Chapter 22 Hostile Criticism
Adult patient with atopic dermatitis who died of streptcoccal toxic shock syndrome
By M Kohda (Associate professor of Dermatological Department of Kawasaki Medical School) published in the Dermatology Today
Dermatology today is the booklet that TEIKOKU SEIYAKU (pharmaceutical company) used to distribute to medical experts. All articles are available online as of 2009.
The paper by the same author under the same title is also released in the magazine called Hifuka-no Rinsho (Clinical Report on Dermatology) (41: 315-318,1999), which may have more detailed case study. Here, I chose the Dermatology Today version I read around 1999 to add my impression then.
The following is the case introduced.
----- Excerpt -----
The patient was a 41-year-old female with a history of AD (atopic dermatitis) since childhood. AD evolved in the severe phase when she was around 36 and she was mainly treated with Chinese herb or folk medicine. In August 1997, after getting 2-day spa therapy, she developed edema, fever and diarrhea. She rapidly got worse in conditions and went into shock on the third day. After being seen by a local doctor, she was transferred to our hospital by ambulance. Soon after arrival, she went into respiratory arrest and cardiac arrest. After resurgence, intensive cares including antibiotic administration, continued blood filtration and endotoxin adsorption method were performed in the ICU, but she died on Day 11 after hospitalization.
The test measured the abnormal values of platelet (2,000/μI), CPK (29,940IU/I) and myoglobulin (224,000ng/I) and Streptococcus pyogenes were cultured from blood, urine and subcutis. When she was brought to the hospital (Day 1), her facial and body trunk skins were dried and rough without the Nikolsky phenomenon and showed easy peeling properties due to extreme edema after a massive blood transfusion on Day 2. Four limbs swelled with hemorrhagic bullas and erosions dispersed all over, and necrosed rapidly. Debridement could not be performed as hemodynamics improvement was difficult and necrotic focus expanded more than 50%. At necropsy, we found septic vasculitis of vessel in the skin and subcutaneous fatty tissue, muscular ischemic necrosis, bacterial pneumonia accompanied by coccal colonies and renal tubule necrosis due to clogging by myoglobulin.
----- End of excerpt -----
I think this is the typical progress of streptcoccal toxic shock syndrome. I have not seen the actual case though.
The following is the excerpt from Discussion. The phrase inserted in blue characters in parenthesis is my impression when I read this review.
----- Excerpt -----
Streptcoccal toxic shock syndrome (STSS) is a recently topical group A streptococcus infection, which healthy people commonly develop. Group A streptococci enter through minor injuries. Intervals exposed to this streptococcus will rapidly develop sepsis, multi organ failure will occur and will die at high rate. Cutaneous manifestations are erythroderma, a flare at a possible bacteria entry point, swelling and bulla, which will frequently progress to necrotizing fasciitis.
(I see, I see.)
There are some recent reports on the case indicating the relationship between eczematous dermatitis and STSS. Tanigaki et al. reported on an adult patient with multiple prurigo nodularis who developed STSS and died. In the case reported by Kurihara et al., an adult patient with AD developed necrotizing fasciitis and had no choice other than to have the affected finger cut off.
(Well, it is possible an AD patient unfortunately gets infected.)
They listed, as a causative reason, rapid aggravation of the eruption after the patient stopped topical corticosteroid application out of concern about the side effects. It is less thinkable that AD patients are especially immunodeficient against hemolytic streptococcus and it is more likely that insufficient dermatitis control allowed the streptococcal entry.
(Wait a minute. I read the phrase, “Group A streptococci enter through minor injuries.” Does Dr. Kohda try to attribute STSS to insufficient control of AD? No way!)
I heard of this 41-year-old female who also had been rejecting topical corticosteroid application. She seemed predisposed to skin infection all the more because she got a spa therapy in the hot summer although she had erythroderma. I’m not sure the spa is the potential source of hemolytic streptococcus, but it’s highly possible.
(He apparently criticizes steroid withdrawal. He intends to attribute STSS to her steroid withdrawal decision. Isn’t he obsessed with a hot spring as an infective origin? It seems he has been so much annoyed about “spa therapy selected with steroid application rejected.”)
Considering the present situation made by the mass media’ s way of reporting steroidal side effects, excessive reaction by patients, and doctors who surprisingly seem to sympathize with such patients, we can’t take a wait and see attitude viewing this is as “just a transitional process that we must go through till the general public learn about the disease well.” I felt that we need to explain and convince AD patients of the importance to properly control the skin conditions so that they won’t have an unfortunate experience such as this case any longer.
