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Causal or Casual?
The Relationship between Strep Throat
and Italian Restaurant Food

by
J.C. Dyer, M.L.S.
[Reprinted from HOOFBEATS: THE INTERNATIONAL JOURNAL OF STREPTOCOCCAL INFECTIONS,
v. 911, May 1993]

Introduction

"Against the disease of writing one must take special precautions,
since it is a dangerous and contagious disease." (1 )

Once more, against our better judgment, we have succumbed to the disease of writing, and are thus compelled to report our latest findings on a matter of great importance to public health.Jack Russell Gifts: T-shirts, stickers, mugs, mousepads, more

Our previous research(2) dealt with cases of recurrent canine-transmitted streptococcal pharyngitis.(3) We now turn our attention to a largely undocumented phenomenon: the apparent relationship between strep throat and eating in Italian restaurants. We describe the case of an 8 year-old child.

On at least three occasions, the patient became ill with strep throat within hours of eating at a neighborhood Italian restaurant. His family frequently went out to dinner on Saturday nights, always returning home in time to watch their favorite programs on TV, including COPS, CODE 3, The X-Files, and Alien Autopsy.

The family dog, Lucky Dyer, a Jackass Russell Terrier prone to strep infections, remained at home and typically dined on Pedigree (Country Stew)™ and Science Diet (Canine Maintenance)™, skillfully blended with his favorite leftovers from the family's meals. This short, stocky, high-strung, brown and white dog achieved notoriety in our remarkable study of canine pharyngitis(4).

The patient's family rotated their dining out among Chinese, Mexican and Italian restaurants in the area near their home. At no time did any member of the family become ill with strep throat or anything else, for that matter, after eating Mexican or Chinese food. But, oddly enough, the child consistently and predictably contracted streptococcal pharyngitis shortly after ingesting Italian food on Saturday nights.

This case presented a formidable clinical challenge. The child would typically become ill during the night, throw up the Italian food, develop fever, stomach pain, bad taste in the mouth, circumoral pallor, headache, tonsillar exudate, beefy red pharynx, malaise, blah, blah, blah. His ever-vigilant parents would treat his symptoms until morning, at which time he would be taken by his mother to their local doc-in-a-box. Repeatedly, he would test positive for strep and would receive the customary 10-day course of antibiotic therapy.

Jack Russell Gifts: T-shirts, stickers, mugs, mousepads, moreCase Report

On physical examination, the patient appeared well enough. He was an 8 year-old blond, blue-eyed male: alert, intelligent, handsome, and well-behaved - clearly the product of outstanding parenting. He weighed 56 lbs. He presented with sore throat, headache, non-localized abdominal pain and a fever of 38.6ºC. During the warm-up chit-chat preceding the exam, the attending physician initially suspected juvenile cerebral aphasia when the patient was overheard jabbering:

'Twas brillig, and the slithy toves
Did gyre and gimble in the wabe;
All mimsy were the borogroves,
And the mome raths outgrabe.(5)

Pulse, respiration, heart, lungs were within normal limits. The face, nose and eyes were favorably proportioned; the ears did not protrude enough to invite the ridicule of his peers. The skin was clear, with no indication of ringworm, tetter, or the heartbreak of psoriasis.

Neither the psoas sign nor Brudzinski's sign was elicited on examination, ruling out meningitis and appendicitis, but the tonsils were truly yucky. The tonsilar exudate was borderline Level IV, the patient having tonsils resembling maggots embedded in meatballs.

This child rarely suffered from the severely debilitating male cold virus (MCV), in which the male patient must take to bed for an extended period of time, usually at least a week or more. This is distinguished from the relatively mild female cold virus (FCV), requiring no bed rest, no rest of any kind, ever. There was no family history of malingering or of Münchausen's syndrome. He enjoyed his school, friends, family and numerous pets, but not necessarily in this order.

One of the attending nurses remarked, however, that the patient did have that "streppie look". This is not to be confused with the "preppie look" which was absent in this patient, as evidenced by his mismatched socks, untied shoelaces, and uncombed hair. The prominent calf-lick on the right side of his head suggested that he was a member of the Calf-O-Lick Church, but this was not independently confirmed.

The patient's mother observed that the attending physician was a Harvard man. She knew that this was the case because:

You can always tell a Harvard man,
But you can't tell him much.(6)

The physician, for his part, became concerned about the patient's fever, remembering the wise and famous words of the The Father of Modern Medicine, Sir William Osler:

Humanity has but three great enemies:
fever, famine and war; of these by far the greatest,
by far the most terrible, is fever.(7)

Just for the heck of it, the attending physician ran through his hotlist of the latest emerging infectious diseases: hantavirus, plague, lyme disease, ebola, anthrax, but quickly dismissed these due to the patient's having no contact with rodents; no mosquito, tick or flea bites; no travel to Africa; and no personal mail received.

Having eliminated most life-threatening conditions, and armed with a positive strep test result, the physician made the diagnosis of strep throat.

This patient had developed an early detection system that alerted him to the impending onset of strep in the early stages when stomach-ache and low-grade fever were the only clinical manifestations of disease. A prodromal syndrome of grumpiness and vexatious behavior would forewarn his long-suffering parents that strep was imminent. Their anxiety titers would rise in response.

