The Smith Infectious Diseases Foundation
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GREAT CASES IN MEDICINE
One of Dr. Leon Smith favorite past times is discussing the difficult and obscure diseases that affect many people. This is the first in a series of those cases. If you need any additional information, contact Dr. Smith.
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A 60-year old male judge noticed a black spot on his testicle and then a foul odor. Shortly thereafter, the infection traveled through the body. Antibiotics alone were not effective in normal dose. Widespread surgery saved his life. Sitting down a lot caused irritation in the groin.Taxi drivers also got the disease. Few doctors see the urgency of treating the disease aggressively. The odor, however, is so distinctive that Sir William Osler made the diagnosis in the lobby of John Hopkin’s Hospital just by smelling. Diagnosis: Fournier’s Disease.
Fournier's gangrene, sometimes called Fournier's disease, is a bacterial infection of the skin that affects the genitals and perineum (i.e., area between the scrotum and anus in men and between the vulva and anus in women). The disease develops after a wound or abrasion becomes infected.
Treatment for Fournier's Gangrene: Antibiotics (often double or triple drug therapy) along with aggressive surgical removal of the diseased tissue is required immediately for an optimal outcome. Without early treatment, bacterial infection enters the bloodstream and can cause delirium, heart attack, respiratory failure, and death.
CASE 6
A six-month old boy with 106°F fever has the symptoms of strawberry looking tongue, conjunctivitis and peeling skin on fingers. The baby seemed very sick. Almost 20 years later, the patient is very healthy. As a child, he was treated with intravenous doses of gamma globulin (purified antibodies), an ingredient in blood that helps the body fight infection. The child also was given a high dose of Aspirin to reduce the risk of heart problems. Diagnosis: Kawasaki Disease.
Kawasaki disease is an illness that involves the skin, mouth, and lymph nodes, and most often affects kids under age 5. The cause is unknown, but if the symptoms are recognized early, kids with Kawasaki disease can fully recover within a few days. Untreated, it can lead to serious complications that can affect the heart. Kawasaki disease occurs in 19 out of every 100,000 children in the United States. It is most common among children of Japanese and Korean descent, but can affect all ethnic groups.
CASE 5
Five years ago, a patient with a mysterious ailment was sent to Dr. Leon G. Smith, an infectious-disease (ID) specialist in Roseland. Practicing since 1956, Smith is generally regarded as the dean of the ID field in New Jersey. The patient had what’s known as a fever of unknown origin (FUO). Besides examining the patient and ordering a series of preliminary blood tests, Smith took a detailed history, one of the key investigative tools of the ID specialist.
The patient, Smith learned during his questioning, was a runner whose favorite place to exercise was a farm he owned outside the city where he lived—a farm, it turned out, that was overrun by cats. In the course of his jogs through the fields, the man had on numerous occasions brushed up against or touched fences, posts, railings, and other so-called fomites—objects that can transmit infectious agents. Smith used this information, which had escaped other investigators, to pinpoint the cause of his patient’s mysterious fever: It was the parasitic disease toxoplasmosis, which can infect most warm-blooded animals but most commonly infects, and is spread by, cats. Smith treated his patient with a special antibiotic, and the condition cleared.
Welcome to the unpredictable, sometimes baffling world of infectious diseases—and to the unique group of specialists who investigate it. Part master diagnosticians, part medical sleuths, these specially trained doctors are often called upon to solve cases that baffle their colleagues. “We’re the Sherlock Holmeses of the medical world,” says Dr. Kathleen K. Casey, chief of infectious diseases at the Jersey Shore University Medical Center in Neptune.
CASE 4
There is an 87-year old woman who was born in Poland. She moved to Israel with an entirely different weather pattern and she seems constantly sick. In the different climate she has a high fever for six months and feels weak with aches and pains. A massive
work-up came up negative.
The place to blame, however, is not Israel. The diagnosis is Recrudesced Typhus or
Brill-Zinsser Disease, which is defined as mild recrudescence of epidemic typhus years after the initial infection, because rickettsia prowazekii has persisted in body tissue in an inactive state, with humans as the reservoir. She got it from a body louse that she picked up while living in Poland.
CASE 3
A man decided to change his lifestyle and bought a farm that raised sheep. He worked many long hours on the farm and each year sheered the wool from the sheep. One season, while sheering the sheep, he got a large abrasion on one of his fingers. It caused a raised skin lesion that was tough to heal.
The man had a strange disease. Orf is a zoonotic disease, meaning humans can contract this disorder through direct contact with infected sheep and goats or with fomites carrying the orf virus. It causes a purulent-appearing papule locally and generally no systemic symptoms. Infected locations can include the finger, hand, arm, face and even the penis (caused by infection from the hand during urination). It is important to observe good personal hygiene and to wear gloves when treating infected animals. The papule may persist for 7 to 10 weeks and spontaneously resolves. It is an uncommon condition and may be difficult to diagnose. There have been no reported cases of human to human contraction.
CASE 2
A 35-year old man was spending the weekend at a beach in Long Island. He had a big dinner that included raw clams. Shortly after arriving home, he had a bad case of diarrhea and a high fever. The man blamed the meal and he was right.
The man had a case of Vibrios, which typically cause disease in people who eat contaminated seafood.
V. parahaemolyticus typically causes non-bloody diarrhea.
In persons with liver disease, cancer, or another immune-compromising condition, V. vulnificus typically infects the bloodstream, causing a life-threatening illness. About half of V. vulnificus bloodstream infections are fatal, and death can occur within two days. In addition to transmission by raw shellfish, V. vulnificus can enter the body via a wound that is exposed to warm sea water.
CASE 1
A 50-year old male doctor was on vacation. He was in a grassy area and then on a boat in Long Island. He developed a loss of memory and could not read. The doctor eventually lost his surgical skills.
The diagnosis was Babesiosis, which is caused by microscopic parasites that infect red blood cells and are spread by certain ticks. In the United States, tickborne transmission is most common in particular regions and seasons: it mainly occurs in parts of the Northeast and upper Midwest and usually peaks during the warm months.
Although many people who are infected with Babesia do not have symptoms, for those who do effective treatment is available. Babesiosis is preventable, if simple steps are taken to reduce exposure to ticks.
Babesia microti is transmitted by the bite of infected Ixodes scapularis ticks—typically, by the nymph stage of the tick, which is about the size of a poppy seed. An Ixodes scapularis nymph is shown on the face of a penny. (Credit: Graham Hickling, University of Tennessee)
