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Unusual Fatal Hæmorrhage Complicating Enteric Fever

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Unusual Fatal Hæmorrhage Complicating Enteric Fever Nov., 1947] UNUSUAL FATAL HAEMORRHAGE: CHHETRI & DE 663 the UNU3UAL FATAL HEMORRHAGE 3 cases, fever was coming down by lysis when and COMPLICATING ENTERIC FEVER vomiting began the temperature maintained normal till death occurred. In one By M. K. CHHETRI, m.b. (Cal.) case, the temperature was subnormal. There was one where Medical Registrar, Medical College Hospital only example the complication started when the and temperature remained high (103?F.). Signs and symptoms of intestinal M. N. M.R.C.P. f.n.i. DE, m.b., (Lond.), f.s.m.p., hsemorrhage with passage of-tarry stools occurred Professor of Medicine, Medical College Hospitals, in 2 cases just previous to the onset of the Calcutta hsematemesis. Three cases had melsena after the Enteric fever is remarkable for the large hsematemesis. In the remaining 5 cases, from the stomach was not associated number of complications which may occur hsemorrhage with visible from other of during its course. Most of them are very well hsemorrhage any part tract. known to the medical profession with their the gastro-intestinal Purpuric spots on forearms in one case pathogenesis ard prognostic significance. In appeared the hands and 2 where the vomited material this paper the waiters intend to discuss a very only. Except cases, was altered blood serious complication which they have met with consisted of frank blood, there matter looked like in the rout:,ie management of their enteric in all the rest and the vomited cases. The literature on the subject is extremely coffee-ground material. In 6 cases, jaundice meagre and their clinical description is hardly developed, preceding or following the hsemate- a or two. found in any textbook. The pathogenesis of mesis by day cases. Blood the condition is a matter of speculation but the Widal reaction was positive in 5 was successful in 3 cases while in prognostic import is very definitely bad. culture 2, It is for these reasons that the subject is brought neither was positive. These latter cases were, forward to elicit opinion and stimulate scientific however, clinically typical enteric fever. Bleed- interest. ing time and coagulation time determined in 3 Clinical features of these cases are as cases after the onset of the vomiting showed follows : A case of long-continued fever normal values. Platelet count was normal. proved bacteriologically and serologically to be Prothrombin time was determined in 3 selected due to one of the enteric group of infections cases in which both the bleeding and coagula- runs were The were its entire course without any incident tion times normal. figures during the first 2 or 3 weeks. Towards the end definitely prolonged in all the 3 cases. of the course of the fever or in some cases even All the 10 cases proved fatal. The average when the temperature has subsided and the period of survival after the onset of this com- patient is in the stage of convalescence and for plication varied between a few hours and six all practical purposes considered fairly out of days. danger, he suddenly has a set-back due to an Case reports unusual complication, viz, vomiting. At first, the Case 1.?Indian Christian, married female of physician takes it to be due to some error in 22 years, admitted on 5th July, 1946, with a 2 diet producing perhaps a mild gastritis. This history of continuous fever for weeks, and had severe headache in the first week. Patient complacence is, however, soon changed into a serious matter when the patient begins to show looked wasted, ansemic and toxsemic. Tongue coated and presence of blood in the vomited matter?either dry. P/R?120/28. Temperature liver and not No frank blood or altered blood or more usually 102?F., spleen palpable. in the heart and Rose coffee-ground material. The quantity may be abnormality lungs. over the chest and abdomen. moderate or large and the number of vomits spots Laboratory : Hb. 32 per cent red cells may be as many as 10 to 12. There may be findings (Hellige), 1.95 millions. W.B.C. 7,200. 64 some mucus along with the blood. With this Polymorphs per 35 1 haematemesis, sconer or later, the patient begins cent, lymphocytes per cent, large monocytes no malarial Widal . per cent, TH> 1 in to pass blood per anum?usually melaena of parasites, urine and stool?no On large or small quantity. In a few cases, the 150, abnormality. 