You’ve Got a Little Something in Your Eye…

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A Dram of Outlander Voyager Read-Along  Chapter 60 (LISTEN HERE)

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You’ve Got a Little Something in Your Eye… (Listen to the podcast HERE!)

 

Jesus H. Roosevelt Christ,” I said.  “What was that?”

What was that, indeed!  In the search for Young Ian, Claire finds herself doctoring a young man in his twenties who is enslaved at Rose Hall. Lying quietly on a pallet in a dark corner of a kitchen pantry, he doesn’t seem to have a fever nor much distress. In fact, he appears rather well.  Until…

As though in answer to my question, the slave suddenly wrenched himself away from my hand, let out a piercing scream, and rolled up into a ball.  Rolling and unrolling himself like a yo-yo, he reached the wall and began to bang his head against it, still screaming.  Then, as suddenly as the fit had come on, it passed off, and the young man sank back onto the pallet, panting heavily and soaked with sweat.

From Voyager by Diana Gabaldon, Chapter 60

Claire indeed finds a small worm moving underneath the surface of her patient’s eye.

The Loa loa worm and Loa loa filariasis

Nope, this isn’t one of Geillis’ hexes or the product of Diana Gabaldon’s imagination. This is a real disease and Loa loa, with its predilection for swimming under the surface of its victims’ eyes is the stuff of itchy nightmares, my friends!

Loa loa, AKA African eye worm, is a parasitic worm that is passed to humans by the bite of a deerfly. Endemic only to parts of West and Central Africa, Loa loa can only be spread by the bite of the deer fly and cannot be spread person to person.  Claire’s patient at Rose Hall no doubt contracted the illness in Africa before he was enslaved and transported to the West Indies.

africa_en_map
Image: WHO

Humans are the only known hosts of the disease. No other animals are known to become infected with Loa loa.  A deerfly carrying the Loa loa larvae bites a healthy human, depositing larvae into the wound.  Once inside a human host, the larvae grow into adult worms over about 5 months and travel throughout the body.  Adult worms prefer to live between layers of connective tissue, under the skin in the subcutaneous tissue, and between the thin layers of tissue that cover muscle (fascia).  The adult worms can produce thousands of microfilariae (tiny larave) each day and spread throughout the blood stream. The deerfly can then bite an infected human, ingesting the microfilariae, which then evolve into their larval form within the fly, ready to infect the next unsuspecting human again when the deerfly bites again!

l_loa_lifecycle
From CDC – Public Domain

What happens to a person infected with the Loa loa worm?

Many patients with loiasis (infection with Loa loa worm) do not experience any symptoms.  This is more true for those people who live in the endemic regions.  Travelers to these regions are more likely to suffer symptoms.  Most commonly, those infected will develop something called “Calabar swellings.”  These localized swellings, several inches in diameter, are found on the arms and legs are caused by the body’s inflammatory response to the presence of dead worms or the metabolic products of the worms.  Itching occurs around these areas and often all over the body.

Adult worms can be seen moving under the skin, as well as just under the surface of the eye.

UtIRaAp.gif
Image courtesy of Skydmark on Imgur

Presence of the Loa loa worm in the eye causes itching, pain, and light sensitivity.  The worm generally only remains in the eye for less than one week (often just hours) and causes very little damage, since it remains just under the surface, rather than deep within the eye.

Loa loa worms can also lodge in other sites of the body, causing complications in the intestines, kidneys, heart, joints and at times, the retina of the eye.

WWCD?

What would Claire do?  Quickly requesting brandy and a small knife, Claire deftly made a small incision in the sclera of the eye with a sterilized knife. She hooked the needle under the worm and pulled it out.

Did this cure this poor man? Nope.  But it certainly provided relief from the severe eye pain.  Can you imagine the agony of that?

Treatment of Loa loa infection

Surgical removal of Loa loa worms is not curative since it is highly unlikely that a person is infected with a single adult worm. Treatment now is with medication diethylcarbamazine, or DEC, which kills both the adult worm and the thousands of microfilariae circulating in the body. Life-threatening complications including fatal encephalitis (inflammation of the brain) can occur when DEC is used in a person with very high levels of microfilariae in the body.  Therefore, in some cases, other medications are given first to decrease the microfilariae load in the body before DEC is given.  In endemic areas, treatment is reserved for those who have symptoms and also have low levels of microfilariae in the blood.

The good news?  

Loa loa is only passed from infected deerflies to humans in certain rain forests of West and Central Africa.  You cannot become infected with Loa loa from exposure to an infected person – you must be bitten by an infected deerfly to develop the infection.  So, if you haven’t travelled to that region, you are safe!  If you do find yourself traveling to West and Central Africa, there is medication that can be prescribed to prevent infection. In addition, wearing long pants and long sleeved shirts and avoiding times of day when the deerfly is most active will also help prevent infection.

