MEDICAL EMERGENCIES IN VENEREOLOGY
Major. M.P.Vora, M.B.B.S., D.V.D., I.M.S. (Rtd.)
Ex. Hon. Sr. Venereologist, St.George’s Hospital, Bombay
Indian Medical Record
A monthly journal of Public Health, Tropical Medicine and Surgery etc .
Volume LXXXVIII, Number-8 of August 1968
This article was solely contributed to Indian Medical Record
Many physicians in general practice would wonder at the very topic and question “what medical emergencies could be there in venereal practice?”. And this feeling is not at all unusual considering the level of interest and scant attention hitherto paid to venereal diseases. A great deal more is involved than they imagine. Medical emergencies exist in venereology, as they do in either surgery or medicine. No one can rule out lightly the recognised liability to accidents in the management of a venereal patient. To appreciate the point, a much higher level of understanding and overhauling of the present outdated methods of teaching are necessary.
An infectious venereal patient ought to be dealt with as a medical emergency. This is so even if the symptoms are mild, relieved or cured. The diagnosis and treatment of venereal diseases is of great urgency and constitutes one of the important medical emergencies. Prompt investigations and treatment of the contacts of an established case are also implicit in the good practice. If either syphilis or gonorrhoea is not dealt with promptly in their early stages, the rate of cure will be materially affected, chances of transmission of infection to others will be increased, and the possibilities of complications and late sequelae will be enhanced. It will also mean longer period of treatment and laborious and expensive tests of cure. Moreover, a delay of a few days in the institution of specific treatment may make the substantial difference between full recovery and survival with some degree of anatomic or physiologic defect. Serious complications of syphilis and gonorrhoea and their late sequelae can be prevented if every case is treated early and adequately and subsequently subjected to follow-up tests to determine the permanency of cure.
Any patient who calls on a physician either for a genital ulcer or an acute attack of urethritis, following an exposure to the risk of infection is a medical emergency from the point of a venereologist. Prompt diagnosis, its confirmation by laboratory tests ad institution of right treatment must be made immediately.
It must be remembered that it is not possible even for an expert to diagnose accurately by the naked-eye examination. And the treatment of these diseases without an accurate diagnosis amounts to quackery or medical incompetency and is not pardonable to the scientifically trained physician. Blood test for syphilis is done as a routine in every patient, irrespective of the presenting signs and symptoms. When a patient has a genital sore, it is cleaned with normal saline and a drop of serum from the sore is examined for the presence of Treponema pallidum under the dark-field microscopy; by this it is possible to diagnose syphilis long before characteristic signs of syphilis appear or the blood test for syphilis becomes positive. When the patient has urethritis, a smear is made of the pus milked out of the urethra and examined for the Gram-negative intracellular diplococci, morphologically akin to Neisseria gonorrhoeae. After the confirmation of the clinical diagnosis, the specific treatment is instituted. All this is done at one session without loss of time. Failure to do so is likely to increase opportunities for the spread of infection both in the patient and the community, and makes it difficult to obtain anatomic and bacteriologic cure in the shortest possible time with least inconvenience to the patient. This notion about the diagnosis and treatment of venereal diseases needs to be firmly ingrained in the minds of practitioners.
The forgoing principle is equally applicable to other cases such as generalised syphilis, early congenital syphilis, complications of gonorrhoea such as prostatitis, acute retention of urine, peri-urethral abscess, Bartholinitis, salpingitis, arthritis, epididymo-orchitis and vulvo-vaginitis in children. In such cases, attempts must be made first to establish the exact etiology before the start of specific treatment. Precise diagnosis becomes essential now that drugs which are effective and often specific are available. For the liquidation of the focus of infection from the community, quick investigations of contacts and their treatments are equally important. When the serologic tests for syphilis is found positive late in the third trimester of pregnancy, the case needs to be treated as a medical urgency even though the seropositivity may not be supported by the history of clinical evidence. There is no time to waste in verifying whether the seropositivity is genuine or false. An attempt to verify the result will merely mean loss of precious time and reduction in the chances of protecting the foetus from ill effects of syphilis.
Jarish Herxheimer Reaction: - Accentuation of signs and symptoms.
