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Flu Link to Toxic Shock May Help Explain Ancient Epidemic

February 27, 1987

CHICAGO (AP) _ New studies help bolster a theory that a mysterious plague that ravaged ancient Athens nearly 24 centuries ago was caused by a combination of influenza and toxic shock syndrome.

Epidemiologist Dr. Alex Langmuir suggested in 1985 that the presence of toxic shock syndrome may help explain the virulence of the flu epidemic that killed tens of thousands people in Athens between 430 and 427 B.C.

His suggestion, in the New England Journal of Medicine, touched off a controversy. But two new studies in today’s edition of the Journal of the American Medical Association support his argument.

It is well known that flu and flu-like illnesses weaken the body’s natural defenses and leave it vulnerable to other infections, and doctors have recognized the opportunistic nature of toxic shock syndrome, which often occurs as a result of wounds, respiratory tract infections or tampon use.

But the most recent studies demonstrate that a severe bout of flu can be perfect for Staphylococcus aureus, a common bacteria responsible for toxic shock syndrome, to flourish, said Dr. Bruce Dan, senior editor of the Journal, who wrote an editorial in the current issue supporting Langmuir’s theory.

″For toxic shock to follow from flu is so rare that you needed an influenza outbreak the size of the one we had here (in Minnesota) last year just to have enough numbers to recognize″ the relationship, said Dr. Kristine MacDonald of the Minnesota Department of Health, chief author of one of the studies.

MacDonald’s study looked at nine cases in which patients with flu developed toxic shock syndrome. Six subsequently died, and the study suggests failure to identify the bacterial infection early enough may have played a role.

A fatal case of influenza-related toxic shock syndrome in a previously healthy male college student was reported in a second Journal article by Dr. Steven J. Sperber of the University of Virginia School of Medicine at Charlottesville, and Dr. J. Boyd Francis of Roanoke, Va., Memorial Hospital.

″The biggest benefit of this is to make doctors aware to look for toxic shock if they have patients with flu whose condition suddenly deteriorates,″ MacDonald said in a telephone interview Thursday.

Doctors first isolated the toxin responsible for toxic shock syndrome while investigating deaths linked to the use of tampons in the late 1970s. Since 1979, there have been 2,962 cases reported to the federal Centers for Disease Control in Atlanta. Of those, 86 percent were associated with menstruation.

CDC spokeswoman Susanne Gaventa said reports of toxic shock have declined steadily from 980 cases in 1980 to 158 in 1985, the last year for which there are complete figures. Similarly, the rate of fatalities has declined from 4.7 percent in 1980 to 2.5 percent in 1985.

Symptoms of toxic shock include high fever, a drop in blood pressure, a skin rash and often vomiting and diarrhea.

Toxic shock is caused by a toxin produced by the Staphylococcus aureus bacteria, which is present in the nose and throat of one-third of the population at all times. Another one-third of the population harbors the bacteria irregularly, and the remaining one-third may never carry the bacteria.

Scholars who previously studied the Athens epidemic suggested it was caused by smallpox, bubonic plague, scarlet fever, measles, typus and other diseases. Others suggested that the disease is now extinct or changed beyond recognition.

Accounts from the period cite such symptoms as fever, cough, vomiting, thirst, blisters and diarrhea, but Langmuir said the key clue was gangrene, which occasionally accompanies the syndrome.

In his article, Langmuir suggested that the phenomenon of toxic shock following an outbreak of flu ″may reappear as a minor or even major manifestation of some future epidemic.″

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