9/24/2019
Historical Dermatology & Vaccines
GREG SIMPSON MD
Disclosures
I do not have any relevant financial endorsements to disclose.
I will be talking about the off label use of many medications
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Outline
History of select Infectious disease
Infectious Disease and Vaccines
Why the caduceus?
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Case 1- 42 y.o. African male
Dracunculiasis
Guinea Worm
Cyclops water flea in drinking water (carry the larvae)
1980’s- 3.5 million cases, 2018- 28 As of February 2019, only 7 countries remaining to be certified Guinea worm free: Angola, Chad, Democratic Republic of the Congo, Ethiopia, Mali, South Sudan, and Sudan
Metronidazole or thiabendazole and stick
Clean water sources, Larvicide (ABATE) or filters
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CDC eradication program
ERADICATED 1. Small Pox 2. Rinderpest
GLOBAL ERADICATION UNDERWAY 1. Polio 2. Dracunculiasis 3. Yaws 4. Malaria
REGIONAL ELIMINATION ESTABLISHED OR UNDERWAY 1. Hookworm 2. Lymphatic filariasis 3. Measles 4. Rubella 5. Onchocerciasis 6. Bovine spongiform encephalopathy (CJD) 7. Syphilis 8. Rabies
Medical Significance?
Asklepios- Greek God of medicine (1200 BC)
Hippocrates 20th generation “follower”
Today’s medical significance?
Caduceus- Hermes (Greek) staff
1902- US Army and pharmacies used it as a “stamp” on medical supplies
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The Black Death is estimated to have killed 30% to 60% of Europe’s population. In total, the plague may have reduced the world population from an estimated 450 million to 350–375 million in the 14th century. It took 200 years for the world population to recover to its previous level.
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Plague
Yersinia Pestis
Black Death-14th Century
1900-1904- Chinatown in SF
Typically the disease moves back and forth between fleas and their rodent hosts
Yosemite-2015 two cases
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37 yo AAF
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Syphilis (Treponema Pallidum)
Transmission by contact with lesion of primary or secondary stage, or transplacental (secondary is most contagious)
Primary Syphilis
Chancre: painless ulcer, raised indurated borders
Secondary Syphilis
Flu-like syndrome, generalized LAD, HSM
Cutaneous lesions in 80%, bilateral, symmetric macules, papules, pustules
palms/soles, condyloma lata, “moth-eaten” alopecia
Syphilis
Latent: positive serology, o/w asymptomatic
Tertiary Syphilis
Generally 3-5 yrs. after infection (early as 6 mos)
Nodular, Ulcerative mucocutaneous lesions
Bone involvement
Cardiovascular: AI, CVA, aortic mycotic aneurysm
Neurologic: meningitis, CN d/o, ICP, Charcot’s dz (arthropathy secondary to tabes dorsalis)
Famous People who may have died from syphilis?
Hitler, Al Capone, Vladimir Lenin, Oscar Wilde
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Epidemiological Trends in Syphilis, 19 Fresno County
Figure 2a (LEFT) Early Figure 2b (RIGHT) Early Syphilis*Incidence Rates for Syphilis*Incidence Rates for Females by Age Group (in Males by Age Group (in years) Fresno County, 2006– years) Fresno County, 2006– 2015 2015
Ironically, the most productive strain came from a moldy cantaloupe from a Peoria fruit market. A more productive mutant of the so-called cantaloupe strain was produced with the use of X-rays at the Carnegie Institution.
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Tuskegee Experiment
Tuskegee Alabama 1932-1972 400 AA men, “Bad Blood” Tx- Bismuth, mercurials, Salvarsan (didn’t work) 1940’s penicillin- withheld from these men 1972 130 died of syphilis or complications 40 wives contracted it 19 children with congenital syphilis
Tuskegee
“ Longest non-therapeutic experiment on human beings in medical history”
1974- National Research Act
Founded the Institutional Review Boards
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Small Pox
Small Pox
Variola major, Variola minor Inoculation in China-10th century widely practiced by the 16th century, Ming dynasty In 1796, Edward Jenner- cowpox 1802 Vaccine- Latin for cow (vacca) Killed up to 300 million people in the 20th century 1967, 15 million cases occurred a year 1977- Last naturally occurring case (Somalia) 1980- WHO declared eradication By 1986, routine vaccination stopped
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Aral small pox incident
Vozrozhdeniya Island
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Measles-First Disease (aka Rubeola)
Paramyxovirus- ss rna
Spread via respiratory droplets
cough, coryza, conjunctivitis
Complications: superinfection, pneumonia, SSPE
Tx: supportive, Vit A?
pre-1963-US-500,000 cases
2001-world-30 million illnesses and 770,000 deaths
2018- 477,000 cases, 2019(through July)- 487,000
2019 (in US)- 1,234 reported this year- most in 25 years
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Forschheimer’s spots
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Third disease rubella
Togaviridae- ssRNA virus 50% asymptomatic, “rose-pink” macules and papules 1964- US- 12.5 million cases 11,000 miscarriages 20,000 cases of CRS Congenital Rubella syndrome- cardiac, cerebral, ophthalmic and auditory defects. Premie, LBW 2,100 died, 12,000- deaf, 3,600-blind, 1,800-MR. 1969 live vaccine, early 1970s,(MMR) First Trimester!!!
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Dewdrop on a Rose Petal Vesicle becomes cloudy & umbilicated with irregular borders.
Crust forms in center & eventually replaces the remaining portion of the vesicle at the periphery.
“Chicken Pox” Varicella Zoster Virus
Human Herpes Virus 3
Transmission via respiratory droplets (very contagious, from 5 days before onset of symptoms until ALL lesions are dry/crusted)
Successive crops of macules, papules vesicles, pustules, crusting (“dewdrop on a rose petal”)
Facescalptrunk, resolves in 1-3 weeks
1995- vaccine approved (developed 80’s)
Complications (adults): pneumonitis, meningitis, encephalitis, Reye’s syndrome…
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“Shingles” Varicella Zoster Virus
Human Herpes Virus 3
VZV infection of the ganglion, partial immunity?
Groups of vesicles along sensory nerve in dermatomes
Complications: post herpetic neuralgia, facial paralysis, auditory symptoms
Tx: high dose IV acyclovir in immunocompromised hosts
2006- >60 y.o.- Zostavax 2017- >50 y.o.- Shingrix
Herpevac-2002-2010 (Herpes simplex virus 2- didn’t work), Herpes Vaccine-2019- promising
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Anthrax
Bacillus anthracis (GP spore-forming rod)
Derivation of name Anthrax? Greek word- Anthracite (coal)- black skin lesions
Inhalational, GI, Cutaneous
Louis Pasteur in 1881 ( went on to develop vaccines for small pox, cholera and swine erysipelas)
September 18, 2001, Letters containing anthrax spores were mailed to several news media offices and two Democratic US senators killing five people and infecting 17 others.
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Conclusions
Caduceus- Dracunculiasis Plague Syphilis Small pox Measles Rubella Chicken pox/ Shingles Anthrax
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THANK YOU FOR COMING!
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