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Studies on Primary Atypical Pneumonia. I. Clinical Features and Results of Laboratory Investigations

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Studies on Primary Atypical Pneumonia. I. Clinical Features and Results of Laboratory Investigations STUDIES ON PRIMARY ATYPICAL PNEUMONIA. I. CLINICAL FEATURES AND RESULTS OF LABORATORY INVESTIGATIONS Edward C. Curnen, … , Lewis Thomas, Frank L. Horsfall Jr. J Clin Invest. 1945;24(2):209-226. https://doi.org/10.1172/JCI101598. Research Article Find the latest version: https://jci.me/101598/pdf STUDIES ON PRIMARY ATYPICAL PNEUMONIA. I. CLINICAL FEATURES AND RESULTS OF LABORATORY INVESTIGATIONS1 2 By EDWARD C. CURNEN,3 GEORGE S. MIRICK,3 JAMES E. ZIEGLER, JR.4 LEWIS THOMAS,' AND FRANK L. HORSFALL, JR.' (From the United States Navy Research Unit at the Hospita of The RockefeUer Institute for Medical Research, New York City) (Received for publication August 14, 1944) "Primary atypical pneumonia, etiology un- forces, however, it has appeared to be more pre- known" (1) is one of many terms used to desig- valent than the pneumococcal pneumonias and nate an acute respiratory infection which has the total number of man days lost as a result has been widely prevalent in recent years. The ill- been considerable. ness is characteristically gradual in onset, with The term "primary atypical pneumonia" has constitutional as well as respiratory symptoms, been useful in distinguishing the syndrome under and pulmonary changes more manifest in roent- discussion from clinically similar illnesses due to genograms than by physical examination. The known infectious agents (10) such as Rickettsia course of illness varies considerably in duration diaporica (11) and members of the psittacosis and severity. Complications are uncommon and group of viruses (12, 13). although convalescence is frequently protracted Although primary atypical pneumonia has the illness almost invariably terminates with been frequently referred to as "virus pneumonia" complete recovery. Therapy with sulfonamide and most investigators have considered it to be drugs is not effective. of non-bacterial origin, the causative agent, or Contemporary interest in this form of pneu- agents, in the majority of cases has remained monia was aroused by several fairly recent re- obscure. The recovery of a number of different ports (2 to 4), although one author (5) had ob- viruses (14 to 18) from certain patients with served patients with a similar illness several primary atypical pneumonia has been reported years earlier. Numerous other descriptions and but the importance of any of these agents in the investigations of primary atypical pneumonia pathogenesis of the disease has not been es- have since been published, and have been re- tablished. viewed recently (6 to 9). In some of these re- An investigation of primary atypical pneu- ports, unusual outbreaks of acute respiratory monia has been carried out continuously at the illnesses described during the past century were Hospital of The Rockefeller Institute since cited to show that primary atypical pneumonia is February, 1942. Because of circumstances which probably not a new disease. Nevertheless, it is afforded extensive clinical as well as laboratory apparent from these reports that, in recent years, facilities, it was possible while investigating the the incidence of the disease has actually in- pathogenesis of primary atypical pneumonia to creased. The rate of its occurrence in the civil- conduct also an appraisal of its clinical aspects. ian population is not known. In the armed An effort was made to correlate these two lines of investigation and to study each patient in as I The Bureau of Medicine and Surgery does not neces- sarily undertake to endorse the views or opinions which comprehensive a manner as possible are expressed in this paper. Recently, a non-hemolytic streptococcus, iso- ' The work described in this paper was done under a lated from the lungs of 2 patients who died of contract, recommended by the Committee on Medical primary atypical pneumonia, was found to react Research, between the Office of Scientific Research and with sera obtained, during convalescence, from Development and The Rockefeller Institute for Medical not react Research. other patients with this illness but did 3Lieutenant Commander (MC), U.S.N.R. with sera obtained during the acute stage of the 4Lieutenant (MC), U.S.N.R. disease (19). For convenience in reference, this 209 210 CURNEN, MIRICK, ZIEGLER, JR., THOMAS, AND HORSFALL, JR. microorganism has been designated streptococ- laboratory evidence that the pneumonia was not cus MG. Because of the possibility that strep- due to pneumococcus or other microorganisms tococcus MG might have more than an inci- of recognized pathogenicity. dental association with primary atypical pneu- Ninety-five of the patients were male and 11 monia, the properties of this microorganism and were female. All patients were young adults. its relation to the disease were investigated. These patients came from widely separated The bacteriological and serological characteris- areas and had been exposed to multiple and tics of streptococcus MG are described in diverse