Gordon, J. E.

Norton, J. F.

Sharp, W. B.

English

ZENODO

A SORE THROAT EPIDEMIC OF UNUSUAL TYPEINFLUENZA STUDIES. VIII.WI L L I AM B. S II A R P; J 0 II N F. NOR TON,ANDJOHN E. GORDONFrom the Department of H:ygiene and Bacteriology of the University of ChicagoAn unusual disorder involving the upper respiratory tract wasobserved among the students of the High and Elementary Schools ofthe University of Chicago during March, 1920, and continued moreor less in evidence for the following three months. The condition wasnoted by the school physician, Dr. Monilaw, to whom we are indebtedfor valuable assistance in connection with routine throat examinations,first in grades 3 A and 3 B (children 9 to 10 years old), subsequentlyin grade 2 B (6 to 7 years), in grade 7 B (12 to 13 years) and inmany high school students. Subjective symptoms were slight althoughsome of the children at times reported slightly sore or irritated throatswith a general loss of ambition. The teachers noticed that duringMarch the younger children were below par physically and less brightthan usual. The school quarter was nearing its end, however, and suchobservations are not infrequent at that time.Objectively, the children had sometimes a general lassitude, oftena degree or two of fever, usually a mild but distinct reddening, morepersistent and pronounced than in the average throat, of tonsillarpillars, soft palate, uvula or pharynx and occasionally enlargement ofthe cervical lymph nodes. In no instance were the tonsils intenselyinflamed. The most striking clinical feature and the one which ledto our study of what appeared to be an epidemic was the extensionof redness along the tonsillar pillars toward the uvula. This rednessabout the tonsillar region, together with the fact noted in our earlylaboratory tests that the bacterial growth in material from the tonsilswas more abundant than in that from the pharynx, suggested that wewere dealing with an unusual chronic tonsillitis, although many ofthe children gave a history of tonsillectomy.The Respiratory Disease Commission was asked to investigate grade2 B from which 9 children were selected for intensive study. ThisReceived for publication Nov. 2, 1921. at Brunel University on July 17, 2015http://jid.oxfordjournals.org/Downloaded from SORE THROAT EPIDEMIC OF UNUSUAL TYPE 373study was extended and to a certain degree controlled by examinationof 7 children from grade 3 B in which conditions had been observedsimilar to those found in grade 2 B, of 7 children from grades 5 and 6in which conditions were thought to be normal and of 8 high schoolstudents who were convalescent from sore throats of a different clinicalcharacter than that just described.Our work with grade 2 B was started on March 17 (1920) andobservations were made for 3 consecutive days before the spring vaca-tion (March 20 to April 2) intervened. After the return of the chil- .dren to school weekly or biweekly examinations were conducted untilthe close of the spring quarter about the middle of June. A finalobservation was made after the children resumed their school work inthe autumn.The number of examinations made, together with the laboratorydesignation of each subject and the location in school was as follows:In Grade 2 B (intensively studied) : E 1, 2; E 2, 9; E 3, 10; E 4, 11;E5, 10; E6, 7; E7, 9; E8, 10; E9, 9; in Grade 3B (probablyinvolved in the epidemic) : E 25, 1; E 26, 1; E 27, 1; E 28, 1; E 29, 1;E 30, 1; E 31, 1; in Grade 5 A-B (probably normal) : E 21, 1; E 22,1; E 23, 1; E 24, 1; in Grade 6 A-B (probably normal): E 18, 1;E 19, 1; E 20, 1; in high school (sore throat convalescents): E 10,1 ; Ell, 1; E 12, 1; E 13, 1; E 14, 1; E 15, 1; E 16, 1; E 17, 1.The clinical symptoms tended to persist as first observed among thechildren of grade 2 B. Elevated temperature was found in all casesat least once, in subject E 4 nine times in 11 observations, in E 5 ninein 10 observations, in E 6 six in 7 and in E 8 eight in 10. Rednessof the pharynx and tonsillar pillars was continuously observed in thisgroup for