PENICILLIN IN RHEUMATIC CHOREA

By K. N.^GOUR, m.d., m.r.c.p. (Edin.), f*rt.p.s. (Glas.), d.c.h., r.c.p.s. (Eng.), d.p.h. (Lko.)

*

Professor of Medicine, S. N. Medical College, Agra Chorea occurs as a cerebral manifestation of

rheumatism and is probably due to meningo- encephalitis, the brunt being borne by the cortex, basal ganglia and i the cerebellum. There is congestion of the meninges and lymphocytic infiltration in the brain substance especially round the vessels and in the basal ganglia. There is also some degeneration of the ganglion cells. The pathological changes are temporary and usually clear up. No permanent nervous change ever occurs and so all the symptoms completely disappear leaving no legacies as sequelae. But the life of a choreic patient is a miserable

one?who cannot remain restful even for a moment on account of the aimless, irregular, involuntary, spasmodic movements and jerkiness of the voluntary movements of the limbs, face and trunk, and emotional disturbances ; who cannot eat satisfactorily nor sleep soundly.

There is a definite relation to the rheumatic infection. Streptococcus hccmolyticus is believed to be the serological agent but certainly it is not due to direct bacterial attack, rather it is a toxic encephalopathy.

1 The presence of an

allergic hypersensitiveness to streptococci, in addition to streptococcal toxin in the circulation, may play a part in cerebral rheumatism as well as in rheumatic manifestations in other parts of the body \

16 THE INDIAN MEDICAL GAZETTE [Jan., 1951

The treatment of the malady has been practically unsatisfactory, no drug seemed so far to shorten the duration of the disease. It

always took its own course and recovery gradually resulted.

It will be of interest to note the amazing recovery of a patient from the choreic movements and also the joint pains by the use of penicillin and for this reason the following case is reported :

Case report

B., a Hindu female aged 20 years, was admitted in the Sarojini Naidu Hospital, Agra, on 15th November, 1950, with a history of choreiform movements for about a month and

pain in the joints. She had suffered from acute attack of coryza and fever a month before.

All the joints had become painful and swollen. The pain had persisted and about 2 weeks after she began to get some mental con- fusion. A few days had passed, the joints had become less painful, but she had started having awkward and continuous movements of the body, face, trunk, upper and lower extremities. The movements had increased on watching. Her life had becomg^miserable as she could not take any food nor sleep soundly. On clinical examination.?She was fairly

nourished. Pulse 106 per minute, regular, tension and volume normal. Blood pressure 126/72 mm. Apex beat?situated in the 5th left intercostal space 4 inches to the left of the midsternal line. On auscultation in the mitral *

area first sound was replaced by a soft systolic murmur which was conducted towards the left axilla. In the pulmonary area there was a soft systolic murmur with the accentuation of the second sound.

Nervous system.?Intelligence and memory normal. She answered all questions satis- factorily. Co-ordination could not be elicited on account of the violent choreiform movements. Some cranial nerves could not be properly tested for the same reason. Sensation was normal. Reflexes were brisk. No abnormality could be detected in the respiratory >and gastro-intestinal systems. The joints?elbow and knee joints? were painful and swollen. Other joints were painful to be moved. On the day following the admission (16th

November) the choreiform movements increased probably due to the other patients in the ward observing and some remarking that she was a lunatic. She began to complain of severe pain in the joints. She appeared to be ill, ceaselessly moving her painful joints and at times cried with pain. She passed two sleepless nights and could not take any food.

On the 4th day of admission (18th November) it was thought that if the choreiform move- ments resulted from encephalitis it was worth while trying penicillin therapy. She was, there- fore, put on 50,000 units penicillin 4 hourly.

Next day (19th November) she was somewhat better, temperature came down though chorei- form movements persisted and joints were still painful. Two days after penicillin therapy had been started (20th November) she was in a very good condition. The choreiform movements had practically disappeared. The joints were less painful. She took her food well and slept soundly. Laboratory investigations.?Total W.B.C.

count (17th November, 1950) 13,000 per c.mm., polymorphs 84 per cent, lymphocytes 16 per cent, blood culture (18th November, 1950) sterile.

Three weeks after admission (7th December) the patient was all right with no complaints whatsoever. There was no relapse.

Conclusions

1. The wonderful effect of penicillin therapy in chorea was observed in this case. Its use will go a long way in relieving such a troublesome misery of the sufferer.

2. The association of joint involvement and chorea is seen in this case. Though joint pains may precede or follow the choreic movements, they are usually not found together and this is very fortunate for the patients, as one can easily imagine how exhausting the pain may be when these patients are ceaselessly moving the painful joints.

3. The choreiform movements occurring along with the joint pains supports the view that this disease has got the same ^etiological agent, Streptococcus hamolyticus, which is responsible for both the affections.

4. The confusion of thought which the patient suffered from at the onset of the choreiform movements was due to the ence-

phalitis which had been caused.

5. When chorea is treated with nirvanol there may be some aggravation of symptoms at any stage and sometimes mental confusion has followed its use. Penicillin therapy has not got these untoward effects.

6. No record is as yet available where chorea has been treated with penicillin.

7. Penicillin can be regarded as an antirheu- matic drug as it modifies the course of the rheumatic manifestations.

I am grateful to Dr. H. N. Bhatt, m.b., f.r.cs. (Edin.), D.M.R.E. (Lond.), Superintendent of the hos- pital, for allowing me to send this case report for publication.

BIBLIOGRAPHY

Pearson, W. J., and Recent Advances in Diseases Wyllie, W. G. (1935). of Children. J. and A

Churchill, Ltd., London.

Sheldon, W. (1946) .. Diseases of Infancy and Child- hood. J. and A. Churchill, Ltd., London.