sources of infection. Nevertheless, as separate communications (20, 21). The special a group, they exhibited a remarkable degree of techniques for isolating streptococcus MG from clinical homogeneity. the respiratory tract of human beings and an extension of the original observations concerning CLINICAL FEATURES the relation of this microorganism to primary The clinical features of primary atypical atypical pneumonia are described in the accom- pneumonia, as observed in these 106 patients, panying paper (22). were on the whole similar to those which have It is the purpose of the present paper to de- been described in other reports. The onset of scribe the clinical features of primary atypical illness was gradual in 73 per cent of the patients pneumonia as observed in patients studied in the and, in contrast to lobar pneumonia, was usually Hospital of The Rockefeller Institute, to present ill-defined. Constitutional symptoms generally the results of various investigations pertaining preceded those referable to the respiratory tract. to the disease, and to correlate some of these In many instances, the initial complaint, vari- findings with the studies concerning streptococ- ously described by the patient, suggested a cus MG which have been referred to above (20 combination of lassitude, weakness, and fatigue. to 22). From August 1, 1942, to March 2, 1944, 180 TABLE I patients were admitted to this hospital with Symptoms in 106 patients with primary atypical pneumonia acute respiratory infections suspected to be Patients Symptoms Number Per cent primary atypical pneumonia. In each case, a General Headache 69 65 careful and detailed record was made of the Malaise 65 61 Chills or chilliness 63 59 clinical features. Roentgenograms of the chest Generalized aches 30 28 were made at frequent intervals and numerous Anorexia 37 35 Nausea 30 28 clinical laboratory studies were carried out. In Vomiting 25 24 addition, samples of serum were obtained re- Respiratory Cough 104 98 peatedly throughout the illness and were stored Sputum 87 82 at 40 C. for use in serological tests. Specimens Bloody sputum 27 25 Sore throat 32 30 of plasma, sputum, and nasopharyngeal wash- Chest pain ings, as well as specimens of pleural or cerebro- Substernal 25 24 Lateral 16 15 spinal fluid, were examined immediately after Epistaxis 16 15 they were obtained and portions of each speci- Dyspnoea 5 5 men were preserved at - 700 C. for use in subse- quent investigations. In Table I, the commoner symptoms have been From the completed records of these 180 pa- listed, together with the frequency of their oc- tients, 106 were selected on the basis of clinical currence. Chills, fever, headache, and cough and laboratory criteria as representative ex- developed early and occurred frequently. Shak- amples of primary atypical pneumonia. The ing chills were rare but sensations of chilliness, criteria used for selection permitted the inclusion sometimes recurring, were experienced by 59 of only those patients who showed each of the per cent of the patients. Headache, usually following findings: (1) acute febrile respiratory generalized but sometimes predominantly fron- disease; (2) pulmonary consolidation demon- tal, occasionally associated with photophobia, strable by x-ray; and (3) adequate clinical and and ranging from mild to extremely severe, oc- ATYPICAL PNEUMONIA, CLINICAL AND LABORATORY STUDIES 211 curred in 65 per cent of the patients. Aching TABLE II of the trunk and extremities was present in only Abnormal physical signs in 106 pients with one-fourth of the patients and as a rule was mild. primary atypic pneumonsa Patients About a third of the patients exhibited an ap- Physical signs NiNumber Per cent preciable degree of anorexia and nausea. Vomit- Fever 101 95 ing occurred at some stage of illness in one- Nasal congestion 60 57 Pharyngitis 73 69 fourth of the patients but this symptom was Cervical adenopathy 25 24 never a conspicuous or severe manifestation of Pulmonary signs 104 99 Dulness 57 54 the disease. Altered breath sounds 74 70 Cough, one of the most constant and charac- Rftles 99 93 Friction rub 7 7 teristic features of primary atypical pneumonia, Fluid 1 1 was present in all but 2 of the 106 patients. In Bradycardia 72 68 Tachycardia 8 8 some instances, this was the first symptom to Tachypnoea 14 13 appear; in others, it developed gradually after a Cyanosis 12 11 Signs referable to the central nervous 6 6 lapse of several days. Frequently, it becamne system paroxysmal and exhausting. Coughing, al- Palpable spleen 1 1 though dry at first, was ultimately productive of sputum in 82 per cent of the patients. The cant tachycardia was infrequent and, when sputum of one-fourth of the patients contained present, usually developed during convalescence. blood, usually, however, only as streaks or Nasal congestion and mild pharyngitis were traces. Grossly bloody or "rusty" sputum was noted respectively in 57 and 69 per cent of the uncommon. Sore throat when present was patients. Cervical lymph nodes were enlarged rarely severe, and, in many instances, appeared in one-fourth of the patients, but usually were not to result from the irritation of coughing.
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