The patient was the younger of two brothers. His 9 year-old brother rarely contracted strep, but, not to be outdone, habitually developed bilateral otitis media, with no apparent correlation to restaurant type (95 percent confidence interval, 36 to 97 percent; P=0.003).

At the suspect Italian restaurant, which boasted a health department rating of 100, the patient enjoyed a wide variety of foods, usually a child's plate of pasta, salad and bread, gladly sampling the parents' entrées if they appealed to him. The family sat in the non-smoking section of the restaurant, and no alcoholic beverages were consumed by children or parents. We found no statistical correlation between the types of food ingested, speed or quality of table service, or hour of dining (95 percent confidence interval, 44 to 91 percent; P<0.001).

From time to time, the mother, a renowned researcher/artist/writer, and sometime eccentric, observed strep-induced somnambulism. For example, in the middle of the night, the patient would arise from bed, walk to his bathroom, draw himself a warm bath, and enjoy a long soak before being awakened by his mother and put back to bed.

Within 30 minutes, the child would toss his cookies into a large bowl strategically placed at his bedside for this purpose. This would take the child quite by surprise, and he would not even have time to announce:

Non possum credere me totum edisse.
Cave, vomiturus sum!(8)

Visual examination of the vomitus revealed partially digested scampi al forno in white wine and mushroom sauce, lasagna, spaghetti with zesty marinara sauce, black olives, broccoli, mixed salad greens in a red wine vinaigrette dressing, croutons, garlic bread, cheese ravioli, and a dozen or so after-dinner peppermints.

The patient then brushed his teeth thoroughly and slept well until morning. He was seen by a physician. A diagnostic procedure was performed, with the diagnosis of group A beta-hemolytic streptococcal pharyngitis. The patient obviously harbored a substantial strep reservoir, as evidenced by the strong positive strep test.

Discussion

The patient is recovering well on an antibiotic regimen. He can be expected to remain strep-free if he scrupulously avoids Italian food. The most prudent course would be for him to avoid it like the plague.

In light of these findings, we are convinced that we have discovered, almost by serendipity, a new subgroup of strep pyogenes. We have settled upon the appellation of strep pyogenes italiano, or strep pi, since it is consistently associated with the consumption of Italian food.

What is remarkable in addition to its predicable occurrence after eating Italian food is its extremely short incubation period, sometimes only a matter of hours. Relapses are commonplace with this unremitting scourge of young children. The evidence is compelling, and the implications are mind-boggling. We are confident that our work is being closely monitored by a certain international committee, and that we will be receiving an important, not to mention, lucrative, award soon in either Stockholm or Cambridge as a result of this landmark study.

The Magnitude of the Problem

In our stubborn quest for diagnostic certainty, we call upon healthcare professionals world-wide to embark upon independent epidemiological studies to report similar cases of childhood strep following ingestion of Italian food. We anticipate documentation of numerous additional cases.

Our backbiting critics may fuss and fret over our small sample size, our lack of any precise data, and our less-than-meticulous methodology. Nit-picking worrywarts may whine that we are looking for zebras, just because we hear a few hoofbeats. Driveling pissant purists may scoff at the purely anecdotal nature of our study and our complete lack of quantitative data.

Let them whine, carp and jeer. We have heard it all before.(9) Our tried and true response(10) to these picky, picky, picky disgusting, low-life, scum-sucking, bottom feeders is:

E-P-A-D!
Eat Poop And Die!

--------------------------------------------------------------------------------

References

1 Abelard, Peter [1079-1142]. Letter 8, Abelard to Héloise.

2 Dyer, J. C. Guidelines, procedures and universal precautions for swabbing the canine pharynx in persistent strep throat. Dog Health and Fitness 1991;16:900-911.

3 Dyer, J. C. Sore throat in dogs and what to do about it; teaching dogs to gargle salt water is a snap! Veterinary Digest 1990; 57:8-12.

4 Dyer, J. C. Recurrent strep infections in a family of four with an asymptomatic Jack Russell Terrier carrier in residence. Part I: Mutts, butts, and nuts - Report of a great case. Part II: Illustrated techniques of IM penicillin injection in dogs for the novice practitioner, or, How to stay out of the line of fire. MD/DVM Collaboration 1992;6:24-39 [Special Issue].

5 Carroll, Lewis [Charles Lutwidge Dodgson]. Through the Looking-Glass [1871], Jabberwocky, st. 1.

6 Attributed to James Barnes [1866-1936].

7 Osler, Sir William. Science and Immortality, 1904, ch. 14.

8 Latin: "I can't believe I ate the whole thing. Look out, I'm going to barf!" from Beard, Henry. Latin for Even More Occasions. Villard Books, New York, 1991, pages 51, 96.

9 Tunes, Luni. Alert! Medical research is in Dyer Straits: How clinicians, alarmists, and other reactionaries can respond. Clinical Watchdog 1990;25:468-540.

10 Dyer, J. C. Eat Poop and Die: Proven and most timely strategies for dealing effectively with whackos, loonies, crackpots, nutcakes, and weirdoes. Lunatic Fringe Quarterly 1991;1:5-50.

Copyright 2005 J.C. Dyer


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