along in the convalescent period. In 8 cases hemolytic streptococci appeared in the throat, at a time when invasion of the lower respiratory tract by the streptococcus might be expected, and yet none of them developed evidence of streptococcus pneumonia. The 9 cases with hemolytic streptococci appearing late in convalescence are not of particular interest, since the dangers of lower respiratory invasion are much reduced after the acute stage of the pneumonia has passed. Three of these cases (Cases 678, 725 and 398) did however develop ear complications directly referable to the streptococcus invasion of the throat. Two of them terminated in mastoiditis with operation. These cases emphasize the greater tendency of S. hemolyticus to invade the middle ear rather than the lung.
In 3 fatal cases of pneumococcus pneumonia in which during life no hemolytic streptococci were found by throat culture, a few hemolytic streptococci were found at autopsy in culture from the main bronchi, along with predominating growths of pneumococci and B. influenzæ. In 2 instances there was frank lobar pneumonia and in the third bronchopneumonia; there was no evidence to show that hemolytic streptococci had any relation to the pneumonia which was found.
MEASLES PNEUMONIAS; GROUP CARRYING HEMOLYTIC STREPTOCOCCI
Case 705. Onset of measles, Oct. 25; admitted to hospital, Oct. 27; onset of bronchopneumonia, Nov. 10; acute pleurisy, Nov. 16; convalescent in pneumonia ward.
Bacteriology.—1. Throat cultures for: S. hem., Oct. 27, −; Nov. 4, −; 11, +; 15, +; 23, −; 30, −; Dec. 7, −; 12, −. 2. Sputum: Nov. 10, Pneumococcus II atypical, S. hem. and B. influenzæ.
Case 872. Autopsy No. 508. Onset of measles, Nov. 29; admitted to hospital, Nov. 30; onset of lobar pneumonia, Dec. 10; died, Dec. 14.
Bacteriology.—1. Throat cultures for: S. hem., Nov. 30, −; Dec. 5, +; 10, +; 12, +; 14, +. 2. Autopsy culture: Heart blood, Pneumococcus II atypical; right main bronchus, Pneumococcus II atypical, B. influenzæ, S. hem. (a few); left lung, Pneumococcus II atypical; left pleura, Pneumococcus II atypical.
Case 188. Onset of measles, Oct. 3; admitted to hospital, Oct. 4; onset of bronchopneumonia, Oct. 14; recovered and discharged from hospital, Nov. 24.
Bacteriology.—1. Throat cultures for: (a) S. hem., Oct. 5, −; 8, +; 12, +; 19, +; 20, +; 27, −; Nov. 2, −; 9, +; 15, −; (b) B. influenzæ, Oct. 5, −; 8, −; 12, +; 19, +.
Case 678. Onset of measles, Oct. 23; admitted to hospital, Oct. 25; onset of bronchopneumonia, Nov. 2; of otitis media, Nov. 9; of mastoiditis, Nov. 13; mastoid operation, Nov. 20; still under treatment.
Bacteriology.—1. Throat cultures for: S. hem., Oct. 25, −; Nov. 4, −; 5, −; 12, +. 2. Sputum: Nov. 3, Pneumococcus Type IV, and B. influenzæ. 3. Culture from mastoid bone at operation, Nov. 20, S. hem.
Case 389. Admitted to hospital, Oct. 2, with diagnosis of influenza; onset of bronchopneumonia, Oct. 7; onset of measles, Oct. 13; phlebitis (right leg), Oct. 22; otitis media, Oct. 31; recovered.
Bacteriology.—1. Throat cultures for: (a) S. hem., Oct. 16 −; 20, −; 27, +; Nov. 2, +; 9, +; 15, −; 23, −; 30, −; Dec. 7, −; 12, −; (b) B. influenzæ, Oct. 16, −.
Case 725. Onset of measles, Oct. 18; one week in measles barracks; admitted to hospital, Oct. 27; onset of lobar pneumonia, Oct. 23; otitis media, Nov. 7; mastoid operation, Nov. 20; still under treatment.
Bacteriology.—1. Throat cultures for: (a) S. hem., Oct. 29, −; Nov. 1, −; 5, −; 12, +; (b) B. influenzæ, Oct. 29, +. 2. Sputum: Nov. 2, Pneumococcus II atypical. B. influenzæ. 3. Culture from mastoid at operation, Nov. 20, S. hem.
