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VULVO-VAGINAL DIPHTHERIA.
By W. A. Brown, M.D., D.P.H., Senior Assistant Medical Officer, Brook Hospital;
and
J. E. McCartney, M.D., Ch.B., D.Sc., Director of Research and Pathological
Services.
Diphtheritic infection of the genital organs in the female has been recorded at
irregular intervals in the medical literature for the past 40 years. In a search
covering a period of 30 years up to 1923, van Saun1 was able to find reports of 26
cases. The value of a considerable number of these was diminished by the fact
that, in many instances, no bacteriological confirmation was produced, and in
others the morphological diphtheria bacilli found were not subjected to virulence
tests. Of the 26 cases collected, positive cultures were obtained in 15, virulence
tests performed in 6 and 4 deaths occurred. In most of the cases the local lesion was
preceded by nasal or faucial infection, but in 6 instances a primary genital origin
was suggested. It is stated in the Medical Research Council's monograph2 on
diphtheria, in referring to infection of the genitals, that " no instance in the literature
has come to our notice in which the identity of the bacillus has been completely
established."
Since 1923 Unseld3, Smordinzeff4, Grant5, Wallfield and Litvak6, and other
writers have recorded cases. Ker7 mentions a case of primary vulval diphtheritic
infection in a woman during the puerperium.
The following clinical notes and post-mortem findings refer to a case admitted
to the Brook hospital:—
M. E. W., aged 10 years.
History.—18th November: Abdominal pain. 20th November: Redness and swelling of vulva.
Pain on micturition. 21stNovember: Vaginal discharge. 22nd November: Vulvar inflammation
and swelling increased. Ulceration of skin behind anus. Pain on micturition and defœcation.
23rd November: Condition became slowly worse during the following week. 1st December:
Admitted to a general hospital. 4th December: Cultures showed the presence of diphtheria
bacilli and patient was transferred to the Brook hospital.
On admission—Extensive oedema, inflammation and superficial ulceration of the whole
vulva, extending upwards to pubic area. The affected area was covered with a patchy purulent
deposit which in parts showed evidence of thin membrane formation. Ulcers, about the size of
a florin, were present on the gluteal region, intergluteal sulcus and immediately behind the anus.
There was a profuse, thin, purulent vaginal discharge. The inguinal area showed purplish
discolouration with adenitis and periadenitis. Examination of the labia minora and vaginal
orifice was impossible owing to marked pain and tenderness. General condition of patient
satisfactory. No evidence of diphtheritic toxœmia. Temperature 100.4° F., falling to normal
in 24 hours. Pulse rate 100-110.
Bacteriological examination showed:—Nose, non-virulent diphtheria bacilli present;
throat, no diphtheria bacilli found; vulva, virulent diphtheria bacilli present; vulval smear,
no gonococci seen.
7th December.—Local condition somewhat improved—vulva much cleaner. Patient's general
condition good—appetite normal—-sleeping well.
8th December.—Sudden collapse and death in a few seconds without warning.
Treatment.—24,000 units of. diphtheria antitoxin intramuscularly on admission, repeated
in 24 hours. Locally—-Irrigation with sod. bicarb, solution and boric fomentations four hourly.
Post-mortem
examination.
The post-mortem findings were as follows:—
External.—On separating the labia the whole of the vulva and labia minora were found to
be extremely congested and covered with definite yellowish fibrinous membrane. The
inflammatory condition had spread upwards into the vagina.
The heart showed evidence of right-sided failure. The right auricle was markedly dilated,
filled with blood and dark purple in colour. The right ventricle was also distended with blood
in contrast to the left ventricle which was in systole. The superior and inferior vense cavse were
distended with blood, and the other mediastinal veins were prominent. The heart muscle was
pale in colour. Extensive ante-mortem clot was present in the right auricle and ventricle. There
was also a small amount of ante-mortem clot in the left side. The valves were normal and
there was no evidence of congenital abnormalities.
Trachea and bronchi.—Congested.
The lungs were voluminous, dark in colour but not consolidated. On section there was
considerable congestion and oedema, but no evidence of disease.
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