6th, fever to 97?F. and all the and melaena may precede the haematemesis. The dropped signs of Treated patient sooner or later develops some degree of symptoms collapse appeared. with blood transfusion and other jaundice, becomes rapidly anaemic, passes smaller promptly and smaller quantities of urine and finally dies. necessary supportive measures. Temperature rose and fluctuated between 101 ?F. and 103?F. In a group of 10 cases studied, this complica- General condition looked fair. On the tion appeared on an average between the 18th 10th, a and vomited once. and the 24th day of the illness. In 2 cases, patient passed tarry stool The vomited matter contained blood. From 12th however, it started as early as the 10th day, to the had two bouts of whereas in another 2 cases, it appeared as late 14th, patient coffee-ground vomit each remained normal as the 32nd and 52nd days respectively. The day. Temperature Patient temperature, to the onset of the all these days. developed slight jaundice. just previous to 32. time complication, showed interesting features. In P/R?120/30 Bleeding and coagula- tion time were 2 and 5 minutes 5 cases, it was normal for a variable period of respectively. time 44 seconds 1 to 8 days before the haematemesis started. In Prothrombin (normal control 22 664 THE INDIAN MEDICAL GAZETTE [Nov., 1947 seconds). The condition of the patient pro- test in the vomit positive. General condition gressively deteriorated and she died on 15th. No deteriorated. Temperature 98?F. P/R?110/26. autopsy was permitted. Some purpuric spots appeared on the hands and Case 2.?An unmarried Hindu male, aged 20 forearm. Platelet count 250,000 c.mm. Died on years, admitted on 1st July, 1946, with a history 10th July. of continuous fever for 3 weeks and severe head- Case 5.?An unmarried Hindu male, aged 23 ache in the first week. On examination, the years, was admitted on 25th July, 1946, for patient looked anaimic and toxemic. Tongue fever, headache, cough and vomiting of 4 days' coated and furred. Temperature 104?F. P/R? duration. On examination, patient was fairly 112/32. Spleen enlarged 2 fingers, liver not nourished. Tongue was coated in the centre and palpable. Heart?N.A.D. Scattered rhonchi in raw at the edges. Temperature 102?F. P/R? both lungs. Laboratory findings : W.B.C 4,500. 130/40, liver and spleen not palpable. Heart? Polymorphs 60 per cent, lymphocytes 38 per cent, N.A.D. Scattered rales in both lungs. Vomit large monocytes 1 per cent, eosinophils 1 per was bilious in character. Laboratory findings : no Widal cent, malarial parasites detected. Hb. 70 per cent (Hellige), red cells 4.5 millions, reaction and culture both negative. Urine and no malarial parasites. W.B.C. 7,500. Poly- came down stool?normal. On 7th, temperature morphs 65 per cent, lymphocytes 30 per cent, conditions did not to normal but other improve. monocytes 4 per cent and eosinophils 1 On 11th, jaundice appeared and the patient got per cent. Widal reaction was negative. Blood an attack of hsematemesis. Bleeding time and culture positive for B. typhosum. No abnor- coagulation time were within normal limits. mality in urine and stool. Vomiting persisted and Prothrombin time 38 seconds (control 25 on 30th July, 1946, contained streaks of blood. seconds). On 12th, patient got 3 attacks of Occult blood test in vomit was positive. Bleed- hajmatemesis and collapsed. Blood transfusion ing and coagulation times were 4 minutes and was given along with other supportive treatment 5 minutes respectively. Vitamin K was started. but his condition went downhill and he expired. On 4th August, the temperature dropped Case 3.?Indian Christian, married female, aged to 97?F., P/R?96/32. In spite of this, the 40 years, admitted on 12th July, 1946, with condition did not improve much and he now a history of continuous fever and headache for 9 complained of pain in the epigastric region. days and passing tarry stools for 2 days. Jaundice was noticed at this stage. Hemorrhagic On examination, patient restless, general fluid was withdrawn from the stomach by Ryle's condition very low. Extremities cold. P/R? tube after which the viscus was washed out 134/30, temperature 100?F. Tongue coated and with sodi bicarb solution in warm norma) saline. dry. Abdomen soft. Liver and spleen not Prothrombin time determined at this stage was palpable. No abnormal sounds in the lungs. 1 -minute 10 seconds (control 25 seconds). Heart sounds weak. Soon after admission, Vomiting of thick black fluid continued passed a stool with altered blood. Laboratory unabated and the patient died on 5th August. findings : Hb. 45 per cent, red cells 2.5 millions. Case 6.?An unmarried Anglo Indian male, W.B.C. 6,700. Polymorphs 68 per cent, lympho- aged 20 years, was admitted on 1st October, 1946, cytes 30 per cent, large monocytes 2 per cent. for continuous fever for 17 days. On examina- No malarial parasites found. Both Widal reac- tion, he was fairly nourished but toxemic. tion and blood culture negative. On 13th, tem- Tongue coated. Temperature 103?F. P/R? perature became subnormal.
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