one month and in four subjects for 12 weeks. Redness ofthe uvula was found only in the early examinations. The children ingrade 3 B, with the exception of subject E 31 to be described later,were free from any marked symptoms except shght temperature eleva-tions. Those in grades 5 A-B and 6 A-B were normal in all respects.On the other hand, the high school students (sore throat convalescents)showed in all instances a distinct redness of the pharynx accompaniedin 4 subjects by tonsillar redness and a slight temperature elevation.Epidemiology:-In any elementary school there is opportunity formore or less intermingling of children from all classes both inside theschool and at play. Conditions; therefore, exist for the spread ofrespiratory infections. The laboratory data obtained in this studyfurnished further evidence, although not conclusive, of such inter- at Brunel University on July 17, 2015http://jid.oxfordjournals.org/Downloaded from 374 W. B. SHARP; J. F. NORTON AND J. E. GORDONmingling. The records of both the high and elementary schools showedthat there were more absences than usual during the month of April(1920) on account of '(sore throats," "pharyngitis" and "tonsillitis"and that throat infections were unusually prevalent during the entirespring quarter (April 2 to June 10).There were also indications of a connection between high schoolstudents and those in the elementary grades. For example, W.P., ahigh school student, was the brother of J.P., a child in grade 2 B.About April 10 W.P. developed a sore throat much more severe thanthat prevalent among the younger children, though aiso atypical incharacter. On returning to school (April 21) hemolytic streptococciand type 4 pneumococci belonging to the same biologic groups as thosepresent in the throats of the children in grade 2 B were isolated fromhis throat. The mother of W.P. and J.P. and a sister and brotherhome from another college for the holidays also had an infection giving,as did that of W.P., the following clinical picture: a sore throat whichtheir family physician found unusual and unlike follicular tonsillitis,difficulty in swallowing, a temperature of 102 F. and in two casesaccompanied by a rash.' Hemolytic streptococci were found in thethroats of 5 others in the high school group and type 4 pneumococciin 3, but the biologic grouping of these organisms was not determinedin all cases.Laboratory Studies.-The clinical observations were accompaniedeach time by laboratory studies on the bacterial flora of the tonsillarregion. Swabs were made from the tonsils and streaked on blood-agarplates in the usual manner. The swabs were then placed in 5% sheepblood dextrose broth and incubated 6-8 hours. One c c of the bloodbroth culture was then injected into a white mouse. If the animaldied within 24 hours the peritoneal cavity was washed and the presenceor absence of fixed type pneumococci determined by agglutination andprecipitin tests.. Cultures were made on blood-agar plates from theperitoneal fluid and heart blood and the usual confirmatory tests madefor pneumococci. The blood-agar plates made from the originaltonsillar swabs were incubated for 24 hours and then studied in theusual manner.The first examination of cases E 1 to E 9, made on March 17, 1920,showed the presence of a hemolytic streptococcus on all plates and of atype 4 pneumococcus in all instances. These two organisms were the1 Scarlet fever was considered as a possibility but the symptoms did not warrant such adiagnosis. at Brunel University on July 17, 2015http://jid.oxfordjournals.org/Downloaded from SORE THROAT EPIDEMIC OF UNUSUAL TYPE 375principal ones sought for in subsequent examinations of all subjects,those serving as controls as well as those having pathologic throats.Table 1 gives the number of times these organisms were found in com-parison to the attempts made in the selected group from grade 2 B.TABLE 1HEMOLYTIC STREPTOCOCCI AND PNEUMOCOCCI IN GROUP 2 BI Number of Number of Number of Number ofExanilna- Times Examina- TimesCase tions for Hemolytic Percentage tions for Type 4 PercentageStrepto- Strepto- Positive Pneumo- Pneumo- Positivececel cocci cocci cocciFound Found.