The 6th Historical Clinicopathological Conference


Clinicopathological Conference
Dr. Faith Fitzgerald

A 35 year old man presented with fever, rash and anasarca. His illness began suddenly in late November during the course of a local epidemic of a similar disease. Although he had a long history of varied medical complaints, the patient had been feeling well during the year prior to his present illness, which began acutely with high fever, headache, and diaphoresis. These symptoms were accompanied by swelling of the hands and feet, which over the course of a few days progressed to anasarca so severe that the patient had difficulty turning in bed. By the second week of illness, he complained of foul taste and generalized aching and was having recurrent episodes of projectile vomiting and diarrhea. He was so swollen and weak by this time, that he was able to sit up in bed only with assistance and yet his mental faculties remained intact.

The patient had had numerous illnesses during his life. As an infant, he likely suffered from malnutrition in that his principal source of nourishment at that time was a mixture of honey-water and barley gruel. At age six, he had a 4-week illness diagnosed as erythema nodosum. At 7 and 10 years of age, he had episodes of fever and polyarthritis which are believed to have been attacks of acute rheumatic fever. When he was 9, he and his sister developed a febrile illness accompanied by delirium and wasting, which was most likely either typhus or typhoid fever. He had a history of recurrent pharyngitis, the first episode of which occurred at age 8 and may have been complicated by a peritonsillar abscess. He contracted smallpox at age 11 and at age 16 developed jaundice of undetermined etiology. He then enjoyed reasonable good health until age 26, when he had an episode of profuse diaphoresis, severe colic and vomiting. Because other persons in his city were similarly affected, this illness is presumed to have been some form of infectious gastroenteritis. In his thirties, he suffered with intermittent headaches, tonsillitis, arthralgias, stomach cramps, and toothaches. These were particularly troublesome during his 34th year, and may have been magnified by anxiety related to persistent financial difficulties and his wife’s ill health (due to recurrent inflammation of varicose veins). He sought relief from these symptoms through the use of various unspecified medications. During the year prior to the present illness, these complaints appear to have abated.

The patient was one of seven children, only two of whom had survived beyond infancy. His sister, nearly 5 years his senior, was alive and well. When the patient was 22, his 57 year old mother died of an acute febrile illness thought to have been typhoid fever or, perhaps, tuberculosis. His father, who had long suffered with rheumatism, died several years prior to the patient’s current illness of presumed coronary artery disease.

The patient was a celebrated musician and a composer. He was married and had two healthy sons. He drank wine and beer in moderation and did not smoke. He had traveled extensively in western Europe. He had a pet canary and dog. The canary had recently been removed from the patient’s room, because its song in which he had previously delighted, he now found irritating.

The patient was lying in bed dressed in an open-back gown made especially for him to facilitate dressing. He was alert and oriented but appeared acutely ill. He was febrile to the touch and perspiring profusely. His left ear was flat with a poorly developed antihelical curve (His younger son shared the same malformation). Gross anasarca was present as well as a diffuse macular rash over the chest and abdomen.

The patient’s clinical course was dominated by persistent fever, diaphoresis and increasing anasarca. On the 14th day of illness, his condition deteriorated sharply, with the first signs of delirium. Venisection was performed, followed by cold compresses to his head. Coma ensued and the patient died in the early morning of the 15th day of illness. No autopsy was performed.