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DISORDERS OF CARDIAC RHYTHM IN SCARLET FEVER.
By J. T. Wybourn, M.B., B.S., D.P.H., Assistant Medical Officer,
South-Eastem Hospital.
Introduction.
Cardiac arrhythmias of all varieties are not infrequently met with in the severer
forms of diphtheria, but are rarely encountered in the other common infectious
diseases.
A number of examples have, however, been reported in acute rheumatism,
influenza and the several forms of pneumonia.
Scarlet fever.
From the fact that such terms as "Scharlach-herz" figure prominently in continental
literature, one might suppose that cardiac affections are among the common
complications of scarlet fever; but, in actual point of fact, the role of scarlet fever
in the production of cardiac damage is a comparatively minor one. Less than 1 per
cent, of all cases of heart disease are caused by scarlet fever, and of this 1 per cent,
half are preceded by an arthritis.
The chief interest of the cardiac complications of scarlatina lies in their possible
relationship to rheumatism. The heart may become affected in any of the following
ways: (i) long continued fever; (ii) direct action of toxin; (iii) in association
with nephritis, rheumatism or pyaemia.
The characteristic and common lesion produced is a benign endocarditis or
myocarditis.
Joe, in an analysis of 24,000 cases, reported 61 cases (.25 per cent.) with cardiac
lesions, while Zischinsky found only 10 cases (.05 per cent.) with heart complications
in his series of 20,000 cases.
As many of these figures were derived from the clinical records of hospital cases,
and uniformity in the methods of examination and in the criteria of what constituted
a cardiac affection was not possible, statistical variations were inevitable.
Schamberg and Kolmer discovered only two examples of endocarditis in
2,213 cases.
In his investigation of 670 cases, Jamieson found 20 instances of cardiac involvement;
but, in Rosenbaum's series of 1,770 cases, this complication occurred 106
times, 88 of them being cases of myocarditis and 4 of them cases of endocarditis.
The above writers mention only one example of cardiac arrhythmia—a case of
incomplete heart block.
In his thesis on cardiac arrhythmias in the infectious diseases, Tournafond
describes a number of illustrative cases, but none of them was scarlatinal. Text
books mention toxaemia as a cause of arrhythmia, but even such authorities as
Mackenzie, Price and White make no reference to scarlet fever as a causal agent.
The condition would seem to be very rare in scarlet fever.
To obtain some information as to the relative frequency of arrhythmias, I
investigated the hearts of 2,300 cases diagnosed as scarlet fever at the South-Eastern
hospital from August, 1933, until the end of 1934.
Only four cases of arrhythmia could be discovered in the series. The following
are the clinical details:—
Case 1.—L. Charles M., aged 30. Admitted 30th November, 1934, at 4 p.m.
Previous history.—Measles, whooping-cough and chickenpox (in childhood). No previous
rheumatism, syphilis, tonsillitis or suspicion of heart disease.
Present illness.—Illness commenced with pains in lower limbs, headache and sore throat,
20th November, 10 days before admission. The sore throat persisted and three days before
admission he had a general bright rash.
On admission, 10th day.—-General condition : very ill, fading punctate erythema. Tongue
peeled, fauces markedly injected. Patient restless but rational. Heart: regular, rate 110-120,
A.B. V.N.L. 5th space; sounds soft, no murmurs. 40 c.c. anti-scarlet serum injected intramuscularly.
Ilth day.—Patient much more restless, violent and irrational. Pulse small volume; rate
rapid, rhythm completely irregular. Extremely ill. Heart: diffuse pulsation over whole
praecordium. A.B. diffuse, cardiac area enlarged, rhythm irregular, first sound at apex muffled,
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