5~ T H E B R I T I S H J O U R N A L O F T U B E R C U L O S I S

CONSULTATION

CASE B~" JAMES MAXWELL,

M.D., F.R.C.P°

Physlc[an to the Royal Chest Hospital, City Road, and Assistant Physician to St. Bartholomew's Hospital

VIOLET W., aged so, a shop assistant in a London suburb, developed a sore throat on October i5, i936. It appears to have been a very acute attack and the temperature soon after the onset rose to io3 °. Three days later she developed a hard dry cough, and on October 2o she began to cough up a little sputum mixed with blood. In the following week the sputum was constantly streaked with blood and she occasionally coughed up dark red clots as well. The ha~moptysis was never profuse. At no time was there any complaint of pain in the chest. In addition she had the usual febrile symptoms, with headache, loss of appetite, occasional vomiting and constipation.

There was never any ha~morrhage from the other mucous membranes. Apart from measles and mumps in childhood there was no history of any

serious illness; the periods had always been regular and there had been no question of the use of any drug, such as pyramidon. The patient had not been subject to sore throats previously.

There was nothing relevant in the family history. I was asked to see the patient by her family practitioner, Dr. B. Rai,

on November I, !936. She appeared to be acutely ill, with pale mucous membranes, and marked foetor oris was present. The temperature at this stage was 3oo.6 °, the pulse ~oo, and the respirations 26 per minute. Exam- ination of the mouth showed furring of the tongue and gross ulceration of the fauces; there was also considerable whitish exudate on the left tonsil. There were numerous lymphatic glands, about the size of an almond, in the anterior triangles of the neck, and smaller glands in the posterior triangles° These were freely movable and slightly tender.

There were no abnormal physical signs on examination of the respiratory tract and the heart appeared normal. On examination of the abdomen the

C O N S U L T A T I O N 53

spleen was found to extend about one inch below the left costal margin. It was smooth and insensitive. The remainder of the physical examination was negative. No other enlarged glands were detected in any part of the body. The ocular fundi were normal.

In view of the absence of physical signs in the respiratory tract and the positive evidence of some disturbance of the lymphatic system, as shown by ulceration of the fauces, enlargement of the lymphatic glands and a palpable spleen, a provisional diagnosis of one of the acute diseases of the blood-forming organs was made, and the probabilities appeared to favour an acute leuk~emia. The prognosis was necessarily very guarded, and it was decided that the patient should be admitted to St. Bartholomew's Hospital for further investigation.

On admission to hospital the following day the temperature was lOO °, the pulse 12% and the respirations 28 per minute. A blood count was immediately done, and this showed:

R.B.C . . . . . . . . . 4,260,o0o per c.mm. W.B.C . . . . . . . . . 5,800 ,, ,, C.I . . . . . . . . . 0"94 ,, ,,

Polymorphs . . . . Lymphocytes, large

,, small Large mononuclears .. Eosinophils . . . . Basophils . . . .

Differential White Count

Per cent. . . . . 2 0

. . . . 56 . . . . I 2

• • , ° 6

. . . .

Per c.mm. 1,16o 3,248

696 348 ~ 6 232

An X-ray of the chest was also taken at this time, and this showed an increase of the hilum shadows, especially on the left side, which appeared to be due to glandular enlargement. The remainder of the lung fields were normal.

Consideration of the evidence elicited at this stage supported the view that the condition was almost certainly a disease of the blood-forming organs, but the picture was by no means conclusive of leuk~emia. A Paul Bunnell reaction for glandular fever was therefore carried out by Dr. H. F. Brewer, who reported that the serum showed the heterophil agglutinln for sheep's red cells to a titre of I in 1,o24. Agglutination in so high a dilution is diagnostic of glandular fever, and therefore the diagnosis could be regarded as having been definitely established. It could be stated, in view of this, that the prognosis was good and the subsequent course of the illness justified this estimate. The temperature settled to normal on

54 T H E B R I T I S H J O U R N A L O F T U B E R C U L O S I S

November 4, and the throat condition cleared up within a few days. The spleen was not palpable on November 7, and two days later the last of the glands in the neck disappeared. The patient left hospital fully recovered on November I3.

Apart from an iron tonic in the recovery stage, no special treatment was given, nor did any appear to be necessary.

This case illustrates a rare difficulty in diagnosis, and it also shows how important it is to carry out complete investigations in order to establish an exact diagnosis and so to define the prognosis without waste of time.

In the first place the hmmoptysis, which was one of the prominent symptoms in this case, did not indicate disease of the respiratory tract, but rather a general disease of the blood-forming organs. In these cases the cause may be one, such as acute leukmmia, which is serious and almost inevitably fatal, or it may be a much less grave condition from which re- covery is likely. Complete blood examination is absolutely essential in all such cases, and the specific reaction for glandular fever is of great value when the possibility of this diagnosis is being entertained. Hmmoptysis in glandular fever is extremely rare, but this case shows that the diagnosis must be considered in cases of hmmoptysis associated with enlargement of the spleen and lymphatic glands.