A Mirror of Hospital Practice

CHLOROMYCETIN IN TYPHOID

By K. SjHOSSAIN, m.b. (Cal.)

Patuakhali P. 0., Barisal District (East Pakistan)

(Received on 20-6-50)

Chloromycetin is a newly discovered life-

saving antibiotic drug manufactured by Parke, Davis & Company of America. Towards the

beginning of the year 1948, reports of successful treatment of some of the most dreadful diseases, which had no chemotheraputic agents whatso- ever for cure, came out in the press. Towards the later part of the year 1949, the drug was available in small quantities in the markets of India but it could not be made available earlier than the beginning of the year 1950 in Pakistan.

The drug is a white crystalline fine powder, partially soluble in water, produced by the metabolic activity of Streptomyces venezuelce. It can also be produced synthetically. It is a

complex organic chemical known as chlor-

amphenicol having the formula of :

D_ (__) -threo-l-Jp-nitrophenyl-2- dichloroacetamido-1, 3-pro- panediol.

Administration in man is essentially per oral route. It is rapidly absorbed from the gastro-

intestinal tract, mainly small intestine, and reaches the height of serum concentration within two hours after which the blood level declines and is free of the drug at the end of 24 hours. In experimental animals the drug has also been detected in bile, cerebrospinal fluid, kidney, liver in high concentration and smaller amounts in lung, spleen, heart-muscle, and brain sub- stance. Bulk of the drug is excreted through the urine. Excretion is almost as rapid as

absorption and hence the advocacy of repeated doses at three- or four-hourly intervals.

It is claimed that all rickettsise, some gram- negative organisms like the salmonella group, some virus infections like those of the primary atypical pneumonia, psittacosis, pertussis, etc., and some bacilli, viz, V. comma, are susceptible to the new wonder 'drug.

I have given a trial recently to this drug. Though only a single case could be treated with the drug supplied, yet it is worth while to record the effects obtained by me.

Case note

M. Faruque, 13, Mohammedan, male, school boy, was admitted to the Begum Hospital on 6th April, 1950, at 7 p.m. with fever for six days and constant headache for 3 days. The temperature

98 THE INDIAN MEDICAL GAZETTE [March, 1951

was of a fluctuating type with gradual onset; the headache was of a dull aching type. He was living in unhygienic surroundings in a

village; had no history of contact or T.A.B. inoculation. He had suffered from malaria for a fortnight, about 4 or 5 years ago. This time

taking it to be an attack of the old type of fever he took a few paludrine tablets outside without any effect.

On examination the patient was found to be dull, indifferent and apathetic to the surround- ings. He liked to curl up in the bed and did not like being disturbed. Tongue was coated in the centre but the margins were angry look- ing and the tip showed some amount of fibrilla- tion. No icteric tinge; liver and spleen not

palpable; csecal gurgling present; no abnormality detected either in the heart or in the lungs; all other systems were normal including the nervous. T = 100.1 ?F.; P/R, = 70/20 per minute. Blood was taken for total and differential

counts, and parasites. The patient was put on an alkaline mixture containing pot. cit. gr. 10, liq. ammon. acet. dr. 1, syrupii dr. aquam ad oz. and a tablet of codopyrin, H.S.

Laboratory findings : (1) Blood.?Haemo-

globin, 80 per cent (Hellige), 11.00 gm. per 100 cc. Total W.B.C., 4,900 c.mm. (Neubauer ruling counting chamber), neutrophils, 54.4

per cent, lymphocytes, 43.2 per cent, large monocytes, 2.4 per cent, small monocytes, 0.0 per cent, eosinophils, 0.0 per cent, basophils, 0.0 per cent, abnormal cells, 0.0 per cent. Malarial parasites, none found.

(2) Urine.?Colour, pale yellow, clear, sp. gr., 1,014, phosphates, present +, albumen, present +, sugar, casts, etc., nil. The temperature continued and the patient

started passing loose greenish coloured stools. He was put on usual

' enteric precautions' as

a routine practice of hospital treatment of this group of fevers. Cevibex (Parke, Davis & Co.) one tablet thrice daily along with the former mixture was prescribed. Plenty of fluid, glucose drinks and orange juice were added to the diet which contained thin slices of bread, cream

cracker biscuits with honey, citrated milk, egg flip and lean meat soup. On the 10th day of the disease the blood was sent for Widal and culture.

Widal r&port.?