(Oh, he began to criticize doctors who support steroid withdrawal according to the need of patients. Why can’t he think it best that dermatologists accept and support patients who want to withdraw from steroids in order to prevent them from seeking help from dubious folk medicines? Maybe he knows it’s tough to care for such patients. Or he really cannot recognize the steroid addiction?
It seems he wants to say that AD patients should use topical corticosteroids without complaining. OK. But isn’t it unscientific and illogical to make such a conclusion because the patient happened to die of STSS?)
----- End of excerpt -----
According to the investigation made by the National Institute of Infectious Diseases in 2007, the STSS infection routes were uncertain in most of the cases. In skin infection cases, the disease was induced through injury or other ways and attributed to neither AD nor topical steroid withdraw. With no need to wait for the 2007 statistics, as Dr. Kohda himself wrote, it was commonly thought that STSS infection route was “a minor injury.”
Adult patient with atopic dermatitis who died of streptcoccal toxic shock syndrome
By M Kohda (Associate professor of Dermatological Department of Kawasaki Medical School) published in the Dermatology Today
Dermatology today is the booklet that TEIKOKU SEIYAKU (pharmaceutical company) used to distribute to medical experts. All articles are available online as of 2009.
The paper by the same author under the same title is also released in the magazine called Hifuka-no Rinsho (Clinical Report on Dermatology) (41: 315-318,1999), which may have more detailed case study. Here, I chose the Dermatology Today version I read around 1999 to add my impression then.
The following is the case introduced.
----- Excerpt -----
The patient was a 41-year-old female with a history of AD (atopic dermatitis) since childhood. AD evolved in the severe phase when she was around 36 and she was mainly treated with Chinese herb or folk medicine. In August 1997, after getting 2-day spa therapy, she developed edema, fever and diarrhea. She rapidly got worse in conditions and went into shock on the third day. After being seen by a local doctor, she was transferred to our hospital by ambulance. Soon after arrival, she went into respiratory arrest and cardiac arrest. After resurgence, intensive cares including antibiotic administration, continued blood filtration and endotoxin adsorption method were performed in the ICU, but she died on Day 11 after hospitalization.
The test measured the abnormal values of platelet (2,000/μI), CPK (29,940IU/I) and myoglobulin (224,000ng/I) and Streptococcus pyogenes were cultured from blood, urine and subcutis. When she was brought to the hospital (Day 1), her facial and body trunk skins were dried and rough without the Nikolsky phenomenon and showed easy peeling properties due to extreme edema after a massive blood transfusion on Day 2. Four limbs swelled with hemorrhagic bullas and erosions dispersed all over, and necrosed rapidly. Debridement could not be performed as hemodynamics improvement was difficult and necrotic focus expanded more than 50%. At necropsy, we found septic vasculitis of vessel in the skin and subcutaneous fatty tissue, muscular ischemic necrosis, bacterial pneumonia accompanied by coccal colonies and renal tubule necrosis due to clogging by myoglobulin.
----- End of excerpt -----
I think this is the typical progress of streptcoccal toxic shock syndrome. I have not seen the actual case though.
The following is the excerpt from Discussion. The phrase inserted in blue characters in parenthesis is my impression when I read this review.
----- Excerpt -----
Streptcoccal toxic shock syndrome (STSS) is a recently topical group A streptococcus infection, which healthy people commonly develop. Group A streptococci enter through minor injuries. Intervals exposed to this streptococcus will rapidly develop sepsis, multi organ failure will occur and will die at high rate. Cutaneous manifestations are erythroderma, a flare at a possible bacteria entry point, swelling and bulla, which will frequently progress to necrotizing fasciitis.
(I see, I see.)
There are some recent reports on the case indicating the relationship between eczematous dermatitis and STSS. Tanigaki et al. reported on an adult patient with multiple prurigo nodularis who developed STSS and died. In the case reported by Kurihara et al., an adult patient with AD developed necrotizing fasciitis and had no choice other than to have the affected finger cut off.
(Well, it is possible an AD patient unfortunately gets infected.)
They listed, as a causative reason, rapid aggravation of the eruption after the patient stopped topical corticosteroid application out of concern about the side effects. It is less thinkable that AD patients are especially immunodeficient against hemolytic streptococcus and it is more likely that insufficient dermatitis control allowed the streptococcal entry.
