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The Man with a Sore Throat: A Clinical Case Study
We enter Bob’s life not too long ago, while he sits in his living room, drinking a beer with a good friend, whom, we should note was coughing and sneezing up a storm.
“You okay, Charlie?”
“Fine, Bob, just fine. I’ve had this blasted cold for almost two weeks now.”
Fast forward, to a scene just outside of Bob’s home in Chicago.
“Bob, honey, are you coming in for dinner?”
“Just a minute, Cheryl, I’m almost done trimming the hedges.” Bob spotted a stubborn twig, and reached his arm into the bush to retrieve it. “Ouch!” He pulled his arm from the shrub and discovered a bloody gash where a thorn had caught him.
Let's call him Bob...
Born in 1961, Bob’s life represented everything about his birth year: common, ordinary. And yet, every year has something unique about it – some event that defines it, as every person is unique.
1961 was the year the US broke diplomatic relations with Cuba, the year the Berlin wall was erected, and the year the USSR detonated the hydrogen bomb. It was the year the Yankees won the World Series, and the Chicago Blackhawks won the Stanley Cup. It was a big year for entertainment, what with West Side Story coming out, and for science – the first US astronauts entered orbit that year.
But Bob’s life was far more ordinary. He suffered from minor health issues, by today’s standards, like diabetes, sinus problems, and asthma – nothing compared to cancer or Parkinson’s Disease.
Once inside, he set to cleaning the wound, with Cheryl’s help, and placed gauze and a Band-Aid over the cut. Two days later, Bob awoke with a sore throat, and found himself unable to swallow. In fact, he could barely breathe! Cheryl rushed him to the hospital, noting the swelling and redness that had developed around the gash left by the thorn.
In the emergency room, Bob was given steroids to stimulate his adrenal glands, and broad spectrum antibiotics that might fight off any invading bacteria. Tests indicated elevated white blood cell counts, and decreased renal activity. The redness on Bob’s arm had turned into bulbous skin lesions, some of which had ruptured. Throat and wound cultures were positive for Streptococcus pyogenes, Group A, the same bacteria that causes strep throat in many children.
To us, Bob remains faceless, even nameless – merely an imaginary victim of one of the world’s deadliest diseases. How does Streptococcal disease happen? And how does it potentially kill one person, while hardly affecting another for more than a week? Suppose Bob was not diabetic; would he still have responded this way?
What do you think?
Could Bob have avoided getting sick if he'd used hand sanitizer in the first place?
Streptococcus pyogenes is a gram-positive bacterium that is responsible for a wide range of clinical problems. Typically, infections occur in the throat of on the skin, and are non-invasive and very common (strep throat). However, some can be invasive, occurring where bacteria are not normally found, such as the blood, or organs. Our patient experienced such an infection, which resulted in Toxic Shock Syndrome (TSS), a complication caused by a bacterial toxin (see my previous post on Toxic Shock Syndrome).
The bug itself produces three types of toxins – streptolysins, which are responsible for destroying cells in the blood, streptokinase, which digests clots so that the bacteria are free to move about the wound site, and the SPE toxins (A-F). It is the SPE toxins that are responsible for most of the clinical manifestations of this disease – such as the rash of Scarlet Fever, and TSS.
Toxic Shock Syndrome
–Also caused by SPE exotoxins
–Typically present in people with pre-existing skin infections
–These individuals often experience severe pain at the site of the skin infection, followed by rapid progression of these symptoms:
•Low blood pressure
•Stupor, coma, or organ failure
–Caused by SPE exotoxins
• Carried by bacterial virus, which integrates into the Streptococcal genome from where the toxin is transcribed.
–Commonly affects 4-8 year old children
–Blood culture is rarely positive, but throat culture usually demonstrates streptococci.
•Bright red tongue
–Fine, red, and rough texture; starts on the chest, armpits, and behind the ears.
How does your doctor test for Streptococcus pyogenes?
Why did Bob get this disease, instead of strep throat?
We can hypothesize that it is because he was diabetic, and was on immunosuppressive drugs to control his inflammatory response. Insulin causes cells to absorb glucose from the blood to use as energy and stops the use of fat as an energy source. Insulin itself possesses anti-imflammatory properties. However, a person with diabetes has increased blood sugar due to a deficit in insulin, which increases inflammation, and alters the ability of the immune system to clear bacterial infections. With a decreased immune response, further suppressed to decrease his inflammatory response, it would’ve been hard for Bob’s body to keep the pathogen at bay.
So what happened to Bob?
Bob’s doctors called in the Infectious Disease specialists, who recommended antibiotic treatment with Clindamycin. Clindamycin is a relatively inexpensive antibiotic that inhibits bacterial protein synthesis, and makes the bacteria more susceptible to the immune system. It is often used in combination with Vancomycin, which causes a breakdown of the bacterial cell membrane.
Long story short, Bob got better. Here’s what his paperwork said:
The patient had slow improvement of the erythema and swelling of his right arm
during one week of i.v. therapy with these two antibiotics. His blood pressure
stabilized, and his renal function improved. He was discharged to continue oral
clindamycin therapy for an additional 10-14 days, with outpatient clinic follow-up.
Bob’s life will go on to be mostly ordinary, this moment a snapshot in time. And yet, somehow his life seems more significant, representing a victory of sorts. Modern medicine: 1, Bacteria: 0.