Th?positive up to 1 : 100 dilution.

To?negative all dilutions.

Ah?positive up to 1 : 50 dilutions.

Ao?positive up to 1 : 50 dilutions.

Bh?negative all dilutions.

Bo?negative all dilutions.

Blood culture.?Contaminated growth. Cul- ture of urine and stool was not possible. A diagnosis of enteric fever was made.

Luckily a consignment of two phials of chloro-

mycetin (Parke, Davis & Co.) was received from Messrs. Spencer & Co. (Pakistan) Ltd., Chittagong, at this time and it was decided to use the drug.

Dosage.?-As the patient weighed 64 lb., 4

kapseals (each kapseal 0.25 gm.) were given at an hourly interval and then one kapseal (0.25 gm.) every 4 hours except the dose at the early hours of the morning for 4 continuous

days. All other medicines except the alkaline mixture were omitted during this regime of treatment.

Effects of the drug on this case : (1) Temperature.?After the first four kapseals were ingested the patient had sweats around the forehead and the temperature began to swing down and reached as low as 99?F. from 103.2?F. It went up again within the next six hours up to 102 ?F. As the temperature was coming down the patient was bathed in cold sweats and simulated the signs of shock.

(2) General.?The coating of the tongue had vanished by the next morning and the patient, who had both tumidity and anorexia before, felt extremely hungry and the tumidity had vanished ! The loose motions were replaced by formed yellow coloured stools within the next twelve hours. Patient complained of extreme weakness and was prostrated on the third and the fourth day of administration of the drug.

(3) Blood pressure.?A gradual fall of blood pressure during the time of administration of the drug was the most constant feature. Just before the administration of the drug the blood pressure was 100/62 mm. of mercury. Within six hours of administration the pressure came down to 68/30 mm. of Hg. It went up again and was recorded as 80/38 mm. of Hg. next morning. It was again found to be 68/30 mm. of Hg. next morning. On the morning of the fourth day the patient was extremely weak and prostrated and began to sweat at 11 a.m. The

temperature went down to 96?F. and the B.P. was only 48/28 mm. of Hg. The patient was so bad that I had to give him glucose 25 per cent 50 cc. along with 1 cc. of corvotone (25 per cent solution of nikethamide B.P.) intravenously. An injection of eschatin one ampoule was also given intramuscularly. The patient had a

rigor and the temperature went up to 99 ?F. and the B.P. up to 64/30 mm. of Hg.

Discussion

The drug is said to be non-toxic within the level of prescribed dosage (Smith et al). Recently Cook et al. in their series of 25 cases have shown that fever did not persist for more than five days after administration of the drug was started. The drug was found to arrest the disease at whatever stage it has reached and to sterilize the blood at the same time. In fact the

March, 1951] MYOTONIA ACQUISITA : GOUR 99

period of convalescence is practically halved by treatment with the drug within the first two weeks of illness (Cook et al.). The only untoward effect observed in this

case was the steady and gradual fall of blood

pressure which caused much headache during the course of treatment, and the drug ultimately had to be discontinued for this reason only before a full course of five to seven days could be given.

Summary 1. Chloromycetin is a new antibiotic drug

which cures typhus, typhoid, some virus diseases, cholera, etc., etc.

2. Absorption is quick and so is the excre-

tion, hence less chance of toxicity. 3. A trial was given to a case of typhoid and

the temperature was found to be normal within 48 hours of administration of the drug.

4. Fall of blood pressure was recorded as

low as 48/28 mm. of Hg. in the same case

during the trial. I am indebted to the Surgeon-General with the

Government of East Bengal for kindly permitting me to report the case. My grateful thanks are due to Dr. Nawab Ali, Professor of Clinical Medicine, for encouragement.

BIBLIOGRAPHY

Bradley, W. H. (1949). Lancet, i, 869.

Cook, A. J., and Ibid., ii, 975. Marmion, D. E. (1949).

Ehrlich, J., et al. (1947). Science, 106, 417.

Long, P. H., et al. (1949). J. Amer. Med. Assoc., 141, 315.

Smadel, J. E., Leyvth- Science, 108, 160. waite, R., and Savoor, R. (1948).

[On enquiry this patient was found to be ' hale and hearty' in March 1951. The enquiry was made with a view to completing the account. The delay in receiving a reply is responsible for the delay in the publication of this contribution.?Editor, I.M.G.I