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.