Check out this video showing removal of a Loa loa worm from the eye of an infected patient by a physician in Nigeria.  ***(Not for the squeamish!)

Header Image: NIH NIAID on Flickr

 

Edited to add:  A June 15, 2017 article in Huffington Post explains more about how this disease continues to affect millions in Africa and the difficulties in treating those afflicted by it.

 

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Wee Bugs And Wonder Drugs

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A Dram of Outlander Voyager Read-Along (Listen HERE)

Chapters 34-37:

Wee Bugs And Wonder Drugs
Listen HERE!

“I’ve germs in my arm, have I?”

Yes, indeed.  Courtesy of one Mrs. Laoghaire MacKenzie MacKimmie Fraser, in fact.

Jamie has been shot.  The bullet has pierced his upper arm, exited out the other side, and has come to rest about 1 inch deep in the soft tissue of his chest wall.  Fortunately the bullet has avoided any bones and did not penetrate the chest wall deep enough to damage his lungs and vital organs. Jenny has cleaned the wounds as best she can and has removed the bullet but a serious infection has settled in Jamie’s arm.

The wound itself was a ragged dark hole, scabbed at the edges and faintly blue-tinged. I pressed the flesh on either side of the wound; it was red and angry-looking, and there was a considerable seepage of pus. Jamie stirred uneasily as I drew my fingertips gently but firmly down the length of the muscle.
From Voyager by Diana Gabaldon, Chapter 36

Gunshot Wounds

Gunshot wounds become infected frequently, and are considered to be contaminated wounds, which makes sense:

  • Soiled clothing is forced into the skin and various injured tissues during the penetration of the bullet
  • Debris and foreign material is forced into the wound canal
  • Trauma causes nonviable (dead) tissue which enables the proliferation of bacteria
  • The trauma causes the local blood supply to the area to become disrupted, decreasing the ability of one’s immune system to defend against bacteria

Throughout history, death in combat was more often due to infection than battle injuries. Things are not looking so good for Jamie.  In fact, had young Ian not rode a full day’s journey to beg Claire to return to Lallybroch to help save Jamie, the Outlander story may have had a much more rapid resolution!

Fortunately for Outlander fans, Claire had the wisdom and foresight to include a special item in the pocket of her dress in her travel back through the stones. Or perhaps it was just plain good sense, knowing she was returning to Jamie Fraser, a man whom trouble seems to find!

pcn-box

I laid the small, flat case on the table and flipped the latch.  “I’m not going to let you die this time either,” I informed him, “greatly as I may be tempted.”  I carefully extracted the roll of gray flannel and laid it on the table with a soft clicking noise.  I unrolled the flannel, displaying the gleaming row of syringes, and rummaged in the box for the small bottle of penicillin tablets.
“What in God’s name are those?” Jamie asked, eyeing the syringes with interest.  “They look wicked sharp.”
I didn’t answer, occupied in dissolving the penicillin tablets in the vial of sterile water.  I selected a glass barrel, fitted a needle, and pressed the tip through the rubber covering the mouth of the bottle.  Holding it up to the light, I pulled back slowly on the plunger, watching the thick white liquid fill the barrel, checking for bubbles.  Then pulling the needle free, I depressed the plunger slightly until a drop of liquid pearled from the point and rolled slowly down the length of the spike.
“Roll onto your good side,” I said, turning to Jamie, “and pull up your shirt.”
From Voyager by Diana Gabaldon, Chapter 36

Penicillin

Penicillin was indeed a game changer for Jamie, but also for the entire world, even playing a significant role in the success of the Allies in World War II.  The discovery of penicillin was a fortunate accident and starts with Scottish scientist Alexander Fleming.  The story goes that upon returning to his lab in the basement of St. Mary’s Hospital in London in late September 1928 after a two week holiday, Fleming noted an interesting phenomenon in a petri dish that had been left accidentally open.

The petri dish contained Staphylococcus bacteria he had been studying, but now also contained a blue-green mold which he suspected had contaminated his petri dish from an open window.  Upon closer examination, he noticed that there was a clear zone around the mold where no staph bacteria grew, as though the mold and prohibited the growth of bacteria in that area.

petri
From Alexander Fleming’s Nobel Lecture, December 11, 1945

Fleming identified the mold as penicillium, and thus named the active substance capable of killing the surrounding bacteria penicillin.  He authored a paper describing his findings but this was met with little interest.  Penicillin was unstable and Fleming had difficulty producing it in any significant quantity.  No further progress would be made for another decade.

quote

In 1939, a group of scientists at Oxford including Howard Florey and Ernst Chain developed a method for purifying and producing penicillin, though the yield still remained rather low.  A year later, their experiments showed that penicillin could successfully treat strep infections in mice.