----------El 2 ? 100 2 2 100E2 9 5 56 Ii 5 83E3 11 8 73 5 4 80E4 12 11 92 7 4 57E5 12 9 75 5 4 80E6 7 4 67 f • 100E7 lJ 7 78 6 6 100E8 9 7 78 6 5 83E9 II 6 f/l 7 5 71-----ITot als ..••... 0 80 59 48 39Average ...... .. .. 74 .. o • si-The laboratory examinations show that hemolytic streptococci wereisolated in 74% of attempts made and type 4 pneumococci in 81%.The control group, including 8 convalescents from sore throat, gavehemolytic streptococci in 9 instances (41 %) and type 4 pneumococci in10 instances (45%). Eight of the 9 strains of hemolytic streptococciand 4 of the 10 strains of pneumococci were isolated from the groupof convalescents.TABLE 2AGGLUTINATION OF HEMOLYTIC STREPTOCOCCIISerum 4 (5) TH1 Dllutlons Serum 7 (8) THl DilutionsStrain.I-!:l60 1,320 -!:640 1:1,28011:2,560--"""--- "160 I "'''' 1,640 1:1,2801 TH 1 -I- -I- -I- -I- -I- -I- -I- - -4 (5) TH 1-I- -I- -I- -I- -I- -I- -I- - -4 (5) TH2-I- -I- -I- + -I- -I- + + -4 (5) TH 5-I- + + -I- - -I- -I- - - -4 (6) TH 5-I- -I- -I- -I- -I- -I- - - -7 (5) TH 1-I- -I- -I- -I- -I- -I- -I- -I- - -7 (6) TH 1-I- + -I- + -I- + -I- -I- -I- -12TH2-I- -I- -I- -I- + -I- -I- -I- - -17TH2-I- -I- -I- -I- + -I- - - - -The hemolytic streptococci found on the blood plates were difficultto grow on transfers made to blood-agar slants. We were able toobtain them only from subjects E 1, E 4, E 7, E 12, E14, and E 17.All strains from E 1, E 4, E 7, E 12 and E 14 fermented lactose, man-nite and salicin, thus falling in Holman's group S. infrequens. Strains at Brunel University on July 17, 2015http://jid.oxfordjournals.org/Downloaded from 376 W. B. SHARP; j, F. NORTON AND J. E. GORDONfrom E 17 did not ferment mannite. Immune serums for 2 strains[4(S)TH 1 and 7(6)TH 1] were prepared by injection of rabbits andagglutination tests made against a number of strains with the resultsrecorded in table 2.Three strains from influenza cases gave no agglutination in anydilution with either serum. The strains from case E 1 was isolatedat the first examination. Three strains from case E 4 were obtained3 weeks after the first observation and one strain after 4 weeks. Thetwo strains from case E 7 were isolated after 3 and 4 weeks, respec-tively. The strains isolated were thus biologically identical, includingthe strain from subject E 17 which was culturally different.The type 4 pneumococci were likewise tested with an immuneserum prepared with one of the strains (E 4-6). Table 3 gives theresults of agglutination.TABLE 3AGGLUTINATION OF TYPE 4 PNEUMOCOCCIDlIutions (Serum E 4-6)Strain1:10 ~1~1~1~1~1~~I~,llOOE 2-5 + +1+ + + + + + +E2·7 + + + + + + - -I-E 3-5 + + + + + - - - -E3-6 + +1+ +I + -1- - -E4-6 + + + + + + + + +E5-5 + + + + - -1- - -E5-6 + + + - - - - - -E 6-3 + + + + + - - - -E 8-5 + + + + - - - - -ElM + + + + + - - - -EI0 + + + + + - - - -E 12 + + + + - - - - -E 15 + + + - - - - - -E 16 - - - - - - - - --E24 - - i - - - - - - -E 27 + +I+ - - - - - -E 31 + + + + + + + - -Strains from cases of common colds gave no agglutination withthis serum. As with the hemolytic streptococci the strains wereobtained at various times-from -2 days to 4 weeks after our workwas started. A biologically identical type 4 pneumococcus was thusisolated from all the cases of grade 2 B except 2 from which the strainsfailed to survive, from 3 high school students and from 2 children ofgrade 3 B.The persistence of clinical symptoms in some cases led to a studyof the length of time that hemolytic streptococci and type 4 pneumo-cocci remained in the throats of the children of grade 2 B. Unfortu-nately it was not possible to complete this part of the investigationbecause of the withdrawal from school of some of the children and at Brunel University on July 17, 2015http://jid.oxfordjournals.org/Downloaded from SORE THROAT EPIDEMIC OF UNUSUAL TYPE 377the closing of school for the summer. Table 4 gives the availabledata correlated with the appearance of tonsils and pharynx.These results show a close correlation between clinical observationsand the presence of hemolytic streptococci, pneumococci or both.An examination made October 25, after the autumn opening of theschool, revealed the persistence of clinical symptoms in group 2 B.These, however, were less severe in character than those noted 7 monthspreviously. Hemolytic streptococci were absent from, all throats whiletype 4 pneumococci were isolated in 2 instances. It is not knownthat these 2 strains were identical with those previously studied.TABLE 4PERSISTENCE OF HEMOLYTIC STREPTOCOCCI AND PNEUMOCOCCI (PRESENCE AFTER 8 WEEKS)Subject Redness of Redness of Hemolytic Type 4Pharynx Tonsils Streptococci PneumococciE2 + Slight +* +E8 0 Doubtful +* +E4 + + + +E5 + + +* -E6 0 0 - +E7 + + + +E8 0 0 - -E9 0 0 +* -I* Numbers very few.Subject E 31, a member of grade 3 B, proved to be of some interest.This child had an attack about June 9 and presented a clinical pictureof a more severe character than observed in the other children. Thepharynx became so acutely inflamed, edematous and painful that thehead was retracted. The temperature rose several degrees. We iso-lated from the tonsils a type 4 pneumococcus serologically identicalwith the others studied but failed to find a hemolytic streptococcus.Whether or not the pneumococcus was the etiologic factor is unknown,but the finding of a specific serum strain of this organism in connectionwith a distinct pathologic condition is worth noting.SUMMARYThe data here presented show the occurrence of a sore throatepidemic of an unusual clinical type. A hemolytic streptococcus anda type 4 pneumococcus were found simultaneously in the tonsillarregions of a group of children with the symptoms described. Thestreptococcus was of an unusual cultural type, belonging to Holman'sgroup S. infrequens. The hemolytic streptococcus is known to be attimes the etiologic factor in sore throats. That the type 4 pneumo- at Brunel University on July 17, 2015http://jid.oxfordjournals.org/Downloaded from 378 W. B. SHARP; ]. F. NORTON AND J. E. GORDONcoccus present in our group might be pathogenic is suggested by itspresence unaccompanied by hemolytic streptococci in one case of acuteinflammation.One of the most striking features was the carrier condition. It isimpossible to say how long this was maintained, but in 5 of 8 instancesit persisted for not less than 8 weeks as shown by finding irnmuni-logically identical organisms continually on the tonsils during thisperiod. "Hemolytic streptococci were found after 12 weeks. Theproportion of hemolytic streptococci in the tonsillar flora as indicatedon blood-agar plates varied considerably, some examinations beingnegative. It is well recognized that the technic usually employed mayyield discrepancies. The reappearance of these organisms on blood-agar plates does not necessarily mean that a new invasion has occurred.We had no way of determining the relative numbers of the pneumo-coccus.The finding of specific strains of hemolytic streptococci and of type4 pneumococci, biologically identical with those from the group ofchildren intensively studied, in convalescents among high school studentsand in children in other grades of the elementary school indicated theprevalence of these organisms throughout the whole school. Thepossibility of contact among the children existed and was substantiatedby certain well established instances.The persistence of clinical symptoms closely paralleled theoccurrence of the two specific strains of the organisms (see table 4).These symptoms were so mild after the earliest examinations as almostto escape attention.This epidemic may have been caused by one of the organismsisolated or by their simultaneous action. at Brunel University on July 17, 2015http://jid.oxfordjournals.org/Downloaded from 

A sore throat epidemic of unusual type: Influenza studies. VIII

https://zenodo.org/record/1558483/files/article.pdf

A sore throat epidemic of unusual type: Influenza studies. VIII

Abstract

Similar works

Full text

Available Versions

ZENODO