(c) Pneumococcus Pneumonias not Carrying Hemolytic Streptococci.—Thirty-four cases of pneumonia following measles went through their entire course in the hospital with no throat culture positive for hemolytic streptococci. In some of these cases there are records of twelve negative throat cultures. Eleven fatal cases occurred in this group. Autopsy findings and bacteriology showed in each instance that S. hemolyticus was not the cause of the pneumonia.
Measles During the Course of Pneumonia.—Eleven cases of pneumonia which developed measles during the course of the pneumonia came under observation. Hemolytic streptococci appeared in the throats of 3 of these patients during convalescence, but there was no evidence that it invaded the lung. In one fatal case autopsy showed that there was no streptococcus pneumonia; pneumonia followed influenza and the onset of measles occurred three days after the onset of bronchopneumonia.
Bacteriology of Pneumonia Following Measles.—When observations made during life are combined with the results of postmortem cultures, the bacteriology of 35 of the 56 cases is available and is as follows: Pneumococcus Type II atypical in 36 per cent, Type IV in 22.9 per cent, Type I in 2.8 per cent, Type III in 2.8 per cent, hemolytic streptococci in 22.4 per cent, and B. influenzæ in 88.6 per cent of these cases.
Otitis Media and Mastoiditis Complicating Measles.—The occurrence of otitis media and mastoiditis complicating measles in patients harboring hemolytic streptococci in their throats has already been presented (Table LXIV). The bacteriology of these complications was not studied by this commission. The records of the base hospital laboratory at Camp Pike contain reports of twenty-nine cultures made at operation from pus in the middle ear and the mastoid bone. Hemolytic streptococci were found in 22 of these cases. Throat cultures were in accord with these positive findings in all except a few instances. The throat culture serves as a fairly reliable index of the bacterial nature of these complications. By combining our records of throat cultures with the results of the cultures from the lesions, hemolytic streptococci were obtained from 37 of the 48 cases of otitis media. In 23 cases of mastoiditis following the otitis media, hemolytic streptococci were demonstrated in all except 2. It is evident that the great majority of these complications were due to hemolytic streptococci.
The relation between the appearance of hemolytic streptococci in the throat and the onset of the otitis is recorded in all except 4 of the 31 instances of otitis media occurring in patients with throat cultures positive for hemolytic streptococci. These four patients had positive throat cultures when first observed and represent the only patients who carried hemolytic streptococci when admitted to measles wards and developed complications.
The first of these patients had been under treatment in an otologic ward during a month before measles developed. Measles caused a recurrence of disease of the ear with double mastoiditis requiring bilateral operation. Two other patients had been in the hospital ten and eleven days respectively before they were admitted to the measles ward; on admission to the ward otitis media was present in one patient and in the other it developed six days later. The fourth patient was admitted to the measles wards directly from the camp, and culture from the throat on the day of admission showed the presence of S. hemolyticus. Two weeks later at the time of onset of otitis media, culture from the throat contained no hemolytic streptococci. Repeated cultures during the next three weeks were negative. No complications of otitis media developed and no direct cultures from the ear are recorded.
Chart 5.—Shows the time relation between the identification of hemolytic streptococci in the throats and the development of otitis media in 27 cases shown to be due to hemolytic streptococci. The onset of otitis media is represented by the ordinate marked ○. The number of days before or after the onset of the otitis, within which the throat culture which proved positive for hemolytic streptococci was taken, is marked off along abscissæ to the left and right of ordinate ○ respectively. On the curve plotted these symbols are used: A circle represents a throat culture positive for hemolytic streptococci in a case of otitis media without extension to mastoid. The plus sign represents a throat culture positive for hemolytic streptococci in a case of otitis media with mastoiditis and osteitis.
In this series of cases (Chart 5) the appearance of S. hemolyticus in the throat and the onset of otitis media are very closely associated in those patients in whom further extensions of the streptococcus infection occurred. In instances in which appearance of streptococci and of otitis media are separated by an interval of more than seven days, no further extension occurred. In 8 cases in which this interval is seven days or less there has been no further extension of the infection.