Florey and Chain showed that penicillin could treat infections in human in 1941 when they treated a 48 year old policeman by the name of Albert Alexander.  Mr Alexander had scratched the side of his nose while pruning roses and developed a significant infection with abscesses involving the eye, face and lungs.  He was treated with penicillin and within days had a remarkable recovery.  However, the supply of penicillin ran out after 5 days.  His infection worsened again and he died.

By this time, the world was fully engaged in World War II.  The US drug company Merck started production of penicillin and successfully treated in 1942 a patient with streptococcal septicemia – an infection of strep in the blood.  However, treatment of that one patient required half of the total supply of penicillin available at the time.  Work began in earnest to figure out a way to mass produce large quantities of the drug.

The US government hoped to produce enough penicillin for mass distribution to the Allied troops in Europe.  In 1943, the US War Production Board took over responsibility for the increased production of penicillin with the goal to have adequate supply for the planned D-day invasion in France. Ultimately, 2.3 million doses were available in time for the invasion of Normandy in the spring of 1944.  During the war effort, penicillin was limited to military use, with rare exceptions made for civilians in cases where other treatments had failed.  By 1945, increased production allowed for penicillin to be available to consumers for the first time without restriction.  Fleming, Florey and Chain were awarded the Nobel Prize in Physiology or Medicine in 1945.

(L to R:  Alexander Fleming, Howard Florey, Ernst Chain.  From Wikipedia Commons)

Prior to the era of penicillin, seemingly minor infections were often life-threatening: strep throat, scarlet fever, dental infections, skin infections from simple scratches, etc.  Infections like bacterial pneumonia, meningitis and endocarditis (infection of the lining of the heart and the heart valves) were often death sentences.  In World War I, the death rate from bacterial pneumonia was 18%.  With the availability of penicillin in World War II, that fell to less than 1%.  Untreated skin infections from trauma as minor as a simple scratch carried an 11% mortality rate prior to the discovery of penicillin.

pcn-poster
Credit: Research and Development Division, Schenley Laboratories, Inc., Lawrenceburg, Indiana

Fleming, though, foresaw the risk involved with this miracle drug and in his Nobel Lecture, provided this ominous warning:

But I would like to sound one note of warning. Penicillin is to all intents and purposes non-poisonous so there is no need to worry about giving an overdose and poisoning the patient. There may be a danger, though, in under-dosage. It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body.

-Alexander Fleming, Nobel Lecture, December 11, 1945

Antibiotic Resistance

Some suggest that we are headed to a post-antibiotic era – a time when we once again will be defenseless against seemingly simple infections.  Now we have antibiotic resistant pneumonia, tuberculosis, blood infections and even gonorrhea and few, if any, effective antibiotics against them. The CDC estimates that antibiotic resistance has been responsible for over 2 million illness and 23,000 deaths each year.

Antibiotics resistance happens naturally as the bacteria adapt but we must avoid accelerating this process.

resist
From: Center for Disease Control

As patients, we can minimize antibiotic resistance by:

  • Working to prevent infection with good hand washing, food hygiene and common sense, avoiding close contact with those who are ill.
  • Always finishing the full course of prescribed antibiotics and not taking left over antibiotics or someone else’s

It is scary to think we could be headed toward a time when we are unable to effectively fight bacterial, viral, and fungal infections. Progress continues in the development of new antibiotics, but resistance continues to develop at an alarming rate.

Fortunately, the bacteria infecting Jamie’s wound was no match for penicillin.  With no prior exposure to penicillin or similar antibiotics, the bacteria would have had no resistance and would easily succumb to the novel medication. And good thing, too – without antibiotics, this wound could have been fatal for Jamie. Thus, the Outlander saga could have ended much too early, and at the hands of Laoghaire no less (as though we needed any further reason to despise her)!

mold

 

Title Image: Mold Cultures in Petri Dishes (Public Domain)
References:
About Antimicrobial Resistance. (2015). Retrieved October 29, 2016, from http://www.cdc.gov/drugresistance/about.html
American Chemical Society International Historic Chemical Landmarks. Discovery and Development of Penicillin. Retrieved October 29, 2016, from http://www.acs.org/content/acs/en/education/whatischemistry/landmarks/flemingpenicillin.html
Antibiotic resistance. (2015, October). Retrieved October 29, 2016, from http://who.int/mediacentre/factsheets/antibiotic-resistance/en/
Markel, H. (2013, September 27). The real story behind penicillin. Retrieved October 29, 2016, from http://www.pbs.org/newshour/rundown/the-real-story-behind-the-worlds-first-antibiotic/
Sir Alexander Fleming – Banquet Speech. Retrieved October 29, 2016, from http://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-speech.html