(Wait a minute. I read the phrase, “Group A streptococci enter through minor injuries.” Does Dr. Kohda try to attribute STSS to insufficient control of AD? No way!)
I heard of this 41-year-old female who also had been rejecting topical corticosteroid application. She seemed predisposed to skin infection all the more because she got a spa therapy in the hot summer although she had erythroderma. I’m not sure the spa is the potential source of hemolytic streptococcus, but it’s highly possible.
(He apparently criticizes steroid withdrawal. He intends to attribute STSS to her steroid withdrawal decision. Isn’t he obsessed with a hot spring as an infective origin? It seems he has been so much annoyed about “spa therapy selected with steroid application rejected.”)
Considering the present situation made by the mass media’ s way of reporting steroidal side effects, excessive reaction by patients, and doctors who surprisingly seem to sympathize with such patients, we can’t take a wait and see attitude viewing this is as “just a transitional process that we must go through till the general public learn about the disease well.” I felt that we need to explain and convince AD patients of the importance to properly control the skin conditions so that they won’t have an unfortunate experience such as this case any longer.
(Oh, he began to criticize doctors who support steroid withdrawal according to the need of patients. Why can’t he think it best that dermatologists accept and support patients who want to withdraw from steroids in order to prevent them from seeking help from dubious folk medicines? Maybe he knows it’s tough to care for such patients. Or he really cannot recognize the steroid addiction?
It seems he wants to say that AD patients should use topical corticosteroids without complaining. OK. But isn’t it unscientific and illogical to make such a conclusion because the patient happened to die of STSS?)
----- End of excerpt -----
According to the investigation made by the National Institute of Infectious Diseases in 2007, the STSS infection routes were uncertain in most of the cases. In skin infection cases, the disease was induced through injury or other ways and attributed to neither AD nor topical steroid withdraw. With no need to wait for the 2007 statistics, as Dr. Kohda himself wrote, it was commonly thought that STSS infection route was “a minor injury.”
In 1999, I was still working for the National Hospital accepting patients from all over Japan, some of whom were hospitalized. It was lucky that none of my patients were infected with STSS. If any of them had been infected and died, I should have been criticized by all dermatologists, including Dr. Kohda who were against steroid withdrawal.
It was what I feared most. I’ve never been sued for a medical mispractice. If my patient had a poor outcome due to my medical mistake, I would feel sorry and responsible for it, but wouldn’t feel scared. But reaction against steroid withdrawal by many dermatologists and the Japanese Dermatological Association was such a hysteric and illogical one that I did not know how to counteract them.
The people I had considered as my associates showed negative emotions against me for illogical reasons. I’d never had such a sad experience before.
At medical conferences, I repeatedly appealed for cooperation to scientifically and logically clarify the mechanism of steroid addiction and solve this problem, which is like a bad loan in dermatology, and also to treat patients who longed for steroid withdrawal. But, there came no response from the participants.
After all, I got physically and mentally exhausted and suffered from depression and insomnia. I feared that I might make a mistake if I continued medical treatment under such a condition. Then I rather chose to quit the job as a dermatologist with the pride that I had been doing things right.
Even now, I’m attracted to dermatology. Making a diagnosis with pattern recognition of lesions at a glance is the appeal that other medical fields do not give. I think dermatology is an excellent medical science. I believe the steroid addiction problem will be correctly recognized and solved by dermatologists themselves some day.
It was what I feared most. I’ve never been sued for a medical mispractice. If my patient had a poor outcome due to my medical mistake, I would feel sorry and responsible for it, but wouldn’t feel scared. But reaction against steroid withdrawal by many dermatologists and the Japanese Dermatological Association was such a hysteric and illogical one that I did not know how to counteract them.
The people I had considered as my associates showed negative emotions against me for illogical reasons. I’d never had such a sad experience before.
At medical conferences, I repeatedly appealed for cooperation to scientifically and logically clarify the mechanism of steroid addiction and solve this problem, which is like a bad loan in dermatology, and also to treat patients who longed for steroid withdrawal. But, there came no response from the participants.
After all, I got physically and mentally exhausted and suffered from depression and insomnia. I feared that I might make a mistake if I continued medical treatment under such a condition. Then I rather chose to quit the job as a dermatologist with the pride that I had been doing things right.
Even now, I’m attracted to dermatology. Making a diagnosis with pattern recognition of lesions at a glance is the appeal that other medical fields do not give. I think dermatology is an excellent medical science. I believe the steroid addiction problem will be correctly recognized and solved by dermatologists themselves some day.