This may be focal or general or both which may follow the rapidly effective drug such as mapharside or penicillin in cases of syphilis. Ordinarily, the reaction occurs within 12 to 24 hours from the time of the first injection. When it occurs in early syphilis (less than two years duration), the first injection may be followed by fever and exaggeration of signs and symptoms within a few hours. But this is not at all harmful. It is not to be considered as a manifestation of drug toxicity but merely represents the usual reaction of active syphilitic lesions to powerful antispirochetal therapy. However, it may cause a fatal reaction in late syphilis. Occasional severe involvement of the nervous system, cardiovascular system, thrombosis of the large vessel, blocking of the coronary arterial ostium, bursting of the aneurysm or severe oedema of the glottis is not rare in the late syphilis. Careless administration of penicillin or arsenic may give rise to medical emergency. It should be the rule to examine the case carefully, special emphasis being placed on study of the cardiovascular and nervous systems and the cerebrospinal fluid examination before the start of the treatment in late syphilis. Since the contingency of asymptomatic involvement of vital organs cannot be excluded by clinical examination and there is the possibility of some serious effect in an occasional case, it is well to adopt some precautionary measures to prevent hazards, which are likely to endanger life of the patient. Nothing is gained by speed and intensity of treatment in these cases. There is no element of urgency in starting an intensive antiluetic therapy. It is wise to give preliminary treatment with weekly intramuscular doses of 0.2 to 0.3 gm of bismuth metal, and mixture of potassium iodide, one ounce three times daily, for three to four weeks. Small doses of prednisolone or prednisone given before the first two injections appear to have been effective in preventing or diminishing the reaction. However, if a fatal reaction occurs in spite of precautions, it must be dealt with promptly.
Hypersensitivity to penicillin : -
In the treatment of syphilis and gonorrhoea, penicillin is the drug of choice today. Naturally it is freely employed. However, reactions to penicillin are the commonest of drug sensitivity. Although reactions can occur in patients who have never been given drug before, the majority are seen in patients who have been sensitized by previous treatment. Generalised reactions usually result from oral, intramuscular or intravenous administration but any preparation of penicillin given by any route may cause sensitization and precipitate reaction in sensitive patients. Generalised reactions are of two kinds: the first, an immediate and acute anaphylactic type of reaction, which unless immediately treated threatens life of the patient; the second, a delayed in appearance, occurring 24 hours to 4 weeks after penicillin has been given. The skin is nearly always involved; besides urticaria, pruritis, arthralgia may be present.
Unfortunately, there is no reliable way by which patients liable to develop generalised reaction can be identified. The skin and the corneal tests are unsatisfactory and their results are often unreliable. A negative test does not exclude hypersensitivity and a positive test does not necessarily mean that the patient will have hypersensitivity reaction when penicillin is given. Hence it is a wise policy to keep ready at hand necessary equipment and items to meet an unexpected emergency. Sterilised syringes, needles, intracardiac needle, adrenaline, coramine, noradrenaline, cortisone, antihistamine, aminophylline, penicillinase, dextrose saline, tongue forceps, mouth gag and oxygen cylinder should be kept ready to meet the emergency. The use of antihistamine, adrenaline and cortisone is of distinct benefit in the treatment of anaphylactic shock. An intravenous drip infusion of a litre of isotonic 5% dextrose to which 4 ml of 1 in 1000 noradrenaline is added should be given and continued till therapeutic effects. Besides, intravenous hydrocortisone should be given.
Nitritoid crisis or vasodilator reaction
It is also called an anaphylactic shock which occurs at the time an intravenous injection of arsenoxide or an arsenical preparation is being given. Vomiting, palpitation, dyspnoea, syncope, swelling of the tongue and the lips, flushing of the face, thready pulse, and sudden fall of blood pressure will indicate the impending respiratory and cardiac distress. A hypodermic injection of atropine Sulphate 1/60 gm half an hour before the injection of arsenic should go a long way in preventing the reaction. If it does occur, immediate intramuscular injection of adrenaline chloride 1 in 1000, ½ to 1 ml will be of great help. Hydrocortisone should be given, in addition.
Tabetic crisis – Gastric crisis
An attack of intractable vomiting associated with epigastric pain, rectal crisis-pain-full and prolonged tenesmus, vesical crisis-severe dysuria, and laryngeal-crisis- prolonged spasm of the larynx causing stridor, cough and dyspnoea are sometimes met with as emergencies. They are likely to be lead to mistaken diagnosis, if sufficient care is not taken to exclude syphilitic etiology.
