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PURPURA HEMORRHAGICA AND SCARLET FEVER.
By W. A. Brown, M.D., D.P.H., Senior Assistant Medical Officer, Brook Hospital;
and
G. E. Breen, M.D., D.O.M.S., Senior Assistant Medical Officer, Northern Hospital.
The occurrence of purpura hsemorrhagica in the course of scarlet fever has
been recognised for some considerable time, and many cases have been reported in
the literature. The time of onset is usually the third, sometimes the fourth, week
of the disease, and is not associated as a rule with a severe attack of scarlet fever.
Frequently the purpura supervenes without premonitory symptoms, but in some
cases it is preceded bv cervical adenitis, albuminuria and some constitutional disturbance.
Bleeding from mucous surfaces, especially epistaxis, is fairly frequent.
In a few instances Henoch's purpura is simulated and colic, associated with gastrointestinal
disturbance, is present.
The etiology is still a matter of dispute. It appears fairly settled that the
toxin of the scarlet fever streptococcus has a selective action on the capillaries, as
evidenced by the rash and the staining which often persists in the flexures after the
rash has disappeared. It is said that as a result of an .attack of scarlet fever a state
of anaphylaxis to this toxin develops. Any fresh introduction of toxin, whether by
a secondary infection or by lysis of organisms still in the body (i.e., an endotoxin),
may precipitate a reaction. When the capillary wall is damaged, platelets are
called upon to provide thrombokinase and to line the gap, and the issue will depend
on the severity of the lesion and on the capacity of the marrow to provide a sufficiency
of platelets rapidly enough to cope with the situation.
Whether this view be correct or not, the blood picture very often shows a large
reduction in the platelet count. There is usually also a secondary anaemia with a
leucocytosis, mainly polymorphonuclear. Although the case here reported cannot
be stated definitely to have been scarlet fever, the history is suggestive of a mild
attack of that disease.
K. W., male, aged 7 years and 7 months.
History : About one month before the onset of purpura he had a slight rash on the legs
but no constitutional disturbance. He was kept in bed for ten days and was apparently quite
well and healthy until 22nd October, when he developed a left cervical adenitis, headache, pains
in the limbs and slight pyrexia. On examination he was found to have a suspicion of desquamation
on the feet and was removed to hospital certified to be suffering from scarlet fever.
On admission, 23.10.34: Heart, lungs and fauces normal. Abdomen retracted. Spleen
not palpable. Dry condition of skin of abdomen (not consistent with history of scarlet fever).
Ecchymoses right leg and both feet. Annular haemorrhagic bulla? on first three toes left foottense,
tender, superficial. Complained of abdominal pain. Urinary examination disclosed a
marked degree of hematuria. Irritable. Mentally unstable. Temperature normal.
24.10.34.—Bullae on feet and toes more extensive. Fresh purpuric areas on calf and back.
Haemorrhage into right upper eyelid. Marked dysuria with almost pure blood on micturition.
No fever.
25.10.34.—Some improvement in general condition. Bright erythematous area around
calf. Urine much clearer. Existing ecchymoses unchanged, no fresh haemorrhage. No fever.
26.10.34.-—Much improved. No ha>maturia. No further haemorrhages, but patches of
erythema around existing purpuric areas.
8.30 p.m.—Condition much worse. Increased htemorrhages, buttocks, left side neck.
Bullae on toes ruptured. Haematuria again marked. No fever.
27.10.34.—General condition unchanged. Colour waxy, lips cyanosed, pulse imperceptible.
Abdominal pain and tenderness, no swellings or subcutaneous hemorrhages visible. Purpuric
areas extended downwards over thighs and upwards over sacral region. 10.13 a.m. Death.
Treatment consisted of daily injections of haemoplastin (2 cc.) intramuscularly and
administration of liquid liver extract (= 1 lb. fresh liver in twenty-four hours).
Examination of the blood on 26.10.34 showed: Haemoglobin, 62 per cent.; red cells,
3,800,000 per c.mm. ; colour index, -8 ; white cells, 8,760 per c.mm.
Differential white cell count: Polymorphonuclears, 41.5 per cent.; small lymphocytes,
35.0 per cent.; large lymphocytes, 8.0 per cent.; large hyalines, 13.5 per cent; eosinophils,
1.5 per cent. ; basophils, 0.5 per cent. ; platelets, 5,600 per c.mm.
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