Two additional cases of a syndrome characterized by arthralgia, fever, anemia, thrombocytopenia, hemorrhagic manifestations, and thromboses of arterioles and capillaries are presented. Pathologic description is given in some detail. Resemblances to certain other processes, including the rickettsial diseases, "vascular collagen" diseases and other conditions are pointed out. Deficiencies in knowledge of the entity are emphasized and a plea is made for continued efforts to define precisely the natural history of the syndrome.
ensues rapidly in a few days. The patient is then permitted to wash the face with soap and water and to apply cold cream and a light dusting of powder.After a rest period of three to six months, the patient is reexamined, and further abrasion is done as indicated. This cycle is repeated until maximum improvement has been achieved. The question of when to stop can, in the last analysis, be answered only by the judgment of the surgeon, based on experience. One must not permit the enthusiasm of the patient to exert undue influence. In general, any patient can tolerate one deep sanding with safety. After three sandiugs, the surgeon should proceed with caution with any patient. Persons who have had much roentgen therapy will tolerate less, and often one thorough sanding is the limit for them. A point to be watched is the appearance of a small keloidal spot or streak on the skin. These areas appear where abrasion has removed all the skin at a given point, allowing granulations to form. Such keloids are small and can be removed by excision, but they serve as a warning that the skin is now extremely thin and that further abrasion is contraiindicated.Patients who, in addition to the usual diffuse pitting, present some unusually large and deep pits, together with mounds and tunnels, require special handling. These lesions must be excised, and I prefer to do this before the skin is sanded. Mounds and tunnels are subjected to elliptic excision and closure with subcuticular nylon suture. I have found it unwise to bury suture material in these cases, as reaction and extrusion of the suture is common. The sequel to this is a new scar, which must be excised.I first attempted to thin the mounds to the level of the surrounding skin. This was not satisfactory, and I now excise them. Occasionally one sees a group of mounds, which gives the skin a nodular surface. There is so little skin between the nodules that the area must be excised as a unit. These excisions are done with local anesthesia. When all craters, tunnels and mounds have been eliminated, a rest period of three to six months is allowed, after which sanding is done.To date the results obtained with these methods have been gratifying. No case has come to my attention in which some degree of improvement has not been achieved, and, in most instances, the improvement has been considerable. It is to be hoped that the use of these methods will become more widespread for the benefit of afflicted persons. .3 However, it appears that the longer such patients are followed, the less impressive are the results. Probably the ultimate survival rate following streptomycin therapy is 5 to 10 per cent, and many of these patients have incapacitating neurologic residua.4We have had the opportunity of following a patient with tuberculous meningitis treated with streptomycin over a twenty\x=req-\ seven month period. He ultimately died of complications and reactivation of his infection. The case is of interest in that this patient was among the first to receive streptomycin therapy for tuberc...
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