General Paralysis of the Insane
Its early detection and treatment is of paramount importance. But this can be possible only, if the study of the cerebrospinal fluid is undertaken timely in syphilitic patients. In absence of early treatment, mental and physical deterioration, progressive dementia and paralysis are almost certain to occur. A paretic curve in the colloidal gold test in association with a positive W.R. of the spinal fluid is often called “Red Flag”, and is strongly suggestive of early general paralysis of the insane. Institution of treatment at this stage will save irreparable structural changes. Antisyphilitic treatment carried out in asymptomatic stages has mush influence on the development of the stages of the disease and appears to improve the outlook and prognosis.
Early detection of uncomplicated syphilitic aortitis
In a syphilitic person, aged 35 to 45, anginal attacks, precordial pain, attacks of dyspnoea and giddiness, and accentuation of the second aortic sound should make one think of early aortitis, to undertake prompt and thorough investigations and to start cautious treatment, if the involvement of aorta is confirmed. This is sure to arrest the progress of the disease and prevent the development of aortic aneurysm or regurgitation.
Serous apoplexy or arsenical encephalopathy
It is a sort of haemorrhagic encephalitis which occurs 24 to 48 hours after the second or third injection of arsenical derivative. It is often misdiagnosed as simple apoplexy or uraemia. There is no known method of its prophylaxis. It is impossible to tell in which case it will develop. It needs urgent attention. Lumbar puncture, venesection, adrenalin and BAL (dimercapto-propanol) should prove beneficial. Haemorrhagic encephalitis following the use of penicillin injections has been reported.
Urethral shock following urethral instrumentation is at times met with as a medical emergency.
Urethral bleeding following urethral instrumentation can be at times serious. Force must not be used while dilating the urethra. The urethroscopic tube must not be pushed in the direction of the bladder, once the obturator is withdrawn. If there is bleeding instrumentation must be postponed.
Sudden entrance of air into the systemic veins often results in death of a patient from heart failure. While doing Urethroscopy, air insufflation or inflation must be done gently and carefully. A faulty technique of intramuscular injection of an oily suspension of bismuth into a vein may lead to an embolism of the pulmonary circulation. Due precaution must betaken to avoid such an accident. It is good practice to withdraw piston of the syringe slightly before the actual injection. If the needle is in the vessel, blood entering the needle and the syringe can be detected. Under such circumstances, the needle must be withdrawn a bit and directed to another site before the injection is given.
In case of penicillin sensitivity, one prescribes other broad-spectrum antibiotics such as tetracycline, chloramphenicol etc. Their use is not devoid of dangers. Tetracycline has occasionally caused rapidly progressive and fatal staphylococcal enterocolitis. If one fails to recognise its existence at the outset and institute treatment, death may supervene. Similarly there are many other reactions such as agranulocytosis, aplastic anaemia, crystalluria, haematuria, anuria, purpura etc. All of which generate medical emergencies and need prompt attention and treatment if one hopes to avoid disaster.
When the genital ulcer assumes rapidly spreading character, the tissue becomes black and necrotic and a large portion of the genetalia may be destroyed. If there is phimosis and this often accompanies this condition, dorsal slitting of the prepuce should be done. It allows a clear view, facilitates investigations and local treatment. This is an emergency and must not be put off. It needs prompt and intensive measures of therapy local and general. This in no way absolves the physician from taking steps to identify the responsible bacterium by collecting specimens and subjecting them to examination before the start of the therapy.
It is a condition in which the prepuce is retracted behind the glans penis and constricted so that it cannot be brought down to cover the glans penis. A tight constriction ring is rapidly formed giving rise to increase oedema, swelling, pain and ulceration. In its very early stage, its reduction by simple manipulation is possible. If the oedema is severe, hyaluronidase 1000 units is mixed in 1 ml of 1% procain hydrochloride and 0.25 ml is injected into the swelling close to the constricting ring at 3,6,9 and 12 o’ clock points. The part is covered with sterilised gauze and a tight bandage is applied for 15 to 30 minutes. By this time the oedema disappears and the prepuce can be pulled down. Once this early opportunity is lost, a division of the constricting ring of the prepuce is necessary. Delay in taking appropriate measures worsens the condition and is dangerous.
In the past, many of these medical emergencies were regarded as inevitable consequences and their existence was accepted in a fatalistic way. But the recent spectacular rise in the wealth of knowledge and experience has shown that they are preventive to a great extent. It has in fact become a matter of rationality rather that a decision based on intelligent guess to make every effort promptly to prevent accidents. The above examples should prove of value and serve as a rational background to forestall early emergency measures.