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.
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.
Case 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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