Travels with Bacteria
Erin’s unexpected medical journey started with a bacterial infection, one with a lineage of epidemics and evolution, queens and the Muppets. In modern times, group A streptococcus, its medical acronym is GAS, usually turns up as strep throat. When I really hated high school, I fantasized that a good case of strep would give me reason to miss days, possibly weeks of class. I had no idea.
Group A Streptococcus has been around for centuries. In the 1600s, it swept through Italy, Spain, and Northern Europe in the form of scarlet fever. Tight living arrangements created an ideal breeding ground for the bacteria. Scarlet fever spread from child to child through saliva on shared utensils or tiny bits of mucus sneezed into the air. Along with chills, nausea and vomiting, a rash of tiny red bumps sprouted on affected children’s faces and necks, spread to their chests and backs, and enveloped the rest of their bodies. Children with scarlet fever looked sunburned and their skin had the texture of sandpaper. Without understanding infectious disease and with no antibiotics to treat it, parents and doctors could do little to stem the fever’s tide.
Group A Streptococcus has been around for centuries. In the 1600s, it swept through Italy, Spain, and Northern Europe in the form of scarlet fever. Tight living arrangements created an ideal breeding ground for the bacteria. Scarlet fever spread from child to child through saliva on shared utensils or tiny bits of mucus sneezed into the air. Along with chills, nausea and vomiting, a rash of tiny red bumps sprouted on affected children’s faces and necks, spread to their chests and backs, and enveloped the rest of their bodies. Children with scarlet fever looked sunburned and their skin had the texture of sandpaper. Without understanding infectious disease and with no antibiotics to treat it, parents and doctors could do little to stem the fever’s tide.
Scarlet fever managed to cross the Atlantic, causing 4,000 children’s deaths in a 1736 outbreak. In the 1880s, more than one out of four children with scarlet fever in New York, Chicago, and Norway died. In London, three of Charles Darwin’s 10 children became ill with scarlet fever and his youngest son, Charles Waring died from it when he was 18 months.
Group A strep also found an easy target in delivery rooms. Before modern sterilization techniques took hold, scores of women, including Jane Seymour and Catherine Parr, Henry VIII of England’s third and sixth wives, died of Puerpal Fever days after giving birth. In the 19th century, what was known as child-bed fever took hold in many European maternity wards. In America, where most women still gave birth at home, it followed physicians from house to house. Once GAS got onto physicians’ hands, gowns or instruments it made its way, unobstructed by any form of hand washing or gown changing, to the next patient, and the next.
Group A strep also found an easy target in delivery rooms. Before modern sterilization techniques took hold, scores of women, including Jane Seymour and Catherine Parr, Henry VIII of England’s third and sixth wives, died of Puerpal Fever days after giving birth. In the 19th century, what was known as child-bed fever took hold in many European maternity wards. In America, where most women still gave birth at home, it followed physicians from house to house. Once GAS got onto physicians’ hands, gowns or instruments it made its way, unobstructed by any form of hand washing or gown changing, to the next patient, and the next.
Oliver Wendell Holmes published “The Contagiousness of Puerpal Fever” in 1843 to a lackluster, sometimes hostile response. In the paper, Holmes described how, rather than spreading through populations, the disease and its fatalities followed the course of individual physicians. Some physicians ignored the paper, many others disagreed angrily — puerpal fever was not contagious and doctors, who were gentlemen, were not spreading it.
While physicians debated the issue in America, Ignaz Semmelweis took note of similar trend in Vienna. Women attended to by doctors in his maternity clinic died at a rate three to five times higher than those who delivered children by midwife. These same doctors performed autopsies, most physicians were generalists back then, and often went directly from the morgue to the delivery room. Semmelweis managed to convince the physicians in his clinic to wash their hands in a chlorine solution between the two procedures. The maternal death rate dropped.
Fast forward to the 20th century. Group A strep invaded the US military during World War II, this time in the form of rheumatic fever. In 1943, the Army reported 6,710 hospital admissions for rheumatic fever and designated seven convalescent facilities. Meanwhile, military doctors scrambled to come up with effective treatments. One popular approach required soldiers to lie absolutely still until all signs of the condition disappeared. Many were not allowed to feed, wash, or shave themselves for weeks.
Finally, penicillin came along to keep GAS at bay. The bacteria's apparent defeat coincided with a period of remarkable scientific and medical advances. The world watched the first man walk on the moon. A commission of scientists declared the eradication of smallpox. And then GAS started turning up again.
A Day Home from School or Life-Changing Medical Event
These days, GAS usually turns up as run-of-the-mill strep throat, the sort of cold I once equated with a break from school. In a small number of cases, about 9,000-11,500 a year, the bacteria makes its way into a person’s blood or muscles, often through a simple cut, sometimes during childbirth. Now GAS has an opportunity get invasive. In a tiny percentage of such cases, 6%-7%, GAS works its way into soft tissues and becomes necrotizing fasciitis, a.k.a., flesh-eating bacteria. In another tiny percentage, invasive GAS turns into streptococcal toxic shock syndrome (STSS). Blood pressure drops rapidly, the body goes into shock, and major organs fail.
STSS is similar to the toxic shock syndrome that hit in the early 80s and was eventually linked to tampon use. Group A strep causes the first; staphylococcus (staph) causes the second. Both are bacteria, both take up residence in an unwitting host, both reproduce within that host. Streptococcus grows in spherical chains. Staphylococcus grows in tiny grape-like bunches.
Sporadic cases of STSS started showing up in healthy adults in the mid 1980s. The scenario went something like this: A person in the prime of his or her life felt acute pain and signs of a fever, nothing terribly unusual, except the symptoms got worse instead of better. If the person got to an emergency room and if an observant clinician recognized the symptoms and started treatment right away: antibiotics to control the infection and life support to keep the patient alive, she might make it.
The odds didn’t work in Jim Henson’s favor. After not being able to shake flu-like symptoms for several days, he let his wife take him to New York Hospital on an early morning of May 1990. By then, abscesses had formed throughout his lungs and he could barely breathe. Doctors put him on a ventilator and gave him high doses of antibiotics. But GAS had made too many inroads into his system. He went into kidney failure, heart failure and his blood lost its ability to clot. Twenty hours after arriving at the hospital, Jim Henson died from uncontrollable bleeding into his lungs.
Like Henson, Erin started out healthy and vibrant before GAS invaded her system. She too became a minority within a minority, first when GAS invaded her system and then when it turned into STSS. When Rob rushed Erin to the emergency department, he put wheels in motion that would move her to the third level of minority, the people who pull through. But not before GAS waged a monumental attack that would leave permanent scars.
Sources
1. Stevens, DL, Streptococcal Toxic-Shock Syndrome: Spectrum of Disease, Pathogenesis, and New Concepts in Treatment. Emerging Infectious Diseases 1995; 1:69-78. http://www.cdc.gov/ncidod/eid/vol1no3/stevens.htm
2. Stevens, DL. Group A Streptococcus: From Basic Science to Clinical Disease Emerging and Reemerging Global Microbial Threats. WestJMed 1996;164:25-27 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1303288/pdf/westjmed00352-0027.pdf
3. “Infectious Diseases in History: a guide to their causes and effects,” http://www.urbanrim.org.uk/diseases.htm
4. Powell, A. “How Oliver Wendell Holmes helped conquer the ‘black death of childbed,’” Harvard University Gazette, September 18, 1997, http://news.harvard.edu/gazette/1997/09.18/DefeatingInfect.html
5. Rantz, LA, Rheumatic Fever, U.S. Army Medical Department, Office of Medical History. Accessed September 9, 2010. http://history.amedd.army.mil/booksdocs/wwii/infectiousdisvolii/chapter8.htm
6. Goldman, B, Growing number of “Jim Henson’s” disease cases worries Ontario doctors. Canadian Medical Association Journal, 1991; 144: 760-764. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1453023/pdf/cmaj00235-0146.pdf
7. Angier, N. “An Aggressive Infection, Abrupt and Overwhelming.” New York Times, May 17, 1990. http://query.nytimes.com/gst/fullpage.html?res=9C0CEFD6113BF934